American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass.

BACKGROUND: Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB). OBJECTIVE: This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU). METHODS: PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee. RESULTS: Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures. CONCLUSIONS: This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

A 5-year propensity-matched analysis of perioperative outcomes in patients with chronic kidney disease undergoing bariatric surgery.

BACKGROUND: Bariatric surgery can improve renal function in patients with comorbid chronic kidney disease (CKD) and obesity. Additionally, bariatric surgery can enhance outcomes following renal transplantation. The safety of bariatric surgery in patients with CKD has been debated in the literature. This study evaluates the frequency of perioperative complications associated with CKD. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried from 2015-2019. Patients were included if they had a vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) and were stratified based on CKD status. An unmatched and propensity-matched analysis was performed comparing 30-day perioperative outcomes between the groups. RESULTS: A total of 717,809 patients included in this study, 5817(0.8%) had CKD, of whom 2266(0.3%) were on dialysis. 74.3% of patients with CKD underwent VSG with 25.7% underwent RYGB. Comparing RYGB to VSG, patients who underwent RYGB had a higher rate of deep organ space infection (0.7%vs.0.1%,p = 0.021) and re-intervention (5.0% vs. 2.2%,p < 0.001). Within the VSG cohort, a matched analysis was performed for those with CKD and without CKD. The CKD cohort had higher risk of complications such as bleeding (2.1%vs. 0.9%,p < 0.001), readmission (9.3%vs.4.9%,p < 0.001), reoperation (2.7%vs.1.3%,p < 0.001), and need for reintervention (2.2%vs.1.3%,p < 0.001). Notably, patients with CKD also had a higher mortality (0.6%vs.0.2%,p = 0.003). No difference was seen between patients with renal insufficiency and patients on dialysis. CONCLUSION: VSG has been the operation of choice in patients with CKD. Our results showed it is the safer option for patients with CKD compared to RYGB. Although this patient population does have an increased risk of adverse perioperative events, dialysis didn't affect the outcome. Bariatric surgeons who operate on patients with CKD should be well informed and remain vigilant given the increased perioperative risk. The risk is still considerably low, and the potential benefit on renal function and improvement in candidacy for renal transplant outweigh the risk. They should be considered as surgical candidates.

Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database.

BACKGROUND: Vertical sleeve gastrectomy (VSG) has demonstrated to be safe; however, controversy remains on how to decrease major complications, particularly bleeding and leaks. There are variations in staple-line reinforcement techniques, including no reinforcement, oversewing, and buttressing. We sought to evaluate the effect of those methods on post-operative complications using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSAQIP) database. METHODS: The MBSAQIP was queried for patients who underwent VSG during 2015-2019. A propensity-matched analysis was performed between different staple-line reinforcement (SLR) methods, specifically No reinforcement (NR), Oversewing (OS), and Buttressing (BR). The primary outcome of interest was complications within 30 days. RESULTS: A total of 513,354 VSG cases were analyzed. The cohort was majority female (79.0%), with mean (SD) age of 44.2 ± 11.9 years and mean BMI of 45 ± 7.8 kg/m2. Frequency of SLR methods used was 54%BR, 25.6%NR, 10.8% BR + OS, and 9.8%OS. There were no differences in rate of leaks among SLR methods. Compared to NR, BR was associated with decreased rate of reoperations, overall bleeding, and major bleeding (p < 0.05) but prolonged operative time and length of stay (LOS) (p < 0.05). OS was associated with decreased overall bleeding (p < 0.05) but prolonged operative times and length of stay (p < 0.05) compared to NR. Compared to BR, OS was associated with increased operative times, LOS, and rates of post-operative ventilator use, pneumonia, and venous thrombosis (p < 0.05). Patients with bleeding were associated with lower rate of BR (56% vs 61%) and higher rate of NR (34% vs 28%) compared to patients with no bleeding. Bleeding was associated with a greater frequency of leaks (4.4% vs 0.3%), along with higher morbidity and mortality (p < 0.05). CONCLUSIONS: Of the reinforcement methods evaluated, BR and OS were both associated with decreased bleeding despite longer operative times. No method was found to significantly reduce incidence of leaks; however, bleeding was associated with increased incidence of leaks, morbidity, and mortality. The liberal use of SLR techniques is recommended for further optimization of patient outcomes after VSG.

A Sisyphean Task for Residents: Preparing Literature Reviews About Adverse Events Presented at Morbidity and Mortality Conferences.

OBJECTIVE: Surgery Morbidity and Mortality (M&M) presentations include a thorough literature review. This requires a significant amount of time expenditure frequently incompatible with the current surgical resident work hours. Additionally, literature reviews can be redundant for commonly encountered adverse events. The goal of this study was to explore (a) how surgery residents perform literature reviews, and (b) how repetitive presented adverse events are. DESIGN: A survey was sent out during the academic year 2019-2020. The Morbidity and Mortality repository for that academic year was indexed, and the proportion of adverse events having occurred more than once calculated. The amount of time spent on literature reviews, proportion of repetitive adverse events as well as degree of thoroughness of reviews was evaluated on a 1 to 5 Likert scale. SETTING: Tulane University General Surgery program, New Orleans, LA, USA. PARTICIPANTS: All clinically active residents. RESULTS: All residents, filled out the survey. Seventeen out of 29 (58.6%) residents reported dedicating approximately one hour performing literature reviews. Median studying time was 1 hour (interquartile range: 1-1.5 hours). Seventeen out of 29 (58.6%) residents employed 2 resources. The most common combination of resources was PubMed and Google (11/29, 37.9%). Most residents (21/29, 72.4%) believed that their thoroughness was at most average (≤3/5 on a Likert scale) and 27/29 (93.1%) believed that their literature review could have been more thorough. More than half of the adverse events presented were found to be redundant during that academic year. CONCLUSIONS: Time spent reviewing the literature does not allow for a thorough review, and a significant portion of adverse events presented are redundant. A central repository for literature reviews of adverse events would improve the quality of reviews and avoid duplicating efforts.

First report from the American Society of Metabolic and Bariatric Surgery closed-claims registry: prevalence, causes, and lessons learned from bariatric surgery medical malpractice claims.

BACKGROUND: Bariatric surgery has demonstrated sustained improvements in quality. Malpractice closed claims have been offered as a means of assessing quality. Few studies have investigated malpractice closed claims and opportunities for improvement in bariatric surgery. OBJECTIVES: To examine the prevalence and causes of malpractice claims with examination of prospects for quality improvement. SETTING: University hospital, United States; private practice. METHODS: Four national malpractice insurers participated in the closed-claims registry. Data regarding patients, staff, procedures, and hospital status were gathered from closed-claims files. Following data collection, a clinical summary of each closed claim was collected and later assessed by an expert panel on the basis of the following: contributing diagnosis and treatment events; whether complications were potentially preventable by the surgeon; the role of language, fatigue, distraction, workload, or teaching hospital/trainee supervision; communication concerns; and final care determination. RESULTS: A total of 175 closed claims were collected from index bariatric surgeries within the period from 2006-2014. Of these, 75.9% of surgeons were board certified and 43.3% of the hospitals were accredited for bariatric surgery. Most clinical complications after bariatric surgery that led to malpractice lawsuits were mortality (35.1%) and leaks (17.5%). While they were not the common cause for malpractice suits, bleeding (5.3%), retained foreign body (5.3%), and vascular injury (4.4%) occurred at higher rates than national averages. CONCLUSION: Prevalence of malpractice claims regarding bariatric surgery is low. Failure to diagnose, delay in treatment, postoperative care, and communication domain responses indicate future opportunities for improvement.

Elevation of Serum Copper in the New Orleans Bariatric Clinic Population: the Norm or Geographically Localized Findings?

INTRODUCTION: Circulating micronutrient levels of both serum copper and zinc have been studied to varying degrees in both the general public and patients having undergone bariatric surgery. According to the 2019 ASMBS clinical guidelines, copper supplementation is recommended for patients undergoing metabolic surgery, especially after Roux-en-Y gastric bypass and duodenal switch. Copper excess has not been previously reported to any significant degree in any population. OBJECTIVE: In this study, we investigate an elevated serum copper level in the pre-surgical intervention population of the Bariatric Center of the University Medical Center-New Orleans, a primary safety net hospital for the state of Louisiana. METHODS: Five hundred five consecutive patients from the bariatric surgery undergoing a workup for surgical intervention were assessed. Patients were included regardless of whether they proceeded to surgery. The study was conducted as a retrospective review of deidentified data that was collected as part of our routine workup for bariatric surgery. RESULTS: The study population of the clinic consisted of a mean BMI of approximately 50 kg/m2, with 91% of the population reporting female and 69% recording an African American race. It was discovered in this population that 26% of the patients had an elevated copper level of > 155 mcg/dl. Additional analysis was performed attempting to elucidate an environmental role in the elevation by qualitative analysis of patient's location of residence using reported home address. Additional variables were studied as well including serum zinc concentration, age, BMI, and race to address any correlative variables with our findings. CONCLUSION: This study identifies an elevated serum copper concentration in a pre-intervention underserved bariatric center population positively associated with BMI, female gender, and African American race. Additional studies will be necessary to see if these trends are also apparent in normal weight controls, or if weight loss influences copper levels. Pre-existing serum copper deficiencies may be more prevalent in the bariatric populations than previously believed. Increased serum copper in this population was positively associated with increased BMI, age, and female gender compared to that of the male group. Increased serum copper was also associated more closely with African American ethnicity compared to Caucasian patients.

Investigating the relationship between BMI across adulthood and late life brain pathologies.

BACKGROUND: In view of reported associations between high adiposity, particularly in midlife and late-life dementia risk, we aimed to determine associations between body mass index (BMI), and BMI changes across adulthood and brain structure and pathology at age 69-71 years. METHODS: Four hundred sixty-five dementia-free participants from Insight 46, a sub-study of the British 1946 birth cohort, who had cross-sectional T1/FLAIR volumetric MRI, and florbetapir amyloid-PET imaging at age 69-71 years, were included in analyses. We quantified white matter hyperintensity volume (WMHV) using T1 and FLAIR 3D-MRI; ß-amyloid (Aß) positivity/negativity using a SUVR approach; and whole brain (WBV) and hippocampal volumes (HV) using 3D T1-MRI. We investigated the influence of BMI, and BMI changes at and between 36, 43, 53, 60-64, 69 and 71 years, on late-life WMHV, Aß-status, WBV and mean HV. Analyses were repeated using overweight and obese status. RESULTS: At no time-point was BMI, change in BMI or overweight/obese status associated with WMHV or WBV at age 69-71 years. Decreasing BMI in the 1-2 years before imaging was associated with an increased odds of being ß-amyloid positive (OR 1.45, 95% confidence interval 1.09, 1.92). There were associations between being overweight and larger mean HV at ages 60-64 (ß = 0.073 ml, 95% CI 0.009, 0.137), 69 (ß = 0.076 ml, 95% CI 0.012, 0.140) and 71 years (ß = 0.101 ml, 95% CI 0.037, 0.165). A similar, albeit weaker, trend was seen with obese status. CONCLUSIONS: Using WMHV, ß-amyloid status and brain volumes as indicators of brain health, we do not find evidence to explain reported associations between midlife obesity and late-life dementia risk. Declining BMI in later life may reflect preclinical Alzheimer's disease.