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Can a laparoscopic Roux-en-Y gastric bypass be safely performed by surgical residents in a bariatric center-of-excellence? The learning curve of surgical residents in bariatric surgery

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Abstract

Background

A learning curve (LC) is a graphic display of the number of consecutive procedures performed necessary to reach competence and is defined by complications and duration of surgery (DOS). There is little evidence on the LC of surgical residents in bariatric surgery. Aim of the study is to evaluate whether the laparoscopic Roux-en-Y gastric bypass (LRYGB) can be safely performed by surgical residents, to evaluate the LC of surgical residents for LRYGB and to assess whether surgical residents fit in the LC of the bariatric center which has been established by their proctors.

Methods

Records of all 3389 consecutive primary LRYGB patients, operated between December 2007 and January 2016 in a bariatric center-of-excellence in Amsterdam, were reviewed. Differences in DOS were assessed by means of a linear regression model. Differences in complications (classified as Clavien-Dindo ≥ 2) were evaluated with the χ 2 or the Fisher exact test. Cases were clustered in groups of 70 for comparison and reported for residents with ≥70 cases as primary surgeon.

Results

Four surgeons (S1-4) and three residents (R1-3) performed 2690 (88.2%) and 361 (11.8%) of 3051 LRYGBs, respectively. Median (IQR) DOS was 52.0 (42.0–65.0) min for S1-4 versus 53.0 (46.0–63.0) min for R1-3 (p = 0.52). The LC of R1-3 in their first 70 cases (n = 210) differs significantly from the individual (n = 70) LCs of surgeon 1, 2, and 3, with remarkably shorter DOS for the residents (adjusted p < 0.0001; p < 0.001 and p = 0.0002, respectively) and the same amount of surgical complications 5.1% (137/2690) for S1-4 versus 3.0% (11/361) for R1-3 (p = 0.089).

Conclusion

Laparoscopic Roux-en-Y gastric bypass can be safely performed by surgical residents under supervision of experienced bariatric surgeons. Surgical residents benefit from the experience of their proctors and they fit faultlessly in the LC of the surgical team, as set out by their proctors in a large bariatric center-of-excellence.

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References

  1. Schauer PR, Ikramuddin S (2001) Laparoscopic surgery for morbid obesity. Surg Clin North Am 81:1145–1179

    Article  CAS  PubMed  Google Scholar 

  2. Birkmeyer JD, Finks JF, O’Reilly A, Oerline M, Carlin AM, Nunn AR, Dimick J, Banerjee M, Birkmeyer NJO (2013) Surgical skill and complication rates after bariatric surgery. N Engl J Med 369:1434–1442. doi:10.1056/NEJMsa1300625

    Article  CAS  PubMed  Google Scholar 

  3. Iordens GIT, Klaassen RA, Van Lieshout EMM, Cleffken BI, Van Der Harst E (2012) How to train surgical residents to perform laparoscopic roux-en-Y gastric bypass safely. World J Surg 36:2003–2010. doi:10.1007/s00268-012-1620-2

    Article  PubMed  Google Scholar 

  4. Rovito PF, Kreitz K, Harrison TD, Miller MT, Shimer R (2005) Laparoscopic Roux-en-Y gastric bypass and the role of the surgical resident. Am J Surg 189:33–37. doi:10.1016/j.amjsurg.2004.06.041

    Article  PubMed  Google Scholar 

  5. Fanous M, Carlin A (2012) Surgical resident participation in laparoscopic Roux-en-Y bypass: is it safe? Surgery (United States) 152:21–25. doi:10.1016/j.surg.2012.02.014

    Google Scholar 

  6. Gonzalez R, Nelson LG, Murr MM (2007) Does establishing a bariatric surgery fellowship training program influence operative outcomes? Surg Endosc Other Interv Tech 21:109–114. doi:10.1007/s00464-005-0860-8

    Article  CAS  Google Scholar 

  7. Kothari SN, Boyd WC, Larson CA, Gustafson HL, Lambert PJ, Mathiason MA (2005) Training of a minimally invasive bariatric surgeon: are laparoscopic fellowships the answer? Obes Surg 15:323–329. doi:10.1381/0960892053576640

    Article  PubMed  Google Scholar 

  8. Zacharoulis D, Sioka E, Papamargaritis D, Lazoura O, Rountas C, Zachari E, Tzovaras G (2012) Influence of the learning curve on safety and efficiency of laparoscopic sleeve gastrectomy. Obes Surg 22:411–415. doi:10.1007/s11695-011-0436-8

    Article  PubMed  Google Scholar 

  9. Khan N, Abboudi H, Khan MS, Dasgupta P, Ahmed K (2014) Measuring the surgical “learning curve”: methods, variables and competency. BJU Int 113:504–508. doi:10.1111/bju.12197

    Article  PubMed  Google Scholar 

  10. Corey R (1978) and Manufacturing of learning curves limitations of learning curves. Hosp Heal Serv Adm

  11. Nguyen NT, Rivers R, Wolfe BM (2003) Factors associated with operative outcomes in laparoscopic gastric bypass. J Am Coll Surg 197:548–555. doi:10.1016/S1072-7515(03)00648-3

    Article  PubMed  Google Scholar 

  12. Ballantyne GH, Ewing D, Capella RF, Capella JF, Davis D, Schmidt HJ, Wasielewski A, Davies RJ (2005) The learning curve measured by operating times for laparoscopic and open gastric bypass: roles of surgeon’s experience, institutional experience, body mass index and fellowship training. Obes Surg 15:172–182. doi:10.1381/0960892053268507

    Article  PubMed  Google Scholar 

  13. Oliak D, Ballantyne GH, Weber P, Wasielewski A, Davies RJ, Schmidt HJ (2003) Laparoscopic Roux-en-Y gastric bypass defining the learning curve. Surg Endosc 17:405–408. doi:10.1007/s00464-002-8820-z

    Article  CAS  PubMed  Google Scholar 

  14. Geubbels N, de Brauw LM, Acherman YIZ, van de Laar AWJM, Wouters MWJM, Bruin SC (2015) The preceding surgeon factor in bariatric surgery: a positive influence on the learning curve of subsequent surgeons. Obes Surg 25:1417–1424. doi:10.1007/s11695-014-1538-x

    Article  PubMed  Google Scholar 

  15. Oliak D, Owens M, Schmidt HJ (2004) Impact of fellowship training on the learning curve for laparoscopic gastric bypass. Obes Surg 14:197–200. doi:10.1381/096089204322857555

    Article  PubMed  Google Scholar 

  16. Melissas J (2008) IFSO guidelines for safety, quality, and excellence in bariatric surgery. Obes Surg 18:497–500. doi:10.1007/s11695-007-9375-9

    Article  PubMed  Google Scholar 

  17. ASBS bariatric Training Committee (2006) American society for bariatric surgery’s guidelines for granting privileges in bariatric surgery. Surg Obes Relat Dis 2:65–67. doi:10.1016/j.soard.2005.10.012

    Article  Google Scholar 

  18. Clements R, Saber A, Teixeiro J, Provost D, Fanelli R, Richardson W (2011) Guidelines for institutions granting bariatric privileges for the use of laparoscopic techniques. Surg Endosc Other Interv Tech 25:671–676. doi:10.1007/s00464-010-1375-5

    Article  Google Scholar 

  19. De Luca M, Himpens J, Weiner R, Angrisani L (2015) IFSO statement: credentials for bariatric surgeons 2015. Obes Surg 25:394–396. doi:10.1007/s11695-014-1553-y

    Article  Google Scholar 

  20. Buchwald H, Scopinaro N (2009) Retiring the learning curve. Obes Surg 19:541–542. doi:10.1007/s11695-009-9833-7

    Article  PubMed  Google Scholar 

  21. Fried M, Yumuk V, Oppert JM, Scopinaro N, Torres A, Weiner R, Yashkov Y, Frühbeck G (2014) Interdisciplinary European guidelines on metabolic and bariatric surgery. Obes Surg 24:42–55. doi:10.1007/s11695-013-1079-8

    Article  CAS  PubMed  Google Scholar 

  22. Charlson M, Szatrowski TP, Peterson J, Gold J (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47:1245–1251. doi:10.1016/0895-4356(94)90129-5

    Article  CAS  PubMed  Google Scholar 

  23. DeMaria EJ, Murr M, Byrne TK, Blackstone R, Grant JP, Budak A, Wolfe L (2007) Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg 246:578–582. doi:10.1097/SLA.0b013e318157206e

    Article  PubMed  Google Scholar 

  24. Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications. Ann Surg 240:205–213. doi:10.1097/01.sla.0000133083.54934.ae

    Article  PubMed  PubMed Central  Google Scholar 

  25. Geubbels N, Bruin SC, Acherman YIZ, VandeLaar AWJM, Hoen MB, De Brauw LM (2014) Fast track care for gastric bypass patients decreases length of stay without increasing complications in an unselected patient cohort. Obes Surg 24:390–396. doi:10.1007/s11695-013-1133-6

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to acknowledge A. Amarti, Dr. J.K. de Bakker and Dr. G.F. Giannakopoulos for their contributions to this paper.

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    Authors and Affiliations

    1. Department of Metabolic and Bariatric Surgery, Medical Center Slotervaart, Louwesweg 6, PO box 90440, 1006 BK, Amsterdam, The Netherlands

      Anne-Sophie van Rijswijk, Daan E. Moes, Noëlle Geubbels, Yair I. Z. Acherman, Arnold W. van de Laar, Maurits de Brauw & Sjoerd C. Bruin

    2. Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands

      Barbara A. Hutten

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    1. Anne-Sophie van Rijswijk
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    2. Daan E. Moes
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    6. Arnold W. van de Laar
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    Correspondence to Anne-Sophie van Rijswijk.

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    Disclosures

    A. van Rijswijk, D.E. Moes, N. Geubbels, B.A. Hutten, Y.I.Z. Acherman, A.W. van de Laar, M. de Brauw, S.C. Bruin declared that they have no conflicts of interest or financial ties to disclose.

    Ethical approval

    The Medical Ethics Committee has waived ethical approval of this study.

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    All patients within the used database have agreed upon, and signed for, the anonymous use of their data for scientific use before they underwent bariatric surgery at MC Slotervaart.

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    Anne-Sophie van Rijswijk and Daan E. Moes contributed equally to the paper and should be considered co-first authors.

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    van Rijswijk, AS., Moes, D.E., Geubbels, N. et al. Can a laparoscopic Roux-en-Y gastric bypass be safely performed by surgical residents in a bariatric center-of-excellence? The learning curve of surgical residents in bariatric surgery. Surg Endosc 32, 1012–1020 (2018). https://doi.org/10.1007/s00464-017-5779-3

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    • DOI: https://doi.org/10.1007/s00464-017-5779-3

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