Are incentive spirometers useless?

Has this ever happened to you? You walk into a patient's room on postoperative day 1 and find the incentive spirometer still in its plastic wrap. And it's on a windowsill 10 feet from the patient's bed.

Here's another question. Does it matter?

A friend just had a 4-vessel CABG at a major academic center. Despite a lack of evidence that incentive spirometers are effective, he was told to use one in the hospital and to use it hourly at home which he has faithfully done.

That’s right. The effectiveness of incentive spirometry in postoperative cardiac and abdominal surgery patients has never been proven.

Three Cochrane Reviews (2007, 2012, 2014) have been done. In the 2014 review analyzing 12 studies with 1834 subjects who underwent abdominal surgery, the authors noted problems with study methodologies and lack of data on compliance with the use of spirometers. For preventing pulmonary complications, spirometry was not superior to deep breathing exercises or no respiratory intervention at all.

Should all surgeons have video assessments of their skills?

Last month, a superb study by the Michigan Bariatric Surgery Collaborative showed that the more skilled surgeons were, the better were their outcomes.

Surgeons submitted a video of their choice depicting their performance of a laparoscopic gastric bypass. Since it was self-selected, it was presumably their best work. At least 10 of their peers, blinded as to the name of the surgeon, rated skills on the video which had been edited to include only the key portions of the case.

Surgeons in the lowest quartile of ratings for surgical skill had significantly more postoperative complications, readmissions, reoperations, and deaths.

A New York Times article about the paper features a couple of short video clips—one from a not-so-skilled and one from a very skilled surgeon. The differences are obvious and dramatic.

According to the discussion section of the paper, the Michigan bariatric surgeons are now watching each other operate and will soon be receiving anonymous feedback about their technique from their peers.

It is not clear whether this will improve the skills of the lower-rated surgeons or have any effect on outcomes.

Many people rightfully praised the research. Some suggested that all surgeons should be scrutinized in this same fashion.

I agree that the study was well-done and shows that technically better surgeons have better outcomes.

But there are some problems with generalizing this to all surgeons.

The American Board of Surgery recently noted that there are almost 30,000 board-certified general surgeons in the US. This raises a number of logistical issues.

Let's say we focus on the most common major surgical procedure—laparoscopic cholecystectomy, 10 surgeon-raters would have to view at least 15 to 20 minutes of video for each of the 30,000 board-certified general surgeons. How long would that take? Who would collect and edit all the videos? Who would make sure that the ratings were consistent? Who would collate and distribute the results? How would follow-up be done? Who would pay for all of this?

And that is just for the board-certified general surgeons. What about the general surgeons who are not board-certified and all the other surgical specialists? Maybe gastroenterologists should have their endoscopy procedures scrutinized. Maybe primary care docs should have selected office visits recorded too.

This is similar to the enthusiasm which surrounded the concept of using retired surgeons to coach other surgeons. The idea was based on the experience of one surgeon, who had access to an expert coach and wrote about it. I blogged about the logistical difficulties that would preclude coaching from becoming widespread. To my knowledge in the two years since I wrote that post, coaching has not caught on as a performance improvement measure.

It's too bad, because in an ideal world, video evaluation of operative procedures and coaching would be great. Unfortunately, we don't live in an ideal world.

New weapons in the war against obesity

Just when you think you’ve seen everything, along comes the AspireAssist. This device, not yet FDA-approved, consists of a tube implanted in the stomach which leads to a port which is exposed on the surface of the abdomen.

Now, I’m not making this up.

You can eat whatever you want. Then 20 minutes after your meal, you attach a pump to the port and siphon and lavage the contents of your stomach into a bucket or basin, I guess. The manufacturer says that this will remove about a third of what is eaten leading to weight loss if done after every meal.

It doesn’t tell you how to gracefully dispose of the contents of the stomach, especially if you are dining at say, McDonald’s.

The only research on this product is in the form of a poster that was shown at a meeting of the Obesity Society in October of 2011. It was a randomized prospective trial of 11 patients who received the device plus “lifestyle intervention” compared to 7 patients who had only “lifestyle intervention.” It was funded by the maker of the device.

Ten subjects completed a year with the device vs. only 4 who stuck with the lifestyle intervention. Baseline characteristics were similar for the two groups. Percent weight loss and absolute weight loss were significantly greater in the device group. The average one-year weight loss was 20 kg.

However, 10/11 patients had pain more than 4 weeks after surgery and irritation and bleeding at the stoma occurred in about half the patients. Two had infections at the site. Constipation occurred in 6 patients and anemia in 4.

If you can stomach it, there is a video at the company’s website. Thankfully, it’s an animation.

Medgadget describes the concept as “high-tech bulimia.”

If that doesn’t appeal to you, how about something more simple?

Introducing the “smart fork.”

A flashing light and vibration tells you when you are eating too fast. It monitors how long it takes you to eat your meal. It has Bluetooth and USB connectivity so you can upload data to your phone or computer. Here’s an excessively overproduced video explaining it.

But wait, there’s more—it’s dishwasher safe, as a view from inside the dishwasher shows.

As far as I know, Ron Popeil has nothing to do with this product.

At least it looks a lot less messy than washing out your stomach through your abdominal wall.

I don’t think surgeons doing gastric bypasses have anything to worry about just yet.