Skilled Surgeons Matter

If you need to have bariatric surgery to combat obesity, the skill of your surgeon really does matter.  Duh, right? Well, as Rick and I agree on PodMed this week, many of those duh-type studies frequently turn their preconceived notions on their heads when subjected to rigorous study, so although this week's New England Journal of Medicine study on surgical skill and complications following bariatric surgery may have simply confirmed the obvious, a number of important observations were made, with clear implications for improving medical practice.  Kudos, we say, to the surgeons who agreed to participate!

Surgeons performing bariatric surgery in Michigan are registered as part of the Michigan Bariatric Surgery Collaborative, as are all hospitals where the procedure is performed.  Abundant data is gathered on each patient (about 6000 yearly) who undergoes a bariatric procedure. A total of 75 surgeons operate at 40 facilities; 20 surgeons agreed to submit a video of themselves performing a representative laparoscopic gastric bypass.  These videos were edited to remove all patient identifiers and to contain the most critical parts of each procedure only. Final videos were between 25 to 40 minutes in length and were submitted to another group of peer surgeons for review and critique.  A total of 33 surgeons from 24 hospitals performed reviews, although only 15 surgeons provided 78% of the ratings.

The primary surgical outcome measure was any complication arising postoperatively, including surgical site or wound infections, abdominal abscess, anastomotic stricture, bowel obstruction, or bleeding. Medical complications, unplanned reoperation, readmission, ED visits and mortality data were also gathered. These data were correlated with skill levels of the operative surgeon as calculated by an average, weighted measure from the peer review.

Operative surgeons were ranked in quartiles, with a complication rate of 14.5% in the bottom quartile compared with 5.2% in the top quartile. As might be expected, lower quartile ranking was associated with higher rates of infection, readmission, and all other complications.  Mortality among those patients operated by the lowest quartile surgeons was 0.26% versus 0.05% in the highest quartile.

Lowest quartile surgeons had longer operating times, but fascinatingly, there was no correlation with fellowship training in bariatric or laparoscopic surgery, or length of time in practice with lower ranking.  There was a correlation with volume of procedures, however, bearing witness to the idea that the best outcomes are seen in surgeons who do certain procedures again and again and again.

What Rick and I both like very much about this study is the path it points toward collegiality and skill improvement for surgeons, with clear applicability beyond bariatric surgery.  The authors point out that other complicated surgeries and procedures can also be improved with peer review, and they report that in Michigan, surgeons watch each other operate during site visits and videos of very proficient surgeons have been made available.  A win-win all around!

Other topics this week include antibiotics, anti-inflammatory medications and bronchitis in the BMJ, gowns and gloves in reducing infections in the ICU in JAMA, and stent placement and subsequent surgical risk in JAMA.  Until next week, y'all live well.

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