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Publish Date: October 10, 2007   |  Tags:   News

Surgical Weight Loss
23-Hour Gastric Bypass the Shape of Things to Come?
Outpatient gastric bypass? Morbidly obese patients going home in 23 hours? What not long ago was pretty much unheard of may be the shape of things to come, says Todd McCarty, MD, medical director of the Weight Loss Surgery Program at Baylor University Medical Center.

Dr. McCarty, 41, and his colleagues have performed about 1,500 consecutive outpatient laparoscopic gastric bypass procedures (lap-RYGB), with an overall 23-hour discharge (overnight admission, home the next day) of about 75 percent. With optimal patient selection - age less than 60, BMI less than 60 and weight less than 400 pounds - Dr. McCarty says his successful 23-hour discharge rate is more than 90 percent.

He'll discuss his first 1,000 outpatient gastric bypass procedures at next month's 21st annual meeting of the American Society for Bariatric Surgery in San Diego. Dr. McCarty is quick to point out that while gastric bypass can be done on an outpatient basis, it shouldn't be done in a freestanding facility. "These patients are a challenging group with many associated medical problems," he says. "You need to do this surgery in a hospital. And it needs to be offered as part of a comprehensive bariatric services program."

Dr. McCarty is a pioneer in laparoscopic Roux-ex-Y gastric bypass. During the Roux-en-Y procedure, surgeons construct a small stomach pouch about the size of a plastic medicine cup and bypass a small segment of intestines by constructing a Y-shaped limb of small bowel. He can do "one of the most difficult laparoscopic procedures performed today" in an average of 45 minutes to 50 minutes. He says he started discharging lap-RYGB patients on the first post-op day after performing about 150 procedures, about the number of cases he says it takes for surgeons to become proficient in turning a major abdominal surgery into a minimally invasive one.

"As my operative times fell," says Dr. McCarty, "my complication rates decreased. [Outpatient gastric bypass] requires sufficient clinical experience to build subjective post-operative evaluations. You need a reproducible and predictable operative technique as well as an immediate post-operative clinical pathway."

The American Society for Bariatric Surgery (ASBS) estimates that 56 percent of the 103,200 bariatric surgeries performed in the United States last year were laparoscopic. "With morbid obesity is increasing at twice the rate of regular obesity, we're predicting that there will be more even more laparoscopic and less open procedures in 2004," says ASBS Executive Director Georgeann N. Mallory, RD, LD.

As morbid obesity becomes a health epidemic in this country, the benefits of outpatient gastric bypass are significant, says Dr. McCarty.

  • For the patient. There are short operative times, shorter hospital length of stay, less pain, improved mobility, decreased pulmonary complications, reduced wound infections and a faster return to normal activities and work.
  • For the surgeon. There are fewer complications, reduced post-operative workload, increased public exposure and increased patient volume.

- Dan O'Connor

Office Surgery Death
Florida Surgeon Disciplined
A doctor who gained national attention when his patient died after breast enlargement surgery committed gross malpractice, says an emergency order that restricts his license to surgical procedures involving only local or topical anesthesia administered by an anesthesiologist.

Kurt Dangl, MD, failed to adequately administer, monitor and record anesthesia given to Julie Rubenzer, 38, who received a "dazzling array of anesthetic agents" - 250mg of Demerol, 10mg of Valium, 5mg of Versed, 25mg of ketamine and a propofol intravenous drip. She never regained consciousness and died four months later of pneumonia and brain damage from lack of oxygen. The order says:

  • Dr. Dangl simultaneously administered anesthetic agents and performed surgery. No MDA or CRNA was present.
  • Dr. Dangl failed to properly monitor and support Ms. Rubenzer's respiration. After she went into respiratory failure, he twice refused to perform chest compressions for fear of damaging the implants.
  • Dr. Dangl is not a board-certified plastic surgeon and doesn't have hospital admitting privileges.

- Bill Meltzer

An ASC on Every Corner
Competition Forces Myrtle Beach Facility to Close
We always knew Myrtle Beach was an attractive destination spot for tourists. But who knew it was such a hot spot for surgery centers, too? There are about 200,000 year-round residents in Horry County and the greater Myrtle Beach area and, until last month, eight outpatient surgery centers. There are now seven.

South Strand Surgery Center's (1999-2004) decision to cease operations was a simple case of supply and demand: Too many surgery centers and not enough patients, says Joan Carroca, Grand Strand's marketing director. "A glut of day surgery centers have opened in the area, particularly physician-owned facilities, and our case volumes have taken a hit," says Ms. Carroca.

Although South Carolina is a certificate-of-need (CON) state, three new office-based facilities have opened since 2001, says Ms. Carroca. The reason: A physician's office and practice are not subject to CON requirements unless the physician purchases a piece of medical equipment that costs more than $600,000, according to Joel Grice, director of the South Carolina Bureau of Health Facilities.

"Physicians have an enormous competitive advantage," says Phil Clayton, chief executive officer of Conway Medical Center. "Basically, what's happened is the certificate of need laws have been so lax, they have allowed any physician-owned center to open in Myrtle Beach."

Mr. Grice says the current CON process works to balance availability of services and facilities with the potential for over-saturation. "According to our data, South Strand's utilization increased over the last four years, and they were still at functional capacity (defined as 1,000 to 1,200 cases per OR per year)," says Mr. Grice. "However, we do understand they faced increasing competition. The county has reached the saturation point, and we will not be approving any new centers in the county in the near future."

South Strand Surgery Center, a two-OR ASC, was a joint venture between Grand Strand Regional Medical Center and Conway Medical Center. The center also had an endoscopy suite and a pain management clinic. Records show its case volumes were on the rise, going from 1,072 cases in 2000 to 3,309 cases last year, according to Mr. Grice.

- Kristin Royer

Resources On the Web

The first clinical management guidelines to address the treatment of patients with severe sepsis are available for free download at writeOutLink("www.sccm.org/professional_resources/guidelines/table_of_contents",1). The guidelines, jointly developed by 10 sponsoring national and international medical organizations, including the Surgical Infection Society, include recommendations for antibiotic therapies, intraoptic therapy, DVT prophylaxis and pediatric patient considerations.

The Smarter Patient Campaign, sponsored by Ethicon Endo-Surgery, is a program designed to empower your patients to know what questions to ask before their surgery and to better understand issues such as their post-op pain management. You may download free patient education literature at writeOutLink("www.smarterpatient.com",1).

- BM

Accreditation
JCAHO Unveils Proposed 2005 National Patient Safety Goals
Refined OR- and medication-safety protocols highlight JCAHO's proposed 2005 national patient safety goals for the organization's hospital, ambulatory surgery and office surgery accreditation programs. JCAHO will approve its final 2005 National Patient Safety Goals in July. "We're planning substantial changes for 2005," says JCAHO spokesman Mark Forstneger. Some key proposals would require facilities to:

  • Develop a plan for implementing barcoding technology for identifying patients and matching patients to surgical medications. The plan would have to be operational no later than Jan. 1, 2007, and would apply to all facilities - ASCs, offices and hospitals.
  • Create a list of the look-alike and sound-alike drugs they use and develop a plan to prevent errors involving the interchange of these drugs.
  • Require staff to perform independent double checks when programming or reprogramming a patient-controlled analgesia pump.
  • Reduce the risk of surgical fires, including developing and implementing a fire safety program, and testing all surgical team members on the protocol.
  • Reduce the risk of patient falls in the facility, including assessing the patient's medication regimen, implementing a fall-reduction program and taking precautions (such as alarms) for high-risk patients.

- BM

Office Surgery Safety
Study: Accredited Offices As Safe As Hospitals
Surgery performed in accredited office-based surgery facilities is no more dangerous than surgery performed in hospital surgery facilities, concludes a study documenting outcomes for more than 400,000 procedures performed in 621 accredited offices from 2001 through 2002.

The analysis was based on data collected by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Only about 1,300 of the estimated 50,000 office-based surgery practices in the United States are accredited. Currently, only 14 states have mandated accreditation of surgery centers.

AAAASF accreditation standards require all unanticipated issues to be reported, including complications, patient complaints and surgery cancellations. In all, 411,670 procedures were analyzed. Eight deaths were reported, occurring in one in 51,459 procedures (0.0019 percent). The overall fatality risk was comparable between accredited office surgery facilities and hospitals. Of the eight deaths reported in the study, six were related to pulmonary embolism.

- DO

Inside The Numbers

  • 16,200 Bariatric surgeries performed in the United States in 1992.
  • 25,800 Bariatric surgeries performed in the United States in 1998.
  • 103,200 Bariatric surgeries performed in the United States in 2003.
  • 75% Percentage of hospital nurses and pharmacists who consider IV conscious sedation agents (such as midazolam) to be high-alert medications.
  • 64% Percentage of hospital nurses and pharmacists whose facilities take high-alert medication precautions for conscious sedation agents.
  • 77% Percentage of hospital nurses and pharmacists who consider IV general anesthetic agents (such as propofol) and inhalational agents (such as sevoflurane) to be high-alert medications.
  • 58% Percentage of hospital nurses and pharmacists whose facilities take high-alert medication precautions for IV and inhaled general anesthetic agents.

Sources: American Society for Bariatric Surgery, Institute for Safe Medication Practices 2004 High Alert Medications Survey (n=364).

Fast Tracks\

Doubts About Virtual Colonoscopy
Virtual colonoscopy (VC) is less reliable than previously thought and not ready for widespread use as a tool for colon cancer screening, according to a study of 600 patients at nine major clinics published in the Journal of the American Medical Association. In the study, patients underwent VC first, then traditional colonoscopy in the same day. With VC, physicians pinpointed 55 percent of patients with at least one suspicious polyp at least 10mm in diameter; traditional colonoscopy boasted a 100-percent detection rate. For at least 6mm tumors, VC caught 39 percent, traditional colonoscopy 99 percent. Of the eight patients in the study diagnosed with cancer, VC missed two of them.

Traditional Hernia Surgery Tops Laparoscopic Technique
Traditional open mesh surgery is superior to laparoscopic inguinal hernia repair for most hernias, resulting in half as many recurrences and complications, reports a new study in the New England Journal of Medicine reports. "The study establishes open hernia repair for a first-time hernia as a good choice for most patients ... (that) should not be supplanted by laparoscopic surgery," says study chairman Dr. Leigh Neumayer, a staff surgeon at Salt Lake City Veterans Affairs Medical Center in Utah. Laparoscopic surgery might be as good or better than open mesh surgery for patients who've already had hernia repair surgery or who have hernias on two sides, notes Dr. Neumayer.

Seeking Greater Physician/Hospital Cooperation
The American Hospital Association (AHA) has formed a specialty hospital task force designed to help member hospitals deal with competition. One key focus area: helping community hospitals develop partnerships with their credentialed physicians before the physicians leave the hospital to start competing facilities. AHA spokesperson Alicia Mitchell says that the organization recognizes the importance of facilities' being proactive in learning and addressing physician concerns.

Errors, Errors Everywhere
A medication error analysis by MedMarx identified 131 different medications involved in the 645 error reports the researchers examined. The study underscores the vulnerability of the perioperative setting, says lead researcher Rodney Hicks, ARNP, MSN, MPA. Mr. Hicks notes that while errors can and do occur with all types of drugs, some, such as morphine or epinephrine, are more likely to result in devastating consequences when used in error.

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