LAPAROSCOPIC SLEEVE GASTRECTOMY LACKS INTRA AND INTER SURGEON AGREEMENT IN TECHNICAL KEY-POINTS THAT MAY AFFECT GASTROESOPHAGEAL REFLUX DISEASE AFTER THE PROCEDURE
Rafael C. Katayama*1, Fernando A. Herbella1, Carlos H. Arasaki1, Ana C. de Grande1, Marco G. Patti2
1surgery, Universidade Federal de Sao Paulo, Sao Paulo, São Paulo, Brazil; 2University of Virginia, Charlottesville, VA
Background: Sleeve gastrectomy is currently the most performed bariatric technique in several countries. The main drawback of this operation is probably postoperative gastroesophageal reflux disease (GERD). The GERD incidence may be related to technical points leading to disruption of natural antireflux mechanism or creating points of pressurization of the gastric tube. There is no standardization of technique what may explain differences of GERD incidence among distinct groups. However, it is not uncommon to find a variable range of GERD within the experience of the same surgeon. This may lead to the assumption that two gastric tubes may not be born the same even though performed by the same surgeon. The main goal of this study is to evaluate the agreement of technical key-points based on auto and heteroevaluation.
Methods: Ten experienced (> 30 sleeve gastrectomy/year) surgeons (9 males, mean age 55years) were invited to participate in the study. Individuals were asked to send an unedited video with a typical laparoscopic sleeve gastrectomy performed by them. The videos were cropped into small clips comprising 11 key-points of the technique. All anonymized clips (including their own) were returned to all surgeons. Individuals were asked to agree or not with the technique demonstrated. We followed the Delphi process for consensus evaluation. After the round in which all surgeons declared their agreement or not with the technique (first round), the percentage of investigators that agreed was presented to the entire group and they were asked for a second vote (second round). Cronbach Alpha test was used for internal consistency. Inter-rater Reliability (IRR) was calculated to assess inter-observer agreement.
Results: Table 1 shows the agreement rate among surgeons. During first round, agreement was poor/fair for all points except hiatal repair that had a very good agreement. For second round, there was slight increase in agreement for distance esophagogastric junction / proximal stapling and gastric mobilization for stapling; and slight decrease in agreement for gastric tube final shape. Only 1 (10%) surgeon recognized that he evaluated his own video. Five (50%) of the surgeons disagreed with themselves in regards to 1 or more points: diaphragmatic crus dissection (n=2), distance pylorus / distal stapling (n=2), angle of His (n=1), distance esophagogastric junction / proximal stapling (n=1), and omental fixation (n=1).
Conclusions: Laparoscopic sleeve gastrectomy lacks intra and intersurgeon agreement in technical key-points that may affect gastroesophageal reflux disease after the procedure.
Table 1. Round of voting for agreement on technical key-points for sleeve gastrectomy (10 clips / 10 surgeons). Value of K strength of agreement: < 0.20 Poor; 0.21 - 0.40 Fair; 0.41 - 0.60 Moderate; 0.61 - 0.80 Good; 0.81 - 1.00 Very good
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