In Training - Vol. 1, Issue 2

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INSIDE:

New Technologies

Expanding the Walls of Medicine F

rom surgeons tweeting short real-time updates about a procedure in the operating room (OR), to monitoring cases via teleconference across continents, new technologies are changing the face of surgery.

These technologies vary widely, but they all have one key element in common: the ability to easily broadcast information to large groups of people in various locales.

One of the first major advances was the advent of videoconferencing and telemedicine more than a decade ago. When it was first introduced, technologies like the OR1 made the OR a virtual stage, in which distant audiences could remotely watch surgeries as they happened.

“The OR1 platform was amazing when it came out 10 years ago,” said Philip Glick, MD, MBA, vice chairman of surgery and professor of surgery, pediatrics,

O

A discussion of the science behind surgical staplers, tissue compression, and how tissue thickness affects staple size choices.

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IN PRACTICE

and obstetrics/gynecology at the State University of New York in Buffalo. “It allowed our OR to touch the world and it allowed the world to look in on our OR.” Since that time, videoconferencing has evolved to include remote monitoring—in which audiences watch operations—and interactive telemedicine that provides real-time interactions among surgeons. see TELEMENTORING, page 4

Life After Gastric Band Surgery ne of the fundamental differences between bariatric surgery and more traditional general surgeries is that weight-loss operations follow a chronic disease model that requires a lifetime of follow-up care, such as access to clinical services or psychological and nutritional counseling through support groups.

“When you place a band or perform another weight-loss operation, you’re committing the patient to a lifetime of

IN TECHNOLOGY

Anecdotes from surgeons’ first day running an OR team and their tips for success.

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IN PRACTICE Advice for effective patient handoffs and discussion on the different methods used in US hospitals to maintain continuity of care.

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follow-up with a bariatric physician,” said Daniel Leslie, MD, assistant professor of surgery at the University of Minnesota in Minneapolis.

Among the common bariatric procedures, gastric banding holds a special place when it comes to follow-up.

“Follow-up is extremely important for all [bariatric] procedures but particularly for the band, because the whole concept see GASTRIC SURGERY, page 7

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IN TECHNOLOGY

Standardized Stapler Education Needed S urgical stapling is one of the most common operative techniques in surgery, from pinching off small dissected blood vessels to closing the thick wall of the stomach. Despite their ubiquity in operating rooms around the country, there is no real standardized education for using a surgical stapler.

Surgeons-in-training most often learn how to use staplers by watching a mentor, but the mechanics behind them are not well understood.

“We’ve had over 3,000 surgeons come through our institution taking advanced laparoscopic training courses and it never ceases to amaze me how many surgeons out there in practice, who have been using staplers for years, actually don’t necessarily know what a 3.5 load is or what a white cartridge represents,” said Kent Kercher, MD, chief of minimal access surgery and co-director of the Carolinas Laparoscopic and Advanced Surgery Program at Carolinas Medical Center in Charlotte, NC. Unlike energy devices, using a surgical stapler correctly doesn’t require a complete understanding of the science behind the device. Instead, surgeons need a sound grasp of technique, coupled with an understanding of basic wound healing and anastomosis.

“The stapler is more of an automatic device, but that being said, there are some choices—such as the length and height of the staples, and whether or not the tissue is appropriate to be stapled in the first place—that offer educational issues that are important for all surgeons,” said Steven Schwaitzberg, MD, associate professor of surgery at Harvard Medical School and chief of surgery at Cambridge Health Alliance in Cambridge, MA. However automated the firing of a stapler may be, mistakes can result in serious complications.1

“The consequences of a failed anastomosis or a poor anastomosis can be substantial ... and if you make a mistake or you use a stapler that’s too big and tear the rectal wall, you may have a disastrous complication on your hands,” said Dr. Kercher.

To establish strong staple lines, the fundamental element is matching staple size to tissue thickness (Figure 1).2 The relationship between tissue thickness and staple size is linear, with thicker tissue requiring longer staple legs; however, other factors also play a role. One major variable is tissue compression—optimally compressed tissue improves healing and increases anastomotic strength.

“I think that the job of the trainee is to try to have an appreciation for the differences [in staplers] and be on the lookout for clinical outcomes.”

—Steven Schwaitzberg, MD

The gap between the anvil jaw and staple cartridge jaw is where tissue compression takes place, so understanding this aspect is vital to the principles of compression. When tissue is adequately compressed, it ensures that excess tensile stress is not produced, allowing all fluids to leave the area and lowering the risk for edema and bleeding. Proper tissue compression also brings the anvil jaw closer to the staple cartridge, causing tighter staple formation and better compression as the knife blade moves forward.

Figure 1. Diagram of the stomach showing tissue thickness measured on excised gastric specimens of obese patients.

Figure 2. Echelon Flex™ Endoscopic Stapler.

Adapted from reference 2.

Image courtesy of Ethicon Endo-Surgery.

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2011 • VOL. 1, ISSUE 2

IN TECHNOLOGY Optimal pressure/compression produces good hemostasis and a strong anastomosis. Insufficient compression— that is, firing the stapler too quickly—leads to poor hemostasis and a weak anastomosis, whereas overcompression leads to tissue damage.

In thin tissue, the anvil jaw is already close to the staple cartridge, so no compression may be required for optimal staple lines. With thick tissue, good technique requires constant pressure delivered through the stapler over an adequate amount of time, usually several seconds.3 For the thickest tissue areas, such as those in the abdominal wall, staple-line efficacy is best when the stapler is held/compressed for at least 15 seconds before firing.3 Compression can significantly change tissue thickness, which affects cartridge selection.4 Excessive force is not required for any type of stapler or tissue thickness, so accurate staple selection, proper stapler positioning, and appropriate compression are imperative to staple-line integrity. “If you’re using a staple that is relatively short [compared with the tissue thickness] and you don’t compress the tissue, the arms of the staples are not going to make their way through the tissue, and you potentially have an anastomosis that’s going to fail,� said Dr. Kercher Whereas early leaks typically result from weak staple lines that cannot withstand high pressure in the early postoperative period, later leaks usually are the result of ischemic tissue.5 “When creating staple lines, surgeons should be mindful of preserving blood supply along the staple line,� said Larry Sasaki, MD, clinical assistant professor of surgery at Louisiana State University School of Medicine at Shreveport.

Whenever possible, staple lines should join at large angles, avoiding smaller angles of 30 to 35 that may create triangles of tissue without adequate blood supply, added Dr. Sasaki.

Residents and fellows can go a long way toward eliminating staple-line leaks simply by learning which stapler is best suited for each particular operation. And unlike older staplers, the latest generation of devices includes multiple staple sizes (Figure 2).

However, with the broad range of staplers available, most of which are uniformly reliable, the decision of which to use is a personal one. “I think that the job of the trainee is to try to have an appreciation for the differences and be clinically on the lookout for the outcomes,� said Dr. Schwaitzberg.

2.

Elariny H, GonzĂĄlez H, Wang B. Tissue thickness of human stomach measured on excised gastric specimens from obese patients. Surg Technol Int. 2005;14:119-124.

3. Baker RS, Foote J, Kemmeter P. The science of stapling and leaks. Obesity Surg. 2004;14(10):1290-1298.

4. McGuire J, Wright IC, Leverment JN. An in vitro assessment of tissue compression damage during circular stapler approximation tests, measuring expulsion of intracellular fluid and force. Proc Inst Mech Eng H. 2001;215(6):589-597.

5. Ho Y-H, Ashour MA. Techniques for colorectal anastomosis. World J Gastroenterol. 2010;16(13):1610-1621.

Editorial Board Frederick Greene, MD Chairman, Department of Surgery Carolinas Medical Center Clinical Professor of Surgery University of North Carolina at Chapel Hill School of Medicine Chapel Hill, NC William B. Inabnet, MD Chief, Division of Metabolic, Endocrine and Minimally Invasive Surgery Director of Surgical Sciences, Metabolism Institute Mount Sinai Medical Center New York, NY Adrian Park, MD Campbell and Jeanette Plugge Professor Vice Chair, Department of Surgery Head, Division of General Surgery University of Maryland Medical Center Baltimore, MD J. Scott Roth, MD Associate Professor of Surgery Commonwealth Professor of Minimally Invasive Surgery Chief of Gastrointestinal Surgery and Director of Minimally Invasive Surgery University of Kentucky, College of Medicine Lexington, KY Copyright Š 2011

Publisher of

1CAB=; ;327/ 545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of reproduction, in whole or in part, in any form. February 2011.

Supported by

References 1.

Yo LS, Consten EC, Quarles van Ufford HM, Gooszen HG, Gagner M. Buttressing of the staple line in gastrointestinal anastomoses: overview of new technology designed to reduce perioperative complications. Dig Surg.

2006;23(5-6):283-291.

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IN TECHNOLOGY

TELEMENTORING continued from page 1

Telestration has allowed proctors to diagram surgical steps and point to potential pitfalls in real time, allowing procedures to be learned in a safer way, said David Kronbach, MD, head of minimally invasive gynecology at Kaiser Permanente Aurora Centrepoint in Colorado. “In addition to [a proctor’s] verbal description, they’re able to do a rendition of what they’re directing us to do, a capacity that enhances the experience and the safety,” he said.

Telementoring grew rapidly with surgeons routinely videoconferencing and proctoring operations in places like Singapore or rural Ecuador, originating from central locations in the United States.1,2 Following these advances, the Society of American Gastrointestinal and Endoscopic Surgeons published guidelines on the surgical practice of telemedicine in 2004.3 Although the guidelines emphasized that teleconferencing is not an acceptable substitute for the on-site preceptorship of residents, telemedicine remains a highly efficient way to share information.

“We have used our telesurgery unit on a 1-on-1 basis to mentor people from afar when they are doing a procedure that is still new to them, or I’ve brought a surgeon into the operating room via the telemonitoring suite to watch us and make suggestions, and that’s worked out very well,” said Dr. Glick.

Recently, the use of personal digital assistants (PDAs) and smartphone applications has exploded in ORs and surgical training programs across the country.

The most commonly used applications are those for prescribing medications, referencing diseases, and working up diagnoses, added Dr. Kronbach. Less commonly, physicians use smartphone applications to find Advanced Cardiovascular Life Support treatment algorithms or to interpret electrocardiograms. “I actually use them for teaching,” said Dr. Kronbach. “I have a number of demonstration videos of my own surgeries on my iPhone that I have the residents watch prior to going into a case so they can be as well prepared as possible.”

Surgeons at Henry Ford Hospital in Detroit have gone one step further and conducted a study examining BlackBerry-based telementoring. The surgeons sent laprascopic cholecystectomy video segments taken on their BlackBerry devices to surgeons in Ontario who undertook a validation survey to assess the videos for usability. The video images were reviewed and the quality was deemed adequate for telementoring.4 Although high-definition smartphone video is a novel ability, cell phones and PDAs have changed daily practice in much more fundamental ways. “We’ve almost done away with beepers. We run our service with texting,” said

Dr. Glick. “When I’m making rounds with the fellows, management changes go out in real time, and I think that’s a huge benefit to patients.”

Dr. Glick, who co-chaired a session on social networking at the American College of Surgeons (ACS) annual congress in October, also uses social networking technologies like Facebook and Twitter as teaching tools.

“Originally, when things like Facebook and Twitter came out, they were perceived as ways to waste your time or gratuitous invasions into your privacy.

But the thing we try to point out is, if you’re a mentee or mentor and you have something to share with your colleagues or mentees, social networking allows you to scale this up tremendously,” said Dr. Glick.

For example, what begins as an informal case discussion with fellows via e-mail may eventually become dispersed into online discussions through Facebook or Twitter, and then broadcast to 1,000 pediatric surgeons nationwide.

Dr. Glick believes that social networking approaches to problem solving and education in this manner may eventually become the norm. “I predict that we are going to see more and more surgeons adopting this because of time constraints and the ease with which applications for smartphones allow you to do tasks,” he said.

Specifically, Dr. Glick points to an informal 2010 survey by the ACS that asked members about their smartphone and social networking habits. “The interesting thing was that 80% of surgeons have smartphones, which is an amazing number when you compare it with the public, which is only about 35%. So the infrastructure is there for telementoring, distance learning, and social networking to go on,” he said.

References 1.

Rosser JC Jr, Bell RL, Harnett B, Rodas E, Murayama M, Merrell R. Use of mobile low-bandwidth telemedical techniques for extreme telemedicine applications. J Am Coll Surg. 1999;189(4):397-404.

2.

Cheah WK, Lee B, Lenzi JE, Goh PM. Telesurgical laparoscopic cholecystectomy between two countries. Surg Endosc. 2000;14(11):1085.

3. Guidelines for the surgical practice of telemedicine. Society of American Gastrointestinal Endoscopic Surgeons. Surg Endosc. 2000;14(10):975-979.

4. Parker A, Rubinfeld I, Azuh O, et al. What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution. Am J Surg. 2010;199(3):336-340.

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2011 • VOL. 1, ISSUE 2

IN PRACTICE

Day 1 as an Attending Surgeon: What Now? A fter years of training, a busy orientation, and a dizzying number of introductions, Lourdes Castanon, MD, did not wait long after July 2010 for her first case as a newly minted trauma surgery attending. It came on her second day on the job and her first overnight, at 3 AM—a stab wound to the heart.

“You go over the case in your head a thousand times and there’s a thousand ways you could proceed,” said Dr. Castanon, who remained organized in the chaos, led her team, and saved her patient from the very long kitchen knife that penetrated his chest. “It’s very exciting but very scary at the same time, because you are transitioning from being a resident or fellow to being a person in charge, the one with the last word.”

As a resident or fellow, there is always somebody who will come to the rescue, but this is not the case as an attending, said Dr. Castanon, who completed her residency at Brookdale University Hospital and Medical Center in Brooklyn, NY, a critical care and burn fellowship at the University of Texas in Galveston, and an acute care and trauma fellowship at Yale-New Haven Hospital in New Haven, CT. As 1 of 5 attendings at Hartford Hospital in Connecticut, her partners may have been at the hospital, but they were not with her on her first case.

Newly graduated residents and fellows can take steps to overcome underlying anxiety, be successful, and build a strong foundation. Much of it, experienced surgeons say, lies in preparing themselves carefully in how to approach different cases, seeking out help when necessary, and being friendly to colleagues, staff, and patients.

Trepidation when doing something for the first time as an attending is natural, said Mary E. Klingensmith, MD, chair of the Graduate Surgical Education Committee of the Association for Surgical Education. A cross-sectional survey of general surgery residents showed that many felt anxiety, expressing fears about not performing well independently after training and about hurting patients.1 “Remember you are well trained,” said Dr. Klingensmith, who also is professor and program director in surgery at Washington University School of Medicine in Saint Louis.

“Use that confidence wisely—but do use it.”

Dr. Klingensmith suggested that those nearing graduation keep a “how-to guide” of some essential operative steps for procedures they will commonly perform as attendings. “I found that writing down some essentials for how some of my attendings did things, in my own language and terms, was very helpful. Little things are good to record in writing and include simple drawings.”

Alan M. Yahanda, MD, FACS, a surgical oncologist with Indiana Surgical Specialists in Fort Wayne, agreed: Graduating residents or fellows should take careful note of

how their supervising attending plans an operation. “See how the attending sets it up, how they get exposure, and take note of the steps of the operation. That is something that you’ll have to know how to do right away.”

When struggling with a particularly difficult procedure, Dr. Klingensmith advised that new attendings divide the operation into smaller parts. “First, do what is easy … break it down into manageable steps and keep moving,” she said.

“Before you know it, you will have made progress.”

Additionally, new attendings should not shy away from asking for help from previous mentors or new partners.

“Remember that ‘once a mentor, always a mentor,’” Dr. Klingensmith said. “Many attendings who trained you will be delighted to have you call them for management advice when you are facing difficult or challenging cases.”

“I think a lot of residents coming out will think it’s a sign of failure if they ask for help,” Dr. Yahanda said. “But, I think that the exact opposite is the case.”

Success as a new attending reaches beyond individual cases, however. Building a solid reputation among fellow attendings and staff will be paramount to any burgeoning career. Both Drs. Klingensmith and Yahanda stressed the importance of what is known as the “3 A’s,” which encourages new attendings to be available, able, and affable. “It’s not just idle talk. It’s very important,” said Dr. Yahanda, who has been in practice for nearly 20 years.

Complementary to the 3 A’s, said Dr. Yahanda, is to be courteous and respectful to all of the staff, especially the operating room (OR) staff. “There’s nothing that will trash your reputation faster than being disrespectful to the OR staff or having a temper tantrum in the OR,” he said. “The talk of that behavior will spread like wildfire.”

Treating fellow staff well includes listening to their suggestions and input, especially as a young, new attending who may be working with an older, more experienced staff.

“Most of the OR staff, and especially the night staff, are not hesitant to give you suggestions. They’ve seen a lot of stuff at night. It doesn’t necessarily mean you have to follow them, but at least consider them,” Dr. Yahanda said.

Last but undoubtedly not least in making sure to flourish in a new workplace is how new attendings work with patients—both in and out of the OR. It is important that surgeons be physically gentle while positioning them and performing the actual operation, and to speak about them with respect while they are under anesthesia. “Treat the tissues well and treat the patient well,” Dr. Yahanda said.

References 1.

Yeo H, Viola K, Berg D, et al. Attitudes, training experiences, and professional expectations of US general surgery residents: a national survey.

JAMA. 2009;302(12):1301-1308.

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Avoid Fumbled Handoffs, Achieve Continuity Table 1. Patient Handoff Tips M

any years ago, patients admitted to the hospital enjoyed the services and care of the same physicianin-training from broken fibula diagnosis to receiving their first pair of crutches and hobbling out of the building.

Medical residents used to actually live their moniker, literally residing in the hospital during training and putting in more than 100-hour workweeks.

After the Accreditation Council for Graduate Medical Education passed a mandatory work-hour restriction in 2003 limiting residents to no more than 80 hours per week,1 the continuum of care faced an inevitable shift.

“The rules of engagement are different, and our teaching practices must be revised so [residents’] education needs are met despite the shorter hours,” said Jonathan Fryer, MD, associate professor of surgery and attending physician, Northwestern Memorial Hospital in Chicago.

Medical education institutions are adapting and searching for effective techniques to ensure the smallest margin for error. These tactics range from face-to-face meetings between physicians during shift changes, to team patient care models adapted from Formula One racing pit crews focused on leadership, task allocation, rhythm, standard processes, and effective communication.2 “With less residents available, patients staying in a hospital for 5 consecutive days may now see up to 15 different changes in their health care team,” said Hilary Sanfey, MB, BCh, FACS, professor of medicine and vice chair for educational affairs at Southern Illinois University in Springfield. Seeking to create an educational tool to train surgical residents while promoting continuity of care, Dr. Sanfey and colleagues at the University of Virginia instituted the morning report (MR).3 Anecdotal reports show MR has helped residents improve their knowledge, leadership, presentation, and problem-solving skills.

In addition, several handoff mnemonics have been studied for their efficacy across the health care spectrum. One particular mnemonic that focuses on communication practices between transitioning providers is the SBAR (Situation, Background, Assessment, and Recommendation) method.4 This handoff tool was first implemented by nurses and now has been adapted for use across the health care provider spectrum. The SBAR strategy requires communication during handoffs to touch on its 4 components: a discussion of the patient’s current situation; relevant background information; an assessment of the patient’s current condition; and a recommendation about future therapeutic steps.4 In 2009, the Joint Commission added the implementation of standardized handoff communications to its list of national patient safety goals. The goals included performance elements for patient handoffs (Table 1).5

Engage in face-to-face meeting with physician Incoming physician should ask pertinent question (eg, history of substance abuse, clinical suspicions) If no EMR exists, create a list of all medications, labs, etc.

Minimize distractions and interruptions during handoffs Adopt 2-way read-back system: outgoing physician reads off patient info, incoming physician repeats aloud Don’t be afraid to speak with other members of care team Discuss potential immediate risks to the patient EMR, electronic medical record Adapted from reference 5.

Current technology also has helped to promote continuity of care. Electronic medical records (EMRs) allow physicians to avoid the cumbersome recopying tasks before beginning shifts, such as noting laboratory values, drug allergies, or patient vital signs. These time-efficiency improvements for physicians afford them more time to discuss patient intricacies during handoffs.

Erik Van Eaton, MD, assistant professor of surgery and assistant director for surgical critical care, University of Washington in Seattle, noted that his institution has developed an electronic patient signout program that combines the stock patient data usually found in an EMR with more sophisticated features. The program, called the University of Washington Computerized Rounding and Sign-Out System (UWCores), offers physicians a centralized, printable patient list sortable by location, the ability to share any resident-entered information among caregivers, and a “notes” area for questions and assumptions outside of the more formal medical record.

After implementing UWCores at 2 hospitals, Dr. Van Eaton found that it led to improvements in the number of patients missed during resident rounds, increased the time spent at a patient’s bedside, decreased the time spent recopying data by hand, and improved residentreported rates of the quality of their signouts and overall continuity of care.6 But he cautions that currently there is no well-validated literature that shows one system is inherently better than another.

“We realize now that there’s no ‘one-size-fits-all’ strategy for patient handoffs; it’s probably the most complicated thing we do in all of medicine,” said Dr. Van Eaton. “The best system currently is the one you find for yourself.”

To help foster an atmosphere where residents can

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2011 • VOL. 1, ISSUE 2

IN THE OR

GASTRIC SURGERY continued from page 1

of banding is doing the adjustments to get the right level of restriction,” said Collin Brathwaite, MD, chief of minimally invasive surgery and director of the bariatric surgery program at Winthrop University Hospital in Mineola, NY. While band adjustments are critical, single-institution studies have proven oven that there is wide variation in weight ht loss among banding patients, even n under the same surgical protocol.1 “When you look at bariatric surrgery across the board, 80% is mental and 20% is the surgery; the band is not some magical way y to automatically lose weight,” said Dr. Brathwaite.

Put another way, “weight-loss loss surgery, including banding, is just behavior modification with surgical reinforcement,” said Dr. Leslie.

Consequently, success in follow-up begins well before surgery. “The way to set up success for a band patient is to set up realistic expectations before surgery, to have them understand what exactly the intention is, and what exactly the band is going to do for them,” Dr. Leslie said.

There are ways to assess whether a patient is committed at this high level. Dr. Leslie has patients lose weight before the operation; Dr. Brathwaite looks closely at the patient’s history of weight loss with dieting or whether they quit smoking. If they’ve been able to modify habits previously, it’s likely they’ll be motivated to modify them again.

However, studies have shown that patients’ “readiness to change” does not always accurately predict weight

“Weight-loss surgery, including banding, is just behavior modification with surgical reinforcement.”

—Daniel Leslie, MD

loss or follow-up compliance, although compliance with a follow-up program is associplia ated with better weight-loss outcomes.2 ate Currently, there is no firmly established protocol for follow-up. “What most providers e have been doing comes out of their own practice experience and the advice of experts prac from large banding centers,” Dr. Leslie said.

Dr. Dr Leslie utilizes a 3-part questionnaire to guide guid a patient’s follow-up care, called the “VEW” form.3 “The entire goal of using the “VE VEW [form] is to provide straightforward V tools for guiding adjustment decisions to t improve consistency of weight loss, lower band adjustment-related complication rates, and reduce costs associated with band adjustment,” Dr. Leslie explained.

The “V” portion of the form includes questions on vomiting and regurgitation, which indicate whether a patient is eating too much or too fast, or if the band is too tight; “E” outlines a patient’s eating habits and postoperative diet; and “W” assesses weekly weight loss. Additional questions on the form assist the surgical team in making a decision regarding band adjustments.

There are currently no studies validating the VEW model for gastric band follow-up, but Dr. Leslie added that a prospective validation study will be initiated in the future. see GASTRIC SURGERY, page 8

IN PRACTICE adapt their own methods, the University of Washington allots protected time for patient signouts on some rotations by planning their residents’ shifts with 3-hour overlaps to allow time for discussions. “We also ask residents to focus on their hunches/suspicions and discuss a patient’s nuances rather than repeating data already in the computer—speculation is important info,” said Dr. Van Eaton.

References 1.

Dimitris KD, Taylor BC, Frankhauser RA. Resident work-week regulations: historical review and modern perspectives. J Surg Educ. 2008;65(4):290-296.

2.

Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17(5):470-478.

3. Sanfey H, Stiles B, Sawyer RG. Morning report: combining education with patient handover. Surgeon. 2008;6(2):94-100.

4. Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-175.

5.

The Joint Commission Accreditation Program: Hospital. National Patient Safety Goals. www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E9BE8-F05BD1CB0AA8/0/HAP_NPSG.pdf. Accessed January 16, 2011.

6. Van Eaton EG, Horvath KD, Lober WD, Rossini AJ, Pellegrini CA. A Randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg. 2005;200(4):538-545.

How does your institution handle patient handoffs?

Please share your experience and take our online poll at www.intrainingsurgery.com.

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GASTRIC SURGERY continued from page 7

Despite the lack of protocols, there are consensus guidelines endorsed by multidisciplinary societies for postoperative care, including the recommendation to see adjustable gastric band patients monthly for at least the first 6 months postoperatively.4 Other resources for patient aftercare can be found on the websites of adjustable gastric band manufacturers.

Ethicon Endo-Surgery has a website specifically for gastric band patients, including an “After Surgery” section that outlines recovery expectations, sample diets, and exercise plans. It is available at www.realize.com.

NL101

DSL#11-0030 / ENDO1134-VOL2

Optimal placement and filling of a band creates a sense of early satiety, while also allowing patients to eat appropriately textured solid, protein-rich foods.

“What you’re looking for when the patient comes in, No. 1, are they losing weight; No. 2, are they making healthy eating choices; and No. 3, are they getting exercise,” said Dr. Brathwaite.

For surgeons unsure about band pressure, there is an art to uncovering whether a band should be filled. The principle behind lower fill volumes is to reduce pressure within the band and achieve the right balance between restriction and diet.

According to Dr. Leslie, optimal placement and filling of a band creates a sense of early satiety, while also allowing patients to eat appropriately textured solid, protein-rich foods such as meat, poultry, beans, eggs, and fish. “These foods typically will allow better satiety control after gastric banding surgery,” said Dr. Leslie.

Intuitively, patients think the band should be tightened to restrict food intake, an instinct that may be reinforced on Internet chat forums or in discussions with relatives and friends who also have had gastric bands placed.

However, an overly tight band is counterproductive, because it leads to poor dietary choices that halt, and even reverse, weight loss.

“Recognition of the ‘too-tight band’ has been classically very challenging because patients will oftentimes come into the clinic and say, ‘I’m absolutely here for a fill today because I’m gaining weight and I’ve just got no satiety— I’m hungry all the time,’” said Dr. Leslie.

Surgeons themselves may feel pressured to acquiesce to patients, but they should resist.

“Maladaptive eating behavior occurs when the band becomes too tight and patients can only consume

crumbly foods or liquid calories, such as creamy soups or ice cream,” said Dr. Leslie. “These liquid forms of calorie may be much easier to eat because they don’t precipitate vomiting, but over time the patient develops a pattern of eating that doesn’t allow weight loss to occur.”

Instead, in cases where the band is already correctly filled, patients need to be reminded, firmly, that their own eating behaviors are the cause.

“The reality is a surgeon would get paid more to do an adjustment and the clinic time would be shorter. Then the patient thinks ‘Ah, it is not my own behaviors; it is still the band.’ And the surgeon has validated that,” said Dr. Leslie.

Patients also need to be provided with access to psychological and nutritional counseling in the form of support groups and access to clinical services.

Dr. Leslie has a “never say no rule” at his clinic, meaning that if a band patient wants to come into the clinic for any reason, they’re unconditionally offered an appointment.

Similarly, in addition to running 6 monthly support groups and postoperative counseling with dieticians, Dr. Brathwaite’s practice also offers a “back on track program” for patients who have relapsed. “There is always help; there is always someone they can lean on with respect to postoperative care,” he said.

References 1.

Nguyen NT, Slone JA, Nguyen XM, Hartman JS, Hoyt DB. A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs. Ann Surg. 2009;250(4):631-641.

2.

Dixon JB, Laurie CP, Anderson ML, Hayden MJ, Dixon ME, O’Brien PE. Motivation, readiness to change, and weight loss following adjustable gastric band surgery. Obesity. 2009;17(4):698-705.

3. Lap-band AP™ system. www.lapbandcentral.com/local/files/documentlibrary/AP_ART_OF_ADJUSTMENT_guide.pdf. Accessed January 11, 2011.

4. Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring). 2009;17(suppl 1):S1-S70, v.

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