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Fellowship experiences

Laparoscopic fellowship at the Cleveland Clinic, Ohio

The Bariatric and Metabolic Institute at the Cleveland Clinic, Ohio, USA is considered one of the leading bariatric surgery units in the world. Haris Khwaja was selected after competitive interview whilst a Fourth Year SpR for the one year Advanced Laparoscopy/Bariatric Fellowship commencing from July 1, 2009 to June 30, 2010. Here, he writes about his experiences.

Haris Khwaja (right) in theatre with Dr Philip Schauer, director of the Bariatric and Metabolic Institute, Cleveland Clinic

My unit was headed by Professor Philip R Schauer, a global leader in bariatric surgery and four attending surgeons: Drs Tomasz Rogula, Stacy Brethauer, Bipan Chand and Matthew Kroh.

The unit performs between 600–700 laparoscopic bariatric surgery cases per year and integral to its success is a dedicated multi-disciplinary team consisting of bariatric physicians, anaesthesists, dieticians, psychologists, endocrinologists and bariatric nursing staff.

Khwaja (left) with Dr Tomasz Rogula at the Fellows Graduation Dinner, June 19 2010

The majority of the surgical workload is focused on the laparoscopic Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG) and revisional bariatric surgery including the banded bypass. The uniqueness of the Fellowship was the high frequency of super-super morbidly obese patients (BMI >60) who underwent surgery (the highest had a BMI of 108), as well as the acuity of the patients in terms of significant cardiovascular, respiratory and liver problems.

These patients had often been turned down for bariatric surgery by other units in the United States and throughout the world. The unit is also at the forefront of clinical bariatric surgery research conducting the Laparoscopic Greater Curvature Plication (LGCP) trial and the Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) randomized study.

The latter is comparing the effectiveness of advanced medical therapy alone for Type 2 diabetes mellitus versus surgery (sleeve gastrectomy or gastric bypass) and medical therapy combined.

There are four fellows selected per year with two on the one year clinical fellowship track and two on the two year research/clinical track. The fellowship is divided into four three-month periods with each fellow starting on a different part of the track. My fellowship timetable is outlined in Table 1 below.

Time Period Workload Attending (Consultant) Experience
July 1 – Sept. 30, 2009 Minimally Invasive Surgery (2 full days/wk), Bariatric Surgery (2 full days/wk), Clinical Research (1 full day/wk) Dr. Philip Schauer, Dr. Tomasz Rogula, Dr. Steven Rosenblatt • Lap Roux-en-Y Gastric Bypass, • Lap Sleeve Gastrectomy, • Lap Splenectomy , • Single Incision Lap
Cholecystectomy, • Lap Incisional/ Inguinal Hernia, • Abstracts prepared & submitted to SAGES & ASMBS
Oct. 1 – Dec. 31, 2009 Bariatric Surgery (2 full days/wk), Bariatric Clinics (2 full days/wk) Dr. Philip Schauer, Dr. Tomasz Rogula • Lap Roux-en-Y Gastric Bypass, • Lap Sleeve Gastrectomy, • Lap/Open Revisional Bariatric Surgery
Jan. 4 – March 31, 2010 Bariatric Surgery (1 full day/wk), Minimally Invasive Surgery (1 full day/wk), Diagnostic/Therapeutic OGD (0.5 day/wk), Bariatric Clinic (0.5 day/wk) Dr. Stacy Brethauer, Dr. Matthew Kroh • Lap Roux-en-Y Gastric Bypass, • Lap Sleeve Gastrectomy, • Lap Gastric Band, • Revisional Bariatric Surgery, • Single Incision Lap Gastric Band, • Lap Gastric Pacemaker, • OGD/PEG Insertion, • Book Chapter written
April 1– June 30, 2010 Bariatric Surgery (2 full days/wk), Bariatric Clinics (2 full days/wk) Dr. Philip Schauer, Dr. Tomasz Rogula •Lap Roux-en-Y Gastric Bypass, •Lap Sleeve Gastrectomy, •Lap/Open Revisional Bariatric Surgery, •Lap Greater Curvature Plication, • Presentations at SAGES & ASMBS

Table 1: Timetable of Clinical Fellowship Track

The fellowship is demanding compared to most advanced laparoscopy/bariatric fellowships. There are no junior staff on the service: all ward rounds, electronic medical record documentation, admission/discharge paperwork and post-operative issues are undertaken by the fellow. The advantage, however, is that all the surgeries are done by the fellow.

Average work days were 16 hours/day with a 1:5 on-call for bariatric surgery from home. There are on average twice weekly surgery days with theatre from 07:15–18:00 and twice weekly bariatric clinics from 08:30–17:00.

In the one year fellowship, I performed 349 cases consisting of 602 surgical procedures. The main procedures are outlined in Table 2 (below).

Operation Supervisor Trainer Unscrubbed Supervisor Trainer Scrubbed Assisting
Lap Roux en Y Gastric Bypass 5 48 35
Lap Sleeve Gastrectomy 1 19 5
Lap Greater Curvature Plication - 2 4
Lap Revisional Bariatric Surgery - 2 15
Lap Total Gastrectomy - 2 3
Lap Splenectomy 4 4 1
Lap Nissen Fundoplication - 15 4
SILS/Lap Cholecystectomy - 9/37 3/2
OGD/PEG Insertion 123/12 - 1

Postgraduate teaching is facilitated by a weekly fellow’s presentation on a topic based on the American Society of Metabolic and Bariatric Surgery (ASMBS) Curriculum, monthly advanced laparoscopy national/international teleconferences, a monthly bariatric webinar (thorough the International Bariatric Club) and weekly hepatobiliary surgery meetings.

The fellowship allowed me to gain the necessary technical skills and case volume to overcome the learning curve of the various bariatric surgeries and be able to undertake these surgeries independently. It also set me up for my Final Year as a SpR at Chelsea & Westminster Hospital, London (a premier UK bariatric surgery centre), where I performed an additional 69 laparoscopic gastric bypasses, 23 sleeve gastrectomies and 45 adjustable gastric bands.

I would encourage any trainee with an interest in advanced laparoscopy/bariatric surgery to undertake a fellowship. The American fellowships do require planning ahead in terms of doing the necessary American USMLE exams in good time, attending interviews in America (I had 12 interviews but decided to attend two) and sorting out the visa requirements once a fellowship has been granted.

However the experience gained in working in a high-volume bariatric unit in terms of surgical training and pre/post-operative management of the morbid obese patient made it an extremely valuable year.