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Better Surgeons Get Better Results

sharma-obesity-bariatric-surgery21This one may not seem all that earth-shattering but according to a paper by John Birkmeyer and colleagues, published in the New England Journal of Medicine, better surgeons get better results.

the study involved 20 bariatric surgeons in Michigan, who each submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass, which was then rated by at least 10 of his colleagues (blinded of course) in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill).

This score (ranging between 2.6 and 4.8 across the 20 surgeons) was then compared to risk-adjusted complication rates, using data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients.

Surgeons rated by their peers as being in the bottom quartile of surgical skill had almost three times higher complication rates and almost five times higher mortality rates than those in the highest skill quartile (14.5% vs. 5.2% and 0.26% vs. 0.05%, respectively).

The lesser skilled surgeons also took longer (137 minutes vs. 98 minutes), their patients were twice as likely to be reoperated (3.4% vs. 1.6%, P=0.01) or readmitted.

This study highlights the wide variability in surgical skill (which can apparently can be judged by other surgeons by watching a single video of the surgeon at work) and the impact that this variation may have in terms of outcome.

Although, I am the first to note that the surgery itself is only one factor in successful outcomes with bariatric surgery, the least you can hope for, is to have the best surgeon perform the procedure.

Montreal, QC

ResearchBlogging.orgBirkmeyer JD, Finks JF, O’Reilly A, Oerline M, Carlin AM, Nunn AR, Dimick J, Banerjee M, Birkmeyer NJ, & the Michigan Bariatric Surgery Collaborative (2013). Surgical Skill and Complication Rates after Bariatric Surgery. The New England journal of medicine, 369 (15), 1434-1442 PMID: 24106936




  1. Wonderful article and so very true. It is easy for patients to forget that surgeons are humans too. They have different abilities and often different techniques in performing the surgery. The VSG for example, is not standardized and is performed quite differently by different surgeons based on their technical skill, overall philosophy, understanding of the current research and so many other factors. All of these differences when taken together make it almost impossible to rely on studies that are aimed at the efficacy of this surgery. Some surgeons make substantially larger sleeves than others, some operate in way that minimize the problem of reflux, others do not. Some have substantially higher rates of leaks and other complications. This does not even begin to address the issues of aftercare and follow-up. I often hear doctors derisively mention that some of the surgeons with lower complication rates have pre-selected their patients. That might very well be the case in some or even many practices, however, I am fortunate enough to know of one where the exact opposite is true. The surgeon is actually known within the medical community for taking cases others will not touch and yet maintaining complication rates that are far bellow the national average. Yes, the surgical technique matters, it matters a great deal. The aftercare also matters as does continued nutritional follow-up. As with everything else in life, it is not surprising that caveat emptor- buyer beware, is as true when choosing a surgeon as when choosing a car. Life is full of inequalities of choice and outcomes.

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  2. Dr Sharma,

    I think it is wrong for obese patients to be put “under the knife” before they have received competent instruction on nutrition matters. The great news is that losing weight can be easy. No-one needs to go hungry. There is no need for semi-starvation. Readers, here’s the centuries-old gold-standard “obesity-reversing, diabetes-reversing” diet (scroll down):

    And here’s an excellent piece by heavy-hitter Gary Taubes on why that “all you can eat” diet works. In the process, he explains how the western world’s negligent low-fat/high-carb dietary advice starting in the 1970s made the world fat and sick:

    The problem is that modern nutrition science has been barking up the wrong (low-fat/high-carb) tree for the past 30-40 years, having forgotten much of what was learned about diet and obesity over the previous couple of centuries. That’s why so many of us have become fat and sick. For most obese people, in my opinion, good nutrition advice would remove any need for surgery.

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  3. I live in Canada.
    How do I find out who is the best, or one of the best, surgeons?
    Is this information publicly available, or is it kept secret within medical circles?

    When I find out how surgeons in my area are rated, how do I get one of the better surgeons to do my surgery?
    When I have had other surgery, not bariatric surgery, I have had no choice in who operated on me. Same for friends undergoing surgery. We show up for an operation and we get whichever surgeon has been assigned to the case. There is no chance to consider who will be operating on us. (I dare say surgeons differ in ability in all surgery, not just bariatric surgery.)

    Is this the same in other countries – in the US, do patients get to choose their surgeon?

    If there is no option to choose a better surgeon, then it doesn’t matter if they’re “good” or not, or what the probable outcome is, you just have to go with the luck of the draw.
    And if poor surgeons get just as many operations as good surgeons, there is no incentive to improve.

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  4. Anonymous,

    Some things that you should ask any bariatric surgeon that you’re seeing (and that they should be very forthcoming with, no mumbles or sidestepping):

    1. What is your rate of DVT/PE, leak, or death within 90 days of surgery? Should be less than 1%
    2. What is your rate of readmission to the hospital within 30 days? Should be less than 5%
    3. What is your rate of reoperation within 30 days of surgery? Should be less than 5%, but not zero – that would mean the surgeon is doing nothing in the face of some concerning symptoms that should prompt a re-look.
    4. What is the average length of stay in the hospital? (should be less than 3 nights for most surgeons)
    5. What is the rate of stricture requiring intervention (for bypass or sleeve).
    6. What is the rate of infection of any kind? (should be less than 5%).

    These are very general numbers, and I’m sure some surgeons would complain that they’re too lax and others would complain that they’re too strict (“It isn’t fair, I can’t achieve that because XXX, the sun is in my eyes, the grass is too high, etc. etc.”) If they can’t answer these you have to ask yourself if they’re doing enough self-evaluation of outcomes (results). And if they’re being evasive, that’s a deal-breaker.

    Rory Robertson, I agree that the high-carb advice that started in the 60’s and 70’s (along with the low-fat advice) persists as an unfortunate legacy, and no doubt contributes to weight gain. I’m very familiar with Mr Taubes and Dr Attia’s work. Unfortunately, some patients (it sounds like you’re not one of them) can eat a high protein / high fat diet (or paleo diet or Atkins/South Beach or Weston Price or nutrition science institute or whatever you choose to call it) and they may stop the weight gain, but they typically do not lose 100+ extra pounds. If most people would simply stop the weight gain, though, and never progress to morbid obesity, that would be a real boon. But what works to help one person lose 100 lbs doesn’t always work for everyone. Thanks for your comments, though.

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