New generation evaluations: video-based surgical assessments : A technology update.

BACKGROUND: Surgical skill training, assessment, and feedback are the backbone of surgical training. High-quality skills require expert supervision and evaluation throughout a resource-intensive multi-year training process. As technological barriers to internet access and the ability to save and upload surgical videos continue to improve, video-based assessment technology is emerging as a tool that could reshape surgical training for the next generation of surgeons. Video-based assessment platforms have the potential to allow surgeons from across the globe to upload their surgical videos online and receive high-quality, standardized, and unbiased feedback. They combine visual recordings of a surgeon's operative technique, with standardized grading tools that have the potential to significantly impact surgical training and technical skill acquisition across the world. METHOD: The platforms included in this review are in various stages of development after a thorough discussion with national experts on the SAGES TAVAC (Technology and Value Assessments) Committee. For each VBA program, a description of its platform was given and a literature review was obtained using a PubMed search performed from inception until December 2021. RESULTS: The study reviewed all video-based assessment programs currently available in the market, identified their strengths and weaknesses, and how they can be optimized in future. CONCLUSION: The technological platforms will play a key role in the training and technical skill acquisition of the next generation of surgeons and can have an immense impact on patient care across the world. There is immense potential for all these platforms to grow and become incorporated within the framework of an effective surgical training program.

The effect of diabetes on major robotic hepatectomy.

Studies regarding the influence of diabetes on perioperative outcomes after major hepatectomy are conflicting. The objective of this study is to analyze the effects of diabetes on patients undergoing robotic major hepatectomy. With Institutional Review Board (IRB) approval, 94 patients undergoing major hepatectomy were prospectively followed. Demographic data and postoperative outcomes were analyzed and compared between diabetic and non-diabetic patients. Data were presented as median (mean ± SD). Patients were of age 62 (61 ± 13.0) years, BMI of 29 (29 ± 5.9) kg/m2, and ASA class of 3 (3 ± 0.55). The mass size was 5 (5 ± 3.0) cm. Operative duration was 252 (277 ± 106.6) min with estimated blood loss (EBL) was 175 (249 ± 275.9) mL. One operation was converted to 'open' due to bleeding, accounting for one intraoperative complication. Postoperatively, nine patients required ICU admission, with a duration of 1 (4 ± 5.9) day. Seven patients had postoperative complications. Length of stay (LOS) was 4 (4 ± 2.6) days. Fourteen patients were readmitted within 30 days. There were no deaths in-hospital or within 30 days. Of the 94 patients, 22 were diabetic and 72 were nondiabetic. Diabetic patients were older (70 (69 ± 11.3) years versus 58 (58 ± 12.4) years (p = 0.004)). Intraoperatively, operative duration, EBL, and complications were not significantly different. Postoperatively, LOS, ICU admission, ICU duration, complications, in-hospital mortality, readmission in 30 days, and death after 30 days showed no significant difference between diabetics and nondiabetics. In our experience, diabetes has no significant effect on perioperative outcomes after a robotic major hepatectomy.

Applying IWATE criteria to robotic hepatectomy: is there a "robotic effect"?

BACKGROUND: The objective of this study is to apply this criteria to determine its applicability to robotic hepatectomy. METHODS: We prospectively followed 105 patients undergoing robotic hepatectomy. Operations were categorized into Low (0-3), Intermediate (4-6), Advanced (7-9), and Expert (10-12). RESULTS: Patients had a median age of 62 (61 ± 13.1) years, with a BMI of 28 (29 ± 6.1) kg/m2; 38% were women. ASA class was 3 (3 ± 0.6). Of the 105 operations, 2 were categorized as Low, 31 as Intermediate, 49 as Advanced, and 23 as Expert. EBL and operative duration were found to be significantly greater as the operative difficulty level increased (p < 0.03 and p < 0.01, respectively). Intraoperatively, when comparing Expert and Intermediate, EBL and operative duration were significantly greater (p = 0.0001 and p = 0.0031, respectively). In the comparison of Expert with Advanced, operative duration was significantly longer (p = 0.0001). Postoperatively, comparisons between Expert and Intermediate, Expert and Advanced, and Advanced and Intermediate showed no differences. CONCLUSION: EBL and operative duration increased with IWATE scores reflecting more difficult robotic hepatectomies. However, with the robotic approach, our postoperative outcomes were similar irrespective of IWATE difficulty scores. Perhaps, the robotic approach potentially has a mitigating effect on postoperative outcomes regardless of difficulty level.

Bariatric Surgery Outcomes in Patients with Previous Organ Transplant: Scoping Review and Analysis of the MBSAQIP.

BACKGROUND: Obesity is a major risk factor for transplant. Laparoscopic bariatric surgery (LBS) offers transplant patient benefits including improved comorbidities, graft function, and longevity. We completed a scoping review and analyzed the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to determine the risk-benefit profile of LBS after transplant. We also compared laparoscopic sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGB) following transplant. METHODS: Univariate analysis determined between group differences with subgroup analysis comparing LSG versus LRYGB in transplant patients. Multivariable analysis assessed whether prior transplant was independently associated with major complications or mortality. RESULTS: A total of 469 (0.1%) patients had previous transplant and had more comorbidities and more often underwent LSG. Operative time (93.9 min vs 83 min, p < 0.001) and length of stay were longer. Major complications were threefold higher in patients with a transplant history (9.6% vs 3.2%; p < 0.001. Previous transplant was the second greatest independent predictor for major complication (OR 2.14 [1.54-2.98], p = < 0.001) but was not predictive of death (OR 1.06 [0.14-8.13] p = 0.956). Amongst transplant patients, LRYGB demonstrated higher rates of leak (n = 1), VTE, AKI, unplanned intubation, and readmission. CONCLUSIONS: The 30-day complication rate from LBS is three times higher amongst patients with a transplant. LSG is likely the best surgical approach. Despite risks, post-transplant patients incur important benefits from LBS. Surgeons must be aware of this risk-benefit profile when determining LBS candidacy.

Diagnostic accuracy of sentinel lymph node biopsy using indocyanine green in lung cancer: a systematic review and meta-analysis.

OBJECTIVE: The use of sentinel lymph node biopsy (SLNB) has been gaining popularity with the emergence of indocyanine green (ICG) fluorescence imaging. We aimed to systematically review the literature and perform a meta-analysis on the diagnostic accuracy of SLNB using ICG for lung cancer. METHODS: A comprehensive search of MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Library using search terms "lung/pulmonary" AND "tumor/carcinoma/cancer/neoplasm/adenocarcinoma/malignancy/squamous/carcinoid" AND "indocyanine green" was completed in June 2018. Articles were selected based on the following inclusion criteria: (1) diagnostic accuracy study design; (2) ICG injected at the tumor site with near-infrared fluorescence imaging identification of sentinel lymph nodes; (3) lymphadenectomy or sampling was performed as the gold standard. RESULTS: Eight primary studies were included with a total of 366 patients. 43.0% of patients were females and the mean tumor size was 2.3 cm. Sentinel lymph nodes were identified with ICG in 251 patients, yielding a pooled identification rate of 0.83 (0.67-0.94). A meta-analysis of seven studies computed a diagnostic odds ratio, sensitivity, and specificity of 177.6 (45.6-691.1), 0.85 (0.71-0.94), and 1.00 (0.98-1.00), respectively. The summary receiver operator characteristic demonstrated an area under the curve of 0.963 (SE = 0.038) and a Q* of 0.91 (SE = 0.057). CONCLUSION: Our review found suboptimal results for the diagnostic accuracy of SLNB using ICG and must be improved before routine clinical use. Further research is required to develop a robust protocol for the use SLNB with ICG for lung cancer.

Concurrent Laparoscopic Ventral Hernia Repair with Bariatric Surgery: a Propensity-Matched Analysis.

BACKGROUND: Ventral hernias are a common finding during bariatric surgery; however, the risks and benefits of repair during surgery remain unclear. Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we examined the short-term outcomes of patients undergoing bariatric surgery with concurrent ventral hernia repair (VHR) versus bariatric surgery alone. METHODS: Patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were included. A propensity-matched analysis was performed between laparoscopic bariatric surgery with and without concurrent VHR. The primary outcome was the 30-day major complication rate which includes but is not limited to 30-day reoperation, deep surgical site infection, and sepsis. Secondary outcomes included operative time, length of hospital stay, 30-day readmission, and 30-day mortality. RESULTS: A total of 430,225 patients were included, of which 4690 (1.1%) received concomitant VHR. With one-to-one propensity score matching, 4648 pairs were selected. Concurrent VHR was associated with a higher major complication rate (5.8 vs 3.8%, p < 0.001) but no significant difference in mortality (0.3 vs 0.2%, p = 0.531). Both LSG with VHR (3.2 vs 2.4%, p = 0.007) and RYGB with VHR (9.3 vs 5.7%, p < 0.001) were associated with an increase in major complications. CONCLUSIONS: Patients undergoing VHR during bariatric surgery do not experience higher mortality. However, these patients have an elevated risk of major complications with this risk being higher among patients undergoing VHR and LRYGB. Bariatric surgeons should consider these risks when choosing to perform VHR at the time of bariatric surgery.

Bariatric surgery outcomes in oxygen-dependent patients: analysis of the MBSAQIP database.

BACKGROUND: The number of bariatric procedures performed on complex, oxygen-dependent patients has increased. These patients often have other medical co-morbidities that can be improved after bariatric surgery; however, questions remain regarding their perioperative risk. OBJECTIVE: To assess the safety of bariatric surgery among oxygen-dependent patients, and to compare outcomes in this patient group after laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy. SETTING: University and private hospitals enrolled in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data from 2015 to 2017 was analyzed. A multivariable regression analysis was performed looking at 30-day serious complications for oxygen-dependent patients, with a secondary propensity-matched analysis performed comparing patients undergoing laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass. RESULTS: In total, 430,396 patients were analyzed, 3034 (0.7%) of whom were oxygen dependent. The absolute 30-day complication rate among oxygen-dependent patients was more than twice as high (8.24% versus 3.46%, P < .001). The postoperative leak (.69% versus .41%, P = .017), bleed (2.08% versus .91%, P < .001), cardiac event (.16% versus .07%, P = .034), and pneumonia rate (.89% versus .19%, P < .001) were all significantly higher. Mortality was significantly higher among oxygen-dependent patients (.49% versus .09%, P < .001). On multivariable analysis, oxygen dependency was an independent predictor of adverse outcomes (odds ratio 1.30 [1.22-1.50], P < .001). Laparoscopic Roux-en-Y gastric bypass was associated with a statistically significant higher complication rate compared with laparoscopic sleeve gastrectomy (13.23% versus 5.16%, P < .001). CONCLUSION: Oxygen-dependent patients undergoing bariatric surgery are at a higher risk of both morbidity and mortality postoperatively.

Bariatric Surgery Outcomes in Patients on Preoperative Therapeutic Anticoagulation: an Analysis of the 2015 to 2017 MBSAQIP.

BACKGROUND: Obesity has been found to be an independent predictor of adverse cardiac and pulmonary embolic events. As the popularity of bariatric surgery grows, surgeons are encountering more patients taking therapeutic anticoagulation medications preoperatively. This study aims to assess the safety of bariatric surgery on these patients. METHODS: Data was extracted from 2015 to 2017 using the MBSAQIP database. Included patients were those who underwent a primary LSG or LRYGB. A multivariable regression analysis was performed looking at 30-day outcomes for pre-operatively anticoagulated patients. A secondary propensity-matched analysis was performed comparing outcomes among patients undergoing LSG vs LRYGB. RESULTS: A total of 430,396 patients were analyzed, 11,013 (2.56%) of which were taking anticoagulation medications pre-operatively. Absolute 30-day complication rates (8.73% vs 3.36%, p < 0.001), bleed rates (3.78% vs 0.88%, p < 0.001), leak rates (0.55% vs 0.41%, p = 0.021), cardiac event rates (0.43% vs 0.06%, p < 0.001), and venous thromboembolism rates (0.68% vs 0.25%, p < 0.001) were significantly higher among pre-operatively anticoagulated patients. On multivariable analysis, pre-operative anticoagulation was found to be an independent predictor of postoperative bleeding (OR 2.76, CI 2.43-3.14, p < 0.001) and mortality (OR 2.08, CI 1.49-2.90, p < 0.001). The LRYGB was associated with a significantly higher complication rate compared to the LSG (13.27% vs 7.40%, p < 0.001) in the propensity-matched cohorts. CONCLUSIONS: Patients undergoing bariatric surgery on anticoagulation medications pre-operatively are at a significantly higher risk of adverse outcomes post-operatively. Patients who require long-term anticoagulation should undergo careful consideration before proceeding with bariatric surgery.

Effects of Chronic Corticosteroid and Immunosuppressant Use in Patients Undergoing Bariatric Surgery.

BACKGROUND: Chronic immunosuppression can put surgical patients at additional risk for complications, particularly infection. This is not a contraindication for patients undergoing bariatric surgery. However, with the increasing prevalence of bariatric surgery, it is important to characterize the additional risks for immunosuppressed patients. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry was used to identify immunosuppressed patients who had undergone bariatric surgery. Patients undergoing primary bariatric surgery (laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy) at an accredited institution between 2015 and 2017 were included. A multivariable regression analysis was performed, controlling for age, sex, procedure, and several other comorbidities. Overall 30-day incidence of major complications was the primary outcome. A secondary analysis compared outcomes amongst immunosuppressed patients by procedure type using a propensity-matched analysis. Propensity matching was performed based on preoperative comorbidities and bariatric procedure. RESULTS: A total of 430,936 patients were included in the study. Of these, 7214 (1.7%) were chronically immunosuppressed. Our multivariable regression analysis found statistically higher odds of 30-day major complications (OR 1.39, 95% CI 1.25-1.55; p < 0.001), bleed (OR 1.49, 95% CI 1.24-1.80; p < 0.001) and anastomotic leak (OR 1.38, 95% CI 1.02-1.87; p = 0.037) amongst immunosuppressed patients. However, there was no difference between 30-day mortality (OR 1.15, 95% CI 0.64-2.07; p = 0.644). Our secondary analysis found higher rates of 30-day major complications for immunosuppressed patients undergoing gastric bypass (9.6% vs. 5.0%; p < 0.001). CONCLUSION: Immunosuppressed patients are at higher risk of major complications when undergoing bariatric surgery, especially gastric bypass.

NSAID administration post colorectal surgery increases anastomotic leak rate: systematic review/meta-analysis.

BACKGROUND: Current enhanced recovery guidelines suggest that opioid sparing medications should be used for analgesia whenever possible following colorectal surgery. The present study aims to assess whether post-operative NSAID use is associated with an increased anastomotic leak rate after a colonic or rectal anastomosis. METHODS: A systematic review was performed for studies investigating anastomotic leak rate following NSAID use vs control after colonic or rectal anastomosis. Meta-analysis was performed to assess for overall risk of anastomotic leak with NSAID use, as well as sub-group analysis to compare selective vs non-selective NSAIDs and drug-specific NSAID safety profiles. RESULTS: Seven studies were included in the final review. Use of an NSAID post-operatively was associated with an overall increased risk of anastomotic leakage [OR 1.58 (1.23, 2.03), P = 0.0003]. Non-selective NSAIDs were associated with an increased risk [OR 1.79 (1.47, 2.18), P < 0.00001], but selective NSAIDs were not. The non-selective NSAID diclofenac was associated with an increased leak rate [OR 2.79 (1.96, 3.96), P < 0.00001], but ketorolac was not [OR 1.36 (0.89, 2.06), P = 0.16]. CONCLUSIONS: Great caution must be taken when prescribing NSAIDs following colonic or rectal anastomotic creation. The safety profile varies within the NSAID class and further research is needed to clarify which NSAIDs are safe for use and which are not.