First assistant impact on early morbidity and mortality in bariatric surgery

The future of bariatric surgery depends largely on how effectively residents and fellows are trained. The challenge is to assure patient safety during training. Our study compares the impact of first assistants on patient outcomes after Roux-en-Y gastric bypass and sleeve gastrectomy.

A retrospective review of primary, elective Roux-en-Y gastric bypass and sleeve gastrectomy procedures performed in 2015 and 2016 from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant user files was performed. Patient cohorts were categorized by the level of training of the surgical first assistant (FA). Multivariate regression models were developed to determine the impact of the FA level on patient outcomes, adjusting for patient demographic characteristics and co-morbid conditions.

Compared with an attending weight loss surgeon as FA, minimally invasive surgery fellows and general surgery residents were more likely to have an unplanned admission to the intensive care unit (ICU) within 30 days (odds ratio [OR] 1.422, 95% confidence interval [CI] 1.196-1.691; OR 1.206, 95% CI 1.034-1.406, respectively, P < .0001) and were more likely to have a 30-day hospital readmission (OR 1.143, 95% CI 1.056-1.236; OR 1.127, 95% CI 1.055-1.204, respectively, P < .0001). Compared with having a weight loss surgeon as FA, operative duration was significantly longer for all other assistant levels, or no assistant (P < .0001).

The training level of the FA does not impact early patient mortality or reoperation rates after Roux-en-Y gastric bypass or sleeve gastrectomy. However, unplanned intensive care unit admissions and readmissions within 30 days were significantly associated with surgical resident or minimally invasive surgery fellow FAs. Further analysis is needed to understand this cause and effect; however, these data provide direction to redesign residency and fellowship training.