Goldberg, Ross F.

Objective: To characterize the relationship between surgeon-staff familiarity and the time required to perform an operation. Summary Background Data: The clinical and operational efficiency of operating rooms is a driver of hospital finances and patient outcomes. Surgeon-staff familiarity is an important focus for quality improvement and process optimization. Methods: A retrospective cohort study was performed analyzing operations performed at 4 academic hospitals between July 1, 2019 and December 31, 2023. Exclusion criteria (urgent operations, 2-specialty cases, low surgeon/specialty volume in data set, scheduled length > 8 hours) were applied to limit heterogeneity. The exposure of interest was familiarity between the surgeon and the allied health staff (scrub technicians and circulating nurses) present during an operation (represented as the median staff experience with the index surgeon in the previous 180 d). The primary outcome was whether the actual case length was (vs. was not) 10% shorter than the scheduled case length (“shorter case length”). A secondary outcome was the quantification of the difference between the observed and expected case length and whether the surgical time (cut-close) was shorter. Results: A total of 257,645 operations performed by 25 different specialties comprised the analyzed cohort. Higher levels of surgeon-staff familiarity were associated with a higher likelihood of a shorter case length (observed:expected ratio = 1.16 [1.14–1.18] for high/high levels of familiarity, compared with 0.90 [0.88–0.91] for low/low levels of familiarity). Greater familiarity was also associated with case lengths that were shorter relative to scheduled case length (high/high levels of familiarity 8.7% shorter than low/low levels, P < 0.001). Within the 4 most common types of cases, those operations performed by teams with higher levels of familiarity had shorter surgical times (cut-to-close). Conclusions: This study found that operations were more efficiently performed when the scrub technician and circulating nurse staff had a greater recent experience with the primary surgeon. Surgical team familiarity should be considered a focus of operational and clinical excellence.

Weight gain or loss is determined by the difference between calorie intake and energy expenditure. The Mifflin metabolic equation most accurately predicts resting energy expenditure (REE) in morbidly obese patients. Hypometabolizers have a measured REE that is much less than predicted and pose the greatest challenge for weight loss induced by restriction of calorie intake. We studied 628 morbidly obese patients (467 female and 161 men, aged 52.5 ± 15.7 years, body mass index [BMI] of 42.6 ± 7.6 m/kg 2 [mean ± SD]). REE was measured using the MedGem® device (REEm) and the percentage variance (δREE%) from the Mifflin-predicted expenditure (REEp) was calculated. Patients with δREE% more than 1 standard deviation from the mean were defined as hypometabolizers (REEm greater than 27% below REEp) and hypermetabolizers (REEm less than 13% above REEp), respectively. Hypometabolizers had greater REEp (1900 ± 301 vs 1719 ± 346 calories, P = 0.005) and lower REEm (1244 ± 278 vs 2161 ± 438 calories, P < 0.0001) than hypermetabolizers. Hypometabolizers, when compared with hypermetabolizers, were taller (167.2 ± 8.4 vs 164.0 ± 10.9 cm, P = 0.04), heavier (123.6 ± 22.2 vs 110.2 ± 23.1 kg, P = 0.006), and had increased BMI (44.1 ± 6.5 vs 40.8 ± 6.5 kg/m 2 , P = 0.04). Other measured anthropometrics were not different between hypo- and hypermetabolizers. Hypometabolizers were less likely to be diabetic (23 vs 43%, P = 0.03) and more likely to be black (25 vs 5%, P = 0.002) than hypermetabolizers. This study defines hypometabolizers as having variance in REEm more than 27 per cent below that predicted by the Mifflin equation. We could not identify any distinguishing phenotypic characteristics of hypometabolizers, suggesting an influence unrelated to body composition.

The objective of this study was to examine whether preoperative recommendation for specific reductions in body mass index (BMI) influenced weight loss in obese surgical patients. We retrospectively reviewed the electronic medical records of 48 patients who enrolled between January 2007 to June 2010 in an 800-calorie per day liquid meal replacement (LMR) weight loss program. Of these, 9 patients (surgical group) enrolled as a result of general surgeon-directed weight loss to enable nonbariatric surgery and 39 enrolled seeking weight loss (medical group). Patients enrolled in the LMR program before bariatric surgery were excluded from analysis. All patients were seen in the setting of a comprehensive weight loss program supervised by a medical bariatrician and followed for a period of 4 months. There were no significant differences in mean initial BMI between surgical and medical patients (41.7 ± 4.55 and 41.6 ± 8.54 kg/m 2 , respectively) or participation time in the weight loss program (120 days vs 133 days). Of the nine surgical patients, only five (56%) reached their weight goal and underwent the planned surgical procedure. Weight loss was significantly less in the surgical compared with medical patients (BMI reduction 4.03 ± 3.99 vs 7.75 ± 4.90 kg/m 2 , respectively; P < 0.05). Weight loss was significantly lower in patients directed to undergo BMI reduction to enable a general surgical procedure. Future studies are needed to assess factors influencing weight loss (metabolism, exercise capacity, motivation) in patients requiring weight loss to enable a surgical procedure.

AbstractBackgroundAmpullary and extensive periampullary lesions can be difficult to treat and often require pancreaticoduodenectomy (PD) for complete removal, even if benign. However, PD may be overtreatment for noninvasive lesions, and pancreas‐sparing total duodenectomy (PSTD) is an emerging valid surgical option for selected cases.MethodsWe reviewed patients undergoing PSTD at our institution over 16 months and a comparison group who had undergone PD for benign duodenal disease over the past 15 years. We also reviewed cases in the English‐language literature and performed a meta‐analysis of those patients who had undergone PSTD.ResultsPSTD had been performed in four patients, who had an average hospital length of stay (LOS) of 13 days; two of them experienced complications. None required conversion to PD, experienced a postoperative fistula or endocrine or exocrine insufficiency, or required intensive care. Two of the PSTDs were performed laparoscopically. Open PD for benign duodenal disease was performed in 22 patients, with overall morbidity and pancreas fistula rates of 82 and 27 %, respectively. The meta‐analysis found 128 unique cases of PSTD with morbidity and mortality rates of 46.4 and 2.3 %, respectively. Pancreaticobiliary leak was seen in 20 %, with an average LOS of 17 days.ConclusionsAlthough PSTD can be used to avoid PD and can be performed laparoscopically, it is technically challenging and still associated with morbidity.