Psychologic assessment in patients undergoing bariatric surgery.

BACKGROUND: Psychological Clearance level (PCL) for patients undergoing metabolic and bariatric surgery (MBS) is a critical step for successful postoperative outcomes. This study aims to assess the relationship between the level of psychologic fitness and postoperative outcomes in patients undergoing MBS. METHODS: We retrospectively analyzed the data of patients who underwent MBS (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y Gastric Bypass [LRYGB]) and completed two years follow-up, between 2012 and 2019, in a single medical center. The patients were divided into four groups based on PCL, suggesting level of readiness for surgery: Group A (PCL-0: guarded), group B (PCL-1: Fair/reasonable), group C (PCL-2: Good/appropriate), and group D (PCL-3: Strong/excellent). Primary outcome was the percent of total body weight loss (%TWL), and the absolute change in BMI units. Secondary outcomes were missed postoperative visits and patient compliance. Differences between the groups were analyzed using a generalized linear model (GLM), chi-squared and exact Fisher tests, as appropriate. RESULTS: Of 1411 total patients, 607 (43.20%) had complete data at two years follow-up. 512 (84.34%) were females. LSG was performed in 361 (59.5%). No difference was found in %TWL between the four groups (22.14% vs. 28.0% vs. 26.0% vs. 24.8%, p = 0.118). We found a small difference in the mean (SD) of absolute change in BMI between the groups, and on post-hoc analysis it was found between groups B (PCL-1) and D (PCL-3). Overall, no difference between the groups in number of follow-up visits, or compliance issues. However, patients who attended more follow-up visits had less compliance issues (p < 0.001). PCL is inversely correlated with number of psychologic diagnoses (r = - 0.41, p < 0.001) and medical comorbidities (r = - 0.20, p < 0.001). CONCLUSION: We found no difference in the percent of TWL in patients who underwent MBS based on PCL at two -years follow-up. Medical comorbidities and psychiatric diagnoses impact the PCL.

Do Surgery Residents Prepare Enough for Surgical Cases?

IMPORTANCE: This study aimed to identify both modifiable and nonmodifiable factors that affect intraoperative-specific surgical education and performance, with an overall goal of increasing cognizance of such factors to improve surgical training. OBJECTIVE: To determine whether surgery residents prepare adequately for participation in surgical cases and to examine specific variables that affect resident preparation. DESIGN: This study is a retrospective survey-based study that included data from 1945 postoperative case evaluations completed by 59 different general surgery residents over a period of 8 years (2014-2022). SETTING: A Midwestern medical school's general surgery residency program. PARTICIPANTS: Fifty-nine general surgery residents at Western Michigan University's medical school; 50 attending surgeons and faculty with whom residents regularly operate. The sample was comprised of residents and attendings who voluntarily filled out postoperative performance surveys after elective cases. RESULTS: This retrospective survey-based study included postoperative evaluation data from 1945 procedures performed by 59 different residents and 50 attendings. Participants included 36 male residents, 23 female residents, 39 male attendings, and 11 female attendings. All included data were for elective cases. Self-reported preoperative communication was worst at the PGY1 level with positive correlation of improvement yearly (r = 0.30, p < 0.001). Positive correlation was seen between overall preparedness and case complexity (r = 0.25, p < 0.001). Positive correlation was seen between case complexity and resident perception of intraoperative teaching quality (r = 0.53, p < 0.001). Preoperative communication initiated by residents was significantly worse when the attending surgeon was female, regardless of resident gender (p < 0.001); this effect was particularly profound with male residents. Male residents overall rated themselves as more prepared compared to their female counterparts (11.13 ± 1.96 vs. 10.84 ± 2.03, p = 0.003). CONCLUSIONS AND RELEVANCE: There is a need to identify and address quantifiable gaps in communication between residents and faculty to optimize surgical education; one of the first steps is characterizing nonmodifiable factors that correlate with differences in pre-operative communication and case preparation.

Are There Racial Differences in the Rate of Surgical Site Infection Based on Surgical Subspecialty?

Background: Surgical site infection (SSI) is a common, morbid post-operative complication. We hypothesized the presence of racial differences in SSI rates, comparing black/African American (BAA) to white non-Hispanic (WNH) patients. Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), BAA and WNH surgery patients across 10 surgical specialties were identified: general surgery (GS), vascular surgery (VS), cardiac surgery (CS), thoracic surgery (TS), orthopedics (OS), neurosurgery (NS), urology (US), otolaryngology (ENT), plastic surgery (PS), and gynecology (GYN). The primary outcome was SSI rate (superficial, deep incisional, or organ/space). The secondary outcome was rate of non-surgical infection. Pearson χ2 and Fisher exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, or Mann-Whitney U test, with statistical significance set at a value of p < 0.05. Multivariable logistic regression models were conducted to analyze the association between race/ethnicity and the infection outcomes. Results: A total of 740,144 patients were included: 99,425 (13.4%) BAA and 640,749 (86.6%) WNH, distributed as follows; 32,2976 GS, 17,6175 OS, 44,383 VS, 2,227 CS, 9,645 TS, 42,298 NS, 42,726 US, 18,518 ENT, 20,709 PS, and 60,517 GYN cases. Surgical site infection rates were higher among WNH in GS (4.4% vs. 4.1%; p = 0.003) and TS (3.1% vs. 1.7%; p = 0.015); lower in VS (3.2% vs. 4.4%; p < 0.001), OS (1.2% vs.1.6%; p < 0.001), and GYN (2.4% vs. 3%; p < 0.001); and similar between WNH and BAA in ENT (1.8% vs 1.8%; p = 0.76), and US (1.9% vs. 1.9%; p = 0.90). Non-surgical infection was higher in BAA in NS (3.2% vs. 2.5%; p = 0.003), and higher in WNH in GYN (2.6% vs. 2%; p < 0.001), OS (1.7% vs. 1.1%; p < 0.001), US (4.4% vs. 3.6%; p = 0.014), and VS (3.4% vs. 2.6%; p < 0.001). Conclusions: Variation exists in SSI rates between WNH and BAA patients among surgical subspecialties. Further research is required to understand these differences and address racial disparities in outcomes.

The importance of USMLE step 2 on the screening and selection of applicants for general surgery residency positions.

Background: As announced by the Federation of State Medical Boards (FSMB) and National Board of Medical Examiners (NBME), the United States Medical Licensing Examination (USMLE) Step 1 score reporting has transitioned to pass/fail outcomes instead of the traditional numeric score after January 26, 2022. USMLE Step 1 scores have been used widely as a crucial tool in screening and selecting applicants for residency programs. This study aims to determine the role of USMLE Step 2 in the selection of applicants for general surgery residency. Methods: A retrospective study was conducted over six recruiting cycles from 2016 to 2021. The data from 334 interviewed applicants from one general surgery residency program were assessed. Data analyzed included USMLE Step 1 and Step 2 scores, applicant gender, Alpha Omega Alpha (AOA) status, letters of recommendation (LOR), and research/publications (RS). Results: Of the 334 interviewed applicants, 209 (62.6%) were male. The mean [SD] USMLE Step 1 and USMLE Step 2 C K (Clinical Knowledge) scores were 239.6 [±10.4] and 249.2 [±11.4], respectively. The mean (SD) LOR and RS scores were 4.24 [±0.4] and 3.9 [±0.7], respectively. A positive correlation was observed between USMLE Step 1 and USMLE Step 2 C K (Clinical Knowledge) scores (r = 0.60, p < .001), LOR scores (r = 0.24, p = .008), and AOA status (r = 0.19, p = .038). There was a negligible correlation between USMLE scores and applicant gender. Conclusion: Transitioning USMLE Step 1 to pass/fail will make the initial screening and selection process of applications challenging for residency programs. In the short term, USMLE Step 2 scores, LOR, and AOA status are important as screening assessments. Valid measures to ensure appropriate, equitable, and fair assessments are needed.

Resident Autonomy and Performance Independence in Surgical Training Are Time- and Skill-Dependent.

INTRODUCTION: Appropriate faculty supervision and conditional independence of residents during training are required for autonomous and independent postgraduate practice. However, there is a growing concern that competence for transition to independent practice is not universally met. We hypothesize that surgery residents play a significant and active role in achieving their own independent status. METHODS: Over seven academic years (July 2014 through June 2021), 46 surgeons supervised and intraoperatively assessed the performance of 51 residents using validated Objective Structured Assessment of Technical Skill (OSATS) and Zwisch Operative Autonomy (ROA) assessments. Resident readiness to perform procedures independently (RRI) was graded as yes, no, or not applicable. Data were analyzed using descriptive statistics with categorical variables reported as frequencies and percentages. RESULTS: A total of 1657 elective procedures were performed by residents supervised by faculty. Association between RRI and postgraduate year (PGY), OSATS scores, ROA, resident and faculty gender, and case complexity was analyzed. Results indicated positive correlation between RRI and summative OSATS score (r = 0.510, P < 0.001), PGY (r = 0.535, P < 0.001) and ROA (r = 0.473, P < 0.001). Percentage of overall RRI increased from 7% at PGY1 to 87.4% at PGY5. Meaningful autonomy ratings increased from 23.6% at PGY1 to 92.5% at PGY5. Variations in ratings was observed when considering case category and complexity. CONCLUSIONS: RRI increases with years of training with variation when considering the specialty/The Accreditation Council for Graduate Medical Education procedure category and the complexity of cases. Specialty fellowships are a viable option to address the gap in The Accreditation Council for Graduate Medical Education categories when residency alone cannot reach appropriate independence. Residents' technical skills play a crucial role in evaluating RRI and granting operative autonomy.

Effective reduction in stress induced postoperative hyperglycemia in bariatric surgery by better carb loading.

BACKGROUND: Preoperative carbohydrate loading is a recommended component of enhanced recovery protocols (ERP's), however the impact on postoperative stress-induced insulin resistance remains poorly studied in both diabetics and non-diabetics. METHODS: Using our ERP, a preoperative grape juice group (Grape) was compared to the use of 25 g maltodextrin/3 g citrulline (G.E.D.™, SOF Health, LLC) for carbohydrate loading. RESULTS: The population included 171 patients (Grape n = 96; GED n = 75). Glycemic variability was significantly worse for the Grape group on POD 0 in both non-diabetic (70% vs 41%; p < 0.05) and diabetic patients (66% vs 34%; p < 0.05). Significantly more Grape patients required postoperative insulin regardless of diabetic status. CONCLUSION: Following bariatric surgery, the impact of stress induced hyperglycemia is primarily on POD 0 in non-diabetics whereas the effect extends into POD 1 for diabetics. Preoperative loading with G.E.D.™ versus grape juice is associated with a significantly lower rate of glycemic variation and postoperative insulin requirement, demonstrating that drink composition and treatment process reduces the severity of postoperative stress induced hyperglycemia in bariatric surgery patients.

Resurgence of methamphetamine related burns and injuries: a follow-up study.

PURPOSE: Legislation enacted to curb methamphetamine production has only temporarily succeeded. Experiencing a recent increase in burns as a result of the new one-pot method, we compared methamphetamine related burn patients who utilized the previous anhydrous ammonia method of production to current patients who largely used the new one-pot method of production. BASIC PROCEDURES: Patients who were burned as a result of methamphetamine production were retrospectively reviewed. Comparisons were made including demographics, length of stay, injury severity score, hospital charges, total body surface area burned, inhalation injury, intubation, ventilator days, toxicology, fluid volumes, surgeries and complications. MAIN FINDINGS: Eighteen current study patients (88.9% male) were compared to twenty-nine (86.2% male) previous study patients. The groups were similar in age, pattern of burn injury and intubation. Total body surface area burned, injury severity score, inhalation injuries, and ventilator days were not significantly increased in the current study. Longer length of stay and greater hospital charges were incurred by the current group. Burn surgeries per patient were significantly increased in the current group. PRINCIPAL CONCLUSIONS: A new one-pot method has emerged despite legislative attempts to curtail methamphetamine production, and burns have also increased. The reason for more extensive burn surgeries in the current METH related burn patients remains enigmatic. Severity of injury and cost to society remain high.

Three trocar laparoscopic Roux-en-y gastric bypass: a novel technique en route to the single-incision laparoscopic approach.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is the gold standard bariatric procedure. Typically, the procedure necessitates five to seven small skin incisions for trocar placement. The senior author (AA Saber) has developed a three-trocar approach for laparoscopic Roux-en-Y gastric bypass. METHODS: Sixteen patients underwent triple-incision laparoscopic Roux-en-Y gastric bypass between May 2009 and August 2009. The same surgeon performed all surgical interventions. The umbilicus was the main point of entry for all patients and the same operative technique and perioperative protocol were used in all patients. RESULTS: A total of sixteen triple-incision laparoscopic Roux-en-Y gastric bypasses were performed. The procedures were successfully performed in all patients. Mean operating time was 145.4 min. None of the patients required conversion to an open procedure. There were no mortalities or post-operative technical complications noted during the immediate post-operative period. CONCLUSION: Three trocar laparoscopic Roux-en-Y gastric bypass is safe, technically feasible and reproducible. This technique may be considered a "precursor" to single-incision laparoscopic Roux-en-Y gastric bypass.

Single-incision transumbilical laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy has been gaining popularity due to its simplicity and outstanding results. This procedure is no exception to attempts aimed at minimizing abdominal port access. In this article, the senior author (AAS) presents his technique for an entirely transumbilical single-incision approach where no extraumbilical incisions are necessary. MATERIALS AND METHODS: Seven patients underwent laparoscopic sleeve gastrectomies using this single-incision, totally transumbilical technique. The same surgeon (AAS) performed all surgical interventions. The same perioperative protocol and operative techniques were implemented for all the patients. RESULTS: A total of 7 single-incision transumbilical laparoscopic sleeve gastrectomies were successfully performed using this technique. Two patients required lysis of adhesions, and 1 patient underwent an umbilical hernia repair during the procedure. Mean operating time was 143 minutes. One of the patients required the insertion of an additional trocar. There were no mortalities or postoperative complications noted during the mean follow-up period of 1.5 months. CONCLUSIONS: Single-incision laparoscopic sleeve gastrectomy performed entirely through the umbilicus is safe, technically feasible, and reproducible.