Does Fellow Participation in Laparoscopic Roux-en-Y Gastric Bypass Affect Peri-operative Outcomes?

Aditya Gupta, MBBS, Neil H Bhayani, MD MHS, Valerie J Halpin, MD. Legacy Weight Management Institute, The Oregon Clinic

Introduction: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is an advanced laparoscopic procedure, which requires specialized training most often gained during a fellowship. The learning curve is estimated between 50 and 100 cases. We hypothesized that the presence of fellows affects post-operative patient outcomes and this effect varies over the academic year.

Methods: The 2005-2009 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all LRYGB. Cases without any trainee (ATTENDING) were compared to cases including a trainee at or beyond their 6th year (FELLOW). The outcomes were post-operative pulmonary, infectious, wound, and venous thromboembolic (VTE) complications. Multivariable analysis controlled for age, body mass index (BMI), diabetes, pre-existing cardiac disease, and American Society of Anesthesiology (ASA) class.
Results: There were 18,333 LRYGB; 4,349 (24%) of these were FELLOW cases. The overall population was 80% female with a median age of 45 years and median BMI of 45.8 kg/m2. FELLOW cases had a statistically significantly higher BMI (46.1 v. 45.7, p<0.001) and lower proportion of patients with an ASA class ≥3. The unadjusted rates of mortality were 0.2% and 0.1%, and overall morbidity of 4.8% and 6.0% for ATTENDING and FELLOW groups, respectively. On adjusted analysis, there was no difference in mortality, but morbidity was 30% increased in FELLOW cases (95% Confidence Interval 1.1 – 1.5, p=0.001). This was due to an increased odds of superficial surgical site infections (SSIs) (OR 1.4, p=0.01), urinary tract infections (UTIs) (OR 1.7, p=0.002) and sepsis (OR 1.5, p=0.05). On subset analysis of the first six months, there was an increased morbidity associated with FELLOW cases. This derived from an increased risk of deep venous thrombosis (DVT) during the first quarter (OR 4.7, p=0.01) and SSIs (OR 1.5, P=0.001), UTIs (OR 1.8, p=0.004), and sepsis (OR 1.9, p=0.008) during the second quarter. By the 2nd half of the academic year, FELLOW cases carried morbidity no different than those of an attending alone.
Conclusions: The involvement of surgical fellows during LRYGB was associated with increased odds of DVTs, SSIs, UTIs, and sepsis, primarily in the first half of the academic year. By the second half of their training, cases involving fellows showed no overall increase in risk of complications compared to attending surgeons operating alone. Our study supports both the need for fellowship training in bariatric surgery to optimize outcomes, as well as the success of training programs in producing surgeons with appropriate results.