Associations Between Video Evaluations of Surgical Technique and Outcomes of Laparoscopic Sleeve Gastrectomy

Abstract

Importance: In any surgical procedure, various aspects of technique may affect patient outcomes. As new procedures enter practice, it is difficult to evaluate the association of each aspect of technique with patient outcomes.

Objective: To examine the associations between technique and outcomes in laparoscopic sleeve gastrectomy.

Design, setting, and participants: In this cohort study of bariatric surgery programs participating in a statewide surgical quality improvement collaborative, 30 surgeons submitted intraoperative videos from representative sleeve gastrectomies performed on 6915 patients with morbid obesity. These videos were reviewed by blinded peer surgeons on key technical elements, and 605 reviews were linked to sleeve gastrectomy outcomes of all of the surgeons' patients from January 1, 2015, to December 31, 2016.

Exposures: Surgeons' technical approaches to 5 controversial aspects of laparoscopic sleeve gastrectomy: dissection of the proximal stomach, sleeve caliber, sleeve anatomy, staple line reinforcement, and leak testing.

Main outcomes and measures: The 30-day outcomes were rate of postoperative hemorrhage and staple line leak. The 1-year outcomes were percentage of total weight lost and reflux severity (Gastroesophageal Reflux Disease Health-Related Quality of Life instrument).

Results: A total of 30 surgeons submitted 46 videos of operations performed on 6915 patients (mean [SD] age, 45.4 [11.7] years; 5494 [79.5%] female; 4706 [68.1%] White). Complete dissection of the proximal stomach was associated with reduced hemorrhage rates (higher ratings for complete mobilization of fundus were associated with a decrease in hemorrhage rate from 2.1% [25th percentile] to 1.0% [75th percentile], P = .01; higher ratings for visualization of the left crus were associated with a decrease in hemorrhage rate from 1.5% to 0.94%, P = .006; and higher ratings for complete division of the short gastrics were associated with a decrease in hemorrhage rate from 2.8% to 1.2%, P = .03). The reduction in hemorrhage rates came at the expense of higher leak rates (higher ratings for complete mobilization of fundus were associated with an increase in leak rate from 0.05% [25th percentile] to 0.16% [75th percentile], P < .001; higher ratings for visualization of the left crus were associated with an increase in leak rate from 0.1% to 0.2%, P = .003; and higher ratings for complete division of the short gastrics were associated with an increase in leak rate from 0.02% to 0.1%, P = .01). Surgeons who stapled more tightly to the bougie had smaller decreases in reflux than those who stapled less tightly (-2.0 to -1.3 on a 50-point scale, P = .002). Staple line reinforcement (buttressing and oversewing) was associated with a small (2 of 1000 cases) decrease in hemorrhage rates. Staple line buttressing was also associated with a similarly small increase in leak rates (1 of 1000 cases). Leak testing was associated with a statistically insignificant change in the staple line leak rate (0.16%-0.22%, P = .47).

Conclusions and relevance: Variations in surgical technique can be measured by video review and are associated with differences in patient outcomes.

Figure 1.. Associations of Surgical Technique With Hemorrhage and Leak Rates

Error bars indicate 95% CIs. Hemorrhage and leak rates were measured up to 30 days from surgery. Table 1 provides descriptions and definitions of each technique measurement. Statistically significant differences in outcomes between surgeons at the 25th and 75th percentiles for each element of technique are shown. ^aP < .05. ^bP < .01. ^cP < .001.

Figure 2.. Associations of Surgical Technique With Weight Loss and Gastroesophageal Reflux Disease (GERD) Severity

Error bars indicate 95% CIs. Weight loss and GERD severity were measured at 1 year from surgery. GERD severity was measured with the Gastroesophageal Reflux Disease Health-Related Quality of Life patient-reported outcome instrument. This scale consists of 10 items graded from 0 to 5, with 0 indicating no symptoms and 5 indicating incapacitating symptoms, for an overall composite score ranging from 0 to 50. Table 1 gives descriptions and definitions of each technique measurement. Statistically significant differences in outcomes between surgeons at the 25th and 75th percentiles for each element of technique are shown. ^aP < .05. ^bP < .001. ^cP < .01.