Thyroidectomy Outcomes in Obese Patients.

INTRODUCTION: Obese patients often have higher complication rates after elective general surgeries; however, few studies have examined the outcomes after thyroidectomy. This study examines whether increased body mass index (BMI) is associated with poor postoperative outcomes after thyroid surgery. METHODS: A retrospective review of patients who underwent thyroidectomy from 2015 to 2018 was performed. Demographics, comorbidities, pathology, and extent of resection (total versus hemithyroidectomy) were examined. Patients were classified into BMI groups according to the WHO definitions, and the incidence of surgical outcomes was determined in each group. Surgical outcomes of interest included readmission rates (RRs), length of stay, average operating room time, return to the operating room, hypocalcemia, postop infections, hematomas, and recurrent laryngeal nerve injury. Between-subjects statistics including independent samples t-test, ANOVA, and chi-square analyses were performed. RESULTS: There were n = 465 patients included with a mean BMI 32.35 (standard deviation = 8.55) and median BMI 30.78 (Q1 = 26.26, Q3 = 36.73). There were no differences between BMI groups in age, gender, smoking, heart disease. There was a positive association between increased BMI and postoperative infection (P < 0.001), pneumonia (P = 0.018), and surgical site infection (P = 0.04), which were highest for BMI > 40. Increased BMI was associated with a higher 30-d RR (P = 0.008), particularly for BMI >40 versus BMI <40 (6.2% versus 1.05%; P = 0.003). There were no significant differences between surgical outcomes for patients with increased BMI who underwent total thyroidectomy or hemithyroidectomy. CONCLUSIONS: Excellent postoperative outcomes were observed in all BMI categories. Higher postoperative infection and 30-d RRs were observed in the morbidly obese. Contrary to previous studies, operating room times were similar regardless of BMI.

Using video-based assessment (VBA) to document fellow improvement in safely completing the jejunojejunostomy portion of laparoscopic Roux-en-Y gastric bypass (RYGB) surgery.

BACKGROUND: Surgical assessment instruments are used for formative and summative trainee evaluations. To characterize the features of existing instruments and a novel 12-item objective, procedure-specific assessment tool for Roux-en-Y Gastric Bypass (RYGB-OPSA), we evaluated the progress of a single surgical fellow over 17 consecutive surgeries. METHODS: Seventeen consecutive RYGB videos completed between 8/2021 and 1/2022 by an academic hospital surgical fellow were de-identified and assessed by four board-certified bariatric surgeons using Global Operative Assessment of Laparoscopic Skills (GOALS), General Assessment of Surgical Skill (GASS), and RYGB-OPSA which includes the reflection of transverse colon, identification of ligament of Treitz, biliopancreatic and Roux limbs orientation, jejunal division point selection, stapler use, mesentery division, bleeding control, jejunojejunostomy (JJ) anastomotic site selection, apposition of JJ anastomotic site, JJ creation, common enterotomy closure of JJ, and integrity of anastomosis. The GASS measured economy of motion, tissue handling, appreciating operative anatomy, bimanual dexterity, and achievement of hemostasis. RYGB-OPSA and GASS items were scored "poor-unsafe," "acceptable-safe," or "good-safe." Change in performance was measured by linear trendline slope. RESULTS: Over the course of 17 procedures, significant improvement was demonstrated by three GOALS items, GOALS overall score, GASS bimanual dexterity, and three RYGB-OPSA tasks: JJ creation, jejunal division point selection, and stapler use. Achievement of hemostasis declined but never rated "poor-unsafe." Overall RYGB-OPSA and GOALS trendlines documented significant increase across the 17 procedures. CONCLUSION: This examination of a bariatric surgery fellow's operative training experience as measured by three surgical assessment instruments demonstrated anticipated improvements in general skills and safe completion of procedure-specific tasks. Effective surgical assessment instruments have enough sensitivity to show improvement to enable meaningful trainee feedback (low-stakes assessments) as well as the ability to determine safe surgical practice to enable promotion to greater autonomous practice.

Global assessment of surgical skills (GASS): validation of a new instrument to measure global technical safety in surgical procedures.

BACKGROUND: Broad implementation of the American Board of Surgery's entrustable professional activities initiative will require assessment instruments that are reliable and easy to use. Existing assessment instruments of general laparoscopic surgical skills have limited reliability, efficiency, and validity across the spectrum of formative (low-stakes) and summative (high-stakes) assessments. A novel six-item global assessment of surgical skills (GASS) instrument was developed and evaluated with a focus upon safe versus unsafe surgical practice scoring rubric. METHODS: The GASS was developed by iterative engagement with expert laparoscopic surgeons and includes six items (economy of motion, tissue handling, appreciating operative anatomy, bimanual dexterity, achievement of hemostasis, overall performance) with a uniform three-point scoring rubric ("poor-unsafe", "adequate-safe", "good-safe"). To test inter-rater reliability, a cross-sectional study of four bariatric surgeons with experience ranging from 4 to 28 years applied the GASS and the global operative assessment of laparoscopic skills (GOALS) to 30 consecutive Roux-en-Y gastric bypass procedure operative videos. Inter-rater reliability was assessed for a simplified dichotomous "safe" versus "unsafe" scoring rubric using Gwet's AC2. RESULTS: The GASS inter-rater reliability was very high across all six domains (0.88-1.00). The GASS performed comparably to the GOALS inter-rater reliability scores (0.96-1.00). The economy of motion and bimanual dexterity items had the highest percentage of unsafe ratings (9.2% and 5.8%, respectively). CONCLUSION: The GASS, a novel six-item instrument of general laparoscopic surgical skills, was designed with a simple scoring rubric (poor-safe, adequate-safe, good-safe) to minimize rater burden and focus feedback to trainees and promotion evaluations on safe surgical performance. Initial evaluation of the GASS is promising, demonstrating high inter-rater reliability. Future research will seek to assess the GASS against a broader spectrum of laparoscopic procedures.