Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study
Varban OA, Thumma JR, Finks JF, Carlin AM, Kemmeter PR, Ghaferi AA, and Dimick JB. Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study. Surg Endosc 2019;33(3):895-903.
BACKGROUND: Considerable technical variation exists when performing laparoscopic sleeve gastrectomy (LSG). However, little is known about which techniques are associated with optimal outcomes.
OBJECTIVE: To compare technical variation among surgeons with the lowest complication rates and whose patients achieved the most weight loss.
METHODS: Practicing bariatric surgeons (n = 30) voluntarily submitted a video of a typical LSG performed between 2015 and 2016. Technique-specific data captured from videos and a questionnaire included bougie size, stapler vendor, number of staple loads, use of staple line reinforcement, fibrin sealant, intraoperative leak test, endoscopy, and drain placement. Surgeon-specific outcomes were obtained from cases performed by surgeons during the study period (n = 7023) using a state-wide bariatric-specific data registry. Surgeons were ranked based on 30-day risk-adjusted surgical complication rates ("safety") and excess body weight loss (EBWL) % ("efficacy") at 1 year after surgery. Technique-specific variables were compared between surgeons ranked in the top and bottom quartile for both safety and efficacy.
RESULTS: Surgical complication rates ranged from 0 to 4.32% while EBWL varied from 45.3 to 65.3%. There was no correlation between surgeon rankings for safety and efficacy (Pearson's r = 0.063, p = 0.741). Surgeons ranked in the top quartile for safety and efficacy had significantly shorter mean operative times than surgeons ranked in the bottom quartile (65 min vs. 69 min, p < 0.0001). Surgeons with the highest leak rates were more likely to use buttressing (85.7% vs 40.0%, p = 0.032), otherwise operative techniques varied considerably.
CONCLUSIONS: Technical variation appears to have minimal effect on the safety or efficacy of sleeve gastrectomy among surgeons participating in a state-wide quality improvement collaborative. Top ranked surgeons did have faster mean operative times indicating that there may be other metrics of technical quality that correlate to optimal outcomes.