In weight-loss surgery, skill matters. A lot.


It makes sense that when you’re having your intestinal tract reduced, replumbed and rerouted, you want the professional wielding the scalpel to be good at his or her job. But just how much skill matters in the field of weight-loss surgery has never really been measured. Until now.

Let’s just say it matters. A lot.

A study published this week in the New England Journal of Medicine found that when it comes to performing laparoscopic gastric bypass surgery, the difference between having the most highly skilled surgeon and having one whose skill level lies in the bottom quarter of the pack is huge.

Patients operated on by bariatric surgeons whose surgical skills fell in the bottom 25% had more than four times the number of surgical site complications as patients whose surgeons ranked in the top 25% (4.6% vs. 1.04%). They had more than four times the pulmonary complications, such as blood clots that traveled to the lungs (3.91% vs. .71%). And though death is a rare outcome of such weight-loss surgery, patients of the least-skilled bariatric surgeons were more than five times more likely to die than those of the most-skilled ones (.26% vs. .05%).


The patients who went under the knife of the least-skilled bariatric surgeons were twice as likely as those who had the most skilled surgeons to be reoperated on to fix problems with the initial procedure (3.4% vs. 1.6%), and more than twice as likely to be readmitted to the hospital in the 30 days following surgery (6.3% vs. 2.7%).

The video attached to the study, and available here, is not for the squeamish. But it shows in exquisite detail that the most-skilled surgeons handled tissue gently, thereby reducing injury to delicate internal structures. They kept their objective in plain sight -- a difficult thing to do when the organs you’re working on are slippery and surrounded by a greater deal of fat. They cut and stitched smoothly and precisely, and they moved from phase to phase of the operation without delays.

In short, they followed the age-old adage taught to surgical residents since the dawn of modern surgery, at the end of the 19th century: “cut well, sew well, do well.”

The study recruited 20 surgeons -- from 63 of the surgeons performing laparoscopic gastric bypass in the state of Michigan -- to submit video of a single such operation. Edited versions of those videos were judged by a panel of 33 surgeons who rated the physician’s skill, using a checklist widely employed to rate surgical trainees.

The study found the best surgeons were not necessarily those who had the longest careers in the practice of bariatric surgery. They were not necessarily practicing at a teaching hospital. And they had not necessarily completed a fellowship in advanced laparoscopy or bariatric surgery.

The most-skilled surgeons in the study had consistently performed more laparoscopic gastric bypass operations (on average 157 per year) and any bariatric surgeries (241) than had the surgeons rated least skilled (who performed on average 53 laparoscopic gastric bypasses and 106 other bariatric surgeries yearly). And owing to their smooth movements and efficient transitions, and they were speedier too -- taking an average of 98 minutes to complete a laparoscopic gastric bypass -- than were their least-skilled peers, who took an average of 137 minutes to complete the same operation.



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