Bariatric Times - June 2008 - (Page 40)

40 Surgical Perspective Bariatric Times • June 2008 Volume Matters by Walter J. Pories, MD, FACS, and Gary M. Pratt Dr. Pories is from East Carolina University, Greenville, North Carolina, and Mr. Pratt is from Surgical Review Corporation, Raleigh, North Carolina. Practice makes perfect. Pitchers and paperhangers, priests and policemen all improve their performance as they practice their skills. And so it is with surgeons and hospitals. Institutions with greater case volumes deliver care with lower mortality and morbidity rates in cardiac surgery, orthopedics, gynecology, and even the care of strokes. In oncology, greater volumes also produce better long-term outcomes and survival. Volume also affects outcomes in bariatric surgery. Optimum results are achieved after surgeons have a lifetime experience of 125 cases. Application of this principle is one of the mainstays of the Bariatric Surgery Centers of Excellence® (BSCOE) program of the American Society for Metabolic and Bariatric Surgery (ASMBS)—an initiative that has reduced the national mortality of bariatric surgery to 3.4 cases per 1,000 operations, about the same level as cholecystectomies—a remarkable achievement given the high operative risks associated with severe obesity. The significance of this advance comes into focus when these operative outcomes are compared to the national data for gastrectomies (6 operative deaths per 100 cases), pancreatectomies (9 operative deaths per 100 cases), and aortic repairs (6 operative deaths per 100 cases). The effects of volume are further emphasized by the recent data from Surgical Review Corporation (SRC), the independent company that manages the BSCOE program for the ASMBS. These data reveal that institutions with volumes greater than 350 bariatric operations per year have better outcomes than those with 150 to 250 cases per year. If we pursued these observations to a logical conclusion to assure the best outcomes and to protect the public, then one might conclude that all bariatric surgery in the world should be performed at one mammoth institution. Such a conclusion might be logical, but it is certainly not realistic. The first obvious question is whether the issue is really volume or whether volume, per se, is a measurable indicator of a far more complex process. It is much more likely to be the latter (i.e., outcomes reflect far more than the talents of the surgeon). Patient welfare also depends greatly on the qualities of anesthesia, nursing, and other support staff. Whatever the explanation, volume matters. What then are our options? Four approaches seem realistic: 1) Assure that surgeons are well trained when they enter practice 2) Focus not only on the surgeon, but also on the full team delivering care to the patient 3) Develop and implement carefully tested care paths and 4) Continue evaluating outcomes. GRADUATING WELL-TRAINED SURGEONS The best residency programs in the United States graduate surgeons with remarkably little focused operative experience even after five years of intense training. The minimum requirements of the American Board of Surgery (ABS) for certification, shown in Table 1, do not assure that newly certified surgeons are capable of providing safe care. What physician would be willing to undergo resection of the pancreas by a surgeon with the experience of three cases or a thyroidectomy by a colleague who had removed eight? The trainees seem to agree. More than 70 percent of the graduates pursue fellowships even after they qualify for ABS certification, finally entering practice at 33 to 35 years of age. The approach now used by some specialties, such as plastic surgery and cardiothoracic surgery—i.e., two years of general surgical training followed by three INSTITUTIONS WITH VOLUMES >350 BARIATRIC OPERATIONS PER YEAR HAVE BETTER OUTCOMES THAN THOSE WITH 150 TO 250 CASES PER YEAR.

Table of Contents Feed for the Digital Edition of Bariatric Times - June 2008

Bariatric Times - June 2008 Endoluminal Treatment Options for Morbid Obesity: Devices and Techniques for Natural Orifice Approaches The Multidisciplinary Approach to Weight Loss: Defining the Roles of the Necessary Providers Acute Bleeding after Gastric Bypass Editorial Message Contents ASMBS: 25 Years Editorial Board Surgical Site Infection In The Morbidly Obese Patient: A Review Consultant's Corner The Link Between Sleep Loss and Obesity: Understanding the Mechanisms Responsible for Weight Gain with Sleep Deprivation Volume Matters Journal Watch Advertiser Index

Bariatric Times - June 2008

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