Metabolic Bariatric Surgery Across the IFSO Chapters: Key Insights on the Baseline Patient Demographics, Procedure Types, and Mortality from the Eighth IFSO Global Registry Report.

INTRODUCTION: The International Federation for Surgery for Obesity and Metabolic Disorders (IFSO) Global Registry aims to provide descriptive data about the caseload and penetrance of surgery for metabolic disease and obesity in member countries. The data presented in this report represent the key findings of the eighth report of the IFSO Global Registry. METHODS: All existing Metabolic and Bariatric Surgery (MBS) registries known to IFSO were invited to contribute to the eighth report. Aggregated data was provided by each MBS registry to the team at the Australia and New Zealand Bariatric Surgery Registry (ANZBSR) and was securely stored on a Redcap™ database housed at Monash University, Melbourne, Australia. Data was checked for completeness and analyzed by the IFSO Global Registry Committee. Prior to the finalization of the report, all graphs were circulated to contributors and to the global registry committee of IFSO to ensure data accuracy. RESULTS: Data was received from 24 national and 2 regional registries, providing information on 502,150 procedures. The most performed primary MBS procedure was sleeve gastrectomy, whereas the most performed revisional MBS procedure was Roux-en-Y gastric bypass. Asian countries reported people with lower BMI undergoing MBS along with higher rates of diabetes. Mortality was a rare event. CONCLUSION: Registries enable meaningful comparisons between countries on the demographics, characteristics, operation types and approaches, and trends in MBS procedures. Reported outcomes can be seen as flags of potential issues or relationships that could be studied in more detail in specific research studies.

SAGES consensus recommendations on surgical video data use, structure, and exploration (for research in artificial intelligence, clinical quality improvement, and surgical education).

BACKGROUND: Surgery generates a vast amount of data from each procedure. Particularly video data provides significant value for surgical research, clinical outcome assessment, quality control, and education. The data lifecycle is influenced by various factors, including data structure, acquisition, storage, and sharing; data use and exploration, and finally data governance, which encompasses all ethical and legal regulations associated with the data. There is a universal need among stakeholders in surgical data science to establish standardized frameworks that address all aspects of this lifecycle to ensure data quality and purpose. METHODS: Working groups were formed, among 48 representatives from academia and industry, including clinicians, computer scientists and industry representatives. These working groups focused on: Data Use, Data Structure, Data Exploration, and Data Governance. After working group and panel discussions, a modified Delphi process was conducted. RESULTS: The resulting Delphi consensus provides conceptualized and structured recommendations for each domain related to surgical video data. We identified the key stakeholders within the data lifecycle and formulated comprehensive, easily understandable, and widely applicable guidelines for data utilization. Standardization of data structure should encompass format and quality, data sources, documentation, metadata, and account for biases within the data. To foster scientific data exploration, datasets should reflect diversity and remain adaptable to future applications. Data governance must be transparent to all stakeholders, addressing legal and ethical considerations surrounding the data. CONCLUSION: This consensus presents essential recommendations around the generation of standardized and diverse surgical video databanks, accounting for multiple stakeholders involved in data generation and use throughout its lifecycle. Following the SAGES annotation framework, we lay the foundation for standardization of data use, structure, and exploration. A detailed exploration of requirements for adequate data governance will follow.

Residual Risk of Breast Cancer After Bariatric Surgery.

Importance: Excess adiposity confers higher risk of breast cancer for women. For women who have lost substantial weight, it is unclear whether previous obesity confers residual increased baseline risk of breast cancer compared with peers without obesity. Objectives: To determine whether there is a residual risk of breast cancer due to prior obesity among patients who undergo bariatric surgery. Design, Setting, and Participants: Retrospective matched cohort study of 69 260 women with index date between January 1, 2010, and December 31, 2016. Patients were followed up for 5 years after bariatric surgery or index date. Population-based clinical and administrative data from multiple databases in Ontario, Canada, were used to match a cohort of women who underwent bariatric surgery for obesity (baseline body mass index [BMI] ≥35 with comorbid conditions or BMI ≥40) to women without a history of bariatric surgery according to age and breast cancer screening history. Nonsurgical controls were divided into 4 BMI categories (<25, 25-29, 30-34, and ≥35). Data were analyzed on October 21, 2021. Exposures: Weight loss via bariatric surgery. Main Outcomes and Measures: Residual hazard of breast cancer after washout periods of 1, 2, and 5 years. Comparisons were made between the surgical and nonsurgical cohorts overall and within each of the BMI subgroups. Results: In total, 69 260 women were included in the analysis, with 13 852 women in each of the 5 study cohorts. The mean (SD) age was 45.1 (10.9) years. In the postsurgical cohort vs the overall nonsurgical cohort (n = 55 408), there was an increased hazard for incident breast cancer in the nonsurgical group after washout periods of 1 year (hazard ratio [HR], 1.40 [95% CI, 1.18-1.67]), 2 years (HR, 1.31 [95% CI, 1.12-1.53]), and 5 years (HR, 1.38 [95% CI, 1.21-1.58]). When the postsurgical cohort was compared with the nonsurgical cohort with BMI less than 25, the hazard of incident breast cancer was not significantly different regardless of the washout period, whereas there was a reduced hazard for incident breast cancer among postsurgical patients compared with nonsurgical patients in all high BMI categories (BMI ≥25). Conclusions and Relevance: Findings suggest that bariatric surgery was associated with a reduced risk of developing breast cancer for women with prior obesity equivalent to that of a woman with a BMI less than 25 and a lower risk when compared with all groups with BMI greater than or equal to 25.

The effect of bariatric surgery on opioid consumption in patients with obesity: a registry-based cohort study.

BACKGROUND: Misuse of opioid medication has become a major health crisis in several countries. A significant number of patients with obesity use opioid medications, mostly to alleviate symptoms due to obesity-related co-morbidities. OBJECTIVE: To compare patterns of opioid drug usage before and after bariatric surgery in this population, hypothesizing that weight loss and improvement of obesity-related co-morbidities could reduce opioid consumption. SETTING: The Ontario Bariatric Registry (Ontario, Canada). METHODS: In this retrospective cohort study, the Ontario Bariatric Registry was used to compare opioid consumption in adult patients undergoing bariatric surgery between 2010 and 2021. The primary outcome was the number of patients using opioid medication at 1 year after surgery. Multiple logistic regression analyses were performed to identify potential predictors of opioid consumption. RESULTS: Data of 11,179 patients were analyzed. Mean age was 45.7 ± 10.2 years, mean baseline body mass index was 48.9 ± 8 kg/m2, and 83.6% of patients were female. Roux-en-Y gastric bypass was performed in the majority of patients (85.6%), followed by sleeve gastrectomy (14.2%). At baseline, opioids were used by 7.7% and nonopioid pain medications by 42.3% of patients. At 1 year after surgery, these numbers significantly decreased (Δ-1.9% and Δ-18.0%, respectively). The decrease in the consumption of nonopioid pain medication needs to be interpreted in the context of the contraindication to nonsteroidal anti-inflammatory drugs after Roux-en-Y gastric bypass, which was the most commonly performed procedure. Presence of musculoskeletal pain and use of nonopioid pain medication at baseline were identified as independent predictors of opioid consumption at 1 year after surgery. CONCLUSIONS: At 1 year after bariatric surgery, a significant decrease in opioid and nonopioid pain medication consumption was seen among patients with obesity. Aggressive management of excess weight, especially with bariatric surgery, can potentially reduce the impact of the opioid crisis in this population.

SAGES video acquisition framework-analysis of available OR recording technologies by the SAGES AI task force.

BACKGROUND: Surgical video recording provides the opportunity to acquire intraoperative data that can subsequently be used for a variety of quality improvement, research, and educational applications. Various recording devices are available for standard operating room camera systems. Some allow for collateral data acquisition including activities of the OR staff, kinematic measurements (motion of surgical instruments), and recording of the endoscopic video streams. Additional analysis through computer vision (CV), which allows software to understand and perform predictive tasks on images, can allow for automatic phase segmentation, instrument tracking, and derivative performance-geared metrics. With this survey, we summarize available surgical video acquisition technologies and associated performance analysis platforms. METHODS: In an effort promoted by the SAGES Artificial Intelligence Task Force, we surveyed the available video recording technology companies. Of thirteen companies approached, nine were interviewed, each over an hour-long video conference. A standard set of 17 questions was administered. Questions spanned from data acquisition capacity, quality, and synchronization of video with other data, availability of analytic tools, privacy, and access. RESULTS: Most platforms (89%) store video in full-HD (1080p) resolution at a frame rate of 30 fps. Most (67%) of available platforms store data in a Cloud-based databank as opposed to institutional hard drives. CV powered analysis is featured in some platforms: phase segmentation in 44% platforms, out of body blurring or tool tracking in 33%, and suture time in 11%. Kinematic data are provided by 22% and perfusion imaging in one device. CONCLUSION: Video acquisition platforms on the market allow for in depth performance analysis through manual and automated review. Most of these devices will be integrated in upcoming robotic surgical platforms. Platform analytic supplementation, including CV, may allow for more refined performance analysis to surgeons and trainees. Most current AI features are related to phase segmentation, instrument tracking, and video blurring.

Association Between Obesity and Chronic Kidney Disease: Multivariable Mendelian Randomization Analysis and Observational Data From a Bariatric Surgery Cohort.

Obesity is postulated to independently increase chronic kidney disease (CKD), even after adjusting for type 2 diabetes (T2D) and hypertension. Dysglycemia below T2D thresholds, frequently seen with obesity, also increases CKD risk. Whether obesity increases CKD independent of dysglycemia and hypertension is unknown and likely influences the optimal weight loss (WL) needed to reduce CKD. T2D remission rates plateau with 20-25% WL after bariatric surgery (BS), but further WL increases normoglycemia and normotension. We undertook bidirectional inverse variance weighted Mendelian randomization (IVWMR) to investigate potential independent causal associations between increased BMI and estimated glomerular filtration rate (eGFR) in CKD (CKDeGFR) (<60 mL/min/1.73 m2) and microalbuminuria (MA). In 5,337 BS patients, we assessed whether WL influences >50% decline in eGFR (primary outcome) or CKD hospitalization (secondary outcome), using <20% WL as a comparator. IVWMR results suggest that increased BMI increases CKDeGFR (b = 0.13, P = 1.64 × 10-4; odds ratio [OR] 1.14 [95% CI 1.07, 1.23]) and MA (b = 0.25; P = 2.14 × 10-4; OR 1.29 [1.13, 1.48]). After adjusting for hypertension and fasting glucose, increased BMI did not significantly increase CKDeGFR (b = -0.02; P = 0.72; OR 0.98 [0.87, 1.1]) or MA (b = 0.19; P = 0.08; OR 1.21 [0.98, 1.51]). Post-BS WL significantly reduced the primary outcome with 30 to <40% WL (hazard ratio [HR] 0.53 [95% CI 0.32, 0.87]) but not 20 to <30% WL (HR 0.72 [0.44, 1.2]) and ≥40% WL (HR 0.73 [0.41, 1.30]). For CKD hospitalization, progressive reduction was seen with increased WL, which was significant for 30 to <40% WL (HR 0.37 [0.17, 0.82]) and ≥40% WL (HR 0.24 [0.07, 0.89]) but not 20 to <30% WL (HR 0.60 [0.29, 1.23]). The data suggest that obesity is likely not an independent cause of CKD. WL thresholds previously associated with normotension and normoglycemia, likely causal mediators, may reduce CKD after BS.

Clinical safety and efficacy of a fully automated robot for magnetic resonance imaging-guided breast biopsy.

BACKGROUND: Magnetic resonance imaging (MRI)-guided biopsies are an accurate, but technically challenging, method for screening and diagnosis of breast lesions. This study assesses the safety and efficacy of an Image Guided Automated Robot (IGAR) in performing breast biopsies compared to manual procedures. METHODS: Safety was determined from adverse events (AEs) and device deficiencies. Efficacy was assessed using targeting accuracy, number of successful biopsies, pain and scar scores, patient discomfort, and radiologist-determined ease-of-use. RESULTS: All seven procedures in phase I were successfully and safely completed with no AEs and one device deficiency. The 23 IGAR biopsies in phase II outperformed the 18 manual biopsies in 1-week pain scores (p = 0.027), scarring at 1-week (p = 0.035), 1-month (p = 0.004), and components of comfort and ease-of-use. Phase II had seven and three AEs in the IGAR and manual groups, respectively (p = 0.317), with no serious AEs and nine device deficiencies. CONCLUSIONS: The IGAR system is safe and effective for breast biopsy procedures. The results from these trials indicate the IGAR system as a potentially viable alternative to manual breast biopsy procedures.

Bariatric Center Designation and Outcomes Following Repeat Abdominal Surgery in Bariatric Patients.

INTRODUCTION: Repeat abdominal surgery in the bariatric surgery patient population may be challenging for non-bariatric-accredited institutions. The impact of regionalized bariatric care on clinical outcomes for bariatric surgery patients requiring repeat abdominal surgery is currently unknown. This study aims to investigate the association between bariatric center designation and clinical outcomes following hepatobiliary, hernia, and upper and lower gastrointestinal operations among patients with prior bariatric surgery. METHODS: This is a cohort study of a large sample of Ontario residents who underwent primary bariatric surgery between 2010 and 2017. A comprehensive list of eligible abdominal operations was captured using administrative data. The primary outcome was 30-d complications. Secondary outcomes included 30-d mortality, readmission, and length of stay. RESULTS: Among the 3301 study patients, 1305 (40%) received their first abdominal reoperation following bariatric surgery at a designated bariatric center. Nonbariatric center designation was not associated with significantly higher rates of 30-d complications (5.73% versus 5.72%), mortality (0.80% versus 0.77%), readmissions (1.11% versus 1.85%), or median postoperative length of stay (4 versus 4 d). After grouping the category of reoperations, upper gastrointestinal (odds ratio [OR] 0.66, confidence interval [CI] 0.39-1.11) and abdominal wall hernia surgery (OR 0.52, CI 0.27-0.99) showed a lower adjusted OR for complications among bariatric centers. CONCLUSIONS: Our study demonstrates that after adjustment for case-mix and patient characteristics, bariatric surgery patients undergoing repeat abdominal surgery at nonbariatric centers is not associated with higher proportion of complications or mortality. Complex hernia surgery may be considered the most appropriate for referral.

Bariatric Surgery and Breast Cancer Incidence: a Population-Based, Matched Cohort Study.

PURPOSE: Obesity is associated with increased breast cancer risk in women. Bariatric surgery induces substantial weight loss. However, the effects of such weight loss on subsequent breast cancer risk in women with obesity are poorly understood. To examine breast cancer incidence and related outcomes in women with obesity undergoing bariatric surgery. MATERIALS AND METHODS: This was a population-based matched cohort study of breast surgery outcomes utilizing linked clinical databases in Ontario, Canada. Women with obesity who underwent bariatric surgery were 1:1 matched using a propensity score to non-surgical controls for age and breast cancer screening history. The main outcomes were incidence of breast cancer after lag periods of 1, 2, and 5 years. Additional outcomes included tumor hormone receptor status, cancer stage, and treatments undertaken. Time-varying Cox proportional hazard models accounting for screening during follow-up were used to model cancer incidence. RESULTS: A total of 12,724 women per group were included, average age 45.09. After a 1-year lag, breast cancer incidence occurred in 1.09% and 0.79% of the control and surgery groups, respectively (adjusted hazard ratio, 0.81 [95%CI 0.69-0.95]; p = 0.01). This association was maintained after lag periods of 2 and 5 years. Women in the surgical cohort diagnosed with breast cancer were more likely to have low-grade tumors and less likely to have high-grade tumors (overall p < 0.01). No association was found for tumor hormone receptor status, although the surgical group was more likely to have her2neu-negative tumors (p = 0.01). CONCLUSION: Bariatric surgery was associated with a lower incidence of breast cancer and lower tumor grade in women with obesity. Further evaluation of outcomes, including mortality, is required.

What patient factors influence bariatric surgery outcomes? A multiple regression analysis of Ontario Bariatric Registry data.

BACKGROUND: As bariatric surgery evolves and gains popularity, statistical analysis of its outcomes could improve the process of decision-making and risk assessment. This study aimed to evaluate the influence of age and other factors on bariatric surgery outcomes in order to improve patient selection and outcomes. METHODS: We analyzed data from the Ontario Bariatric Registry to evaluate the influence of age and 10 other factors on early (< 90 d) and 1-year surgical outcomes among patients aged 18 years or older who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between January 2010 and May 2013. Early outcomes included composite adverse events and readmission. The 1-year outcomes included percent excess body weight loss (%EBWL), and remission of diabetes mellitus and hypertension. We performed multiple regression analysis to identify independent variables that influenced these outcomes. RESULTS: We identified 3166 patients (2655 women [83.9%] and 511 men [16.1%], mean age 44.8 yr, mean body mass index [BMI] 48.4) who underwent LRYGB (2839 [89.7%]) or LSG (327 [10.3%]) over the study period and completed their 1-year follow-up. Preoperative American Society of Anesthesiologists (ASA) score and history of angina were independent variables that influenced the composite adverse event outcome. Obstructive sleep apnea was the only factor that influenced early readmission. The independent factors that influenced %EBWL were age, type of surgery, BMI and baseline glycosylated hemoglobin (HbA1c) level: age was found to influence hypertension remission, and HbA1c level and obstructive sleep apnea were found to influence diabetes remission. CONCLUSION: Complications after bariatric surgery can be predicted by preoperative ASA score and history of angina; patient age was not related to an increase in postoperative complications. These factors could help both surgeon and patient make appropriate surgical decisions.

Bariatric Surgery as a Bridge to Heart Transplantation in Morbidly Obese Patients: A Systematic Review and Meta-Analysis.

Class 2 obesity or greater [body mass index (BMI) >35 kg/m2] is a relative contraindication for heart transplant due to its associated perioperative risks and mortality. Whether bariatric surgery can act as a potential bridging procedure to heart transplantation is unknown. The aim of this systematic review and meta-analysis is to investigate the role of bariatric surgery on improving transplant candidacy in patients with end-stage heart failure (ESHF). MEDLINE, EMBASE, CENTRAL, and PubMed databases were searched up to September 2019 for studies that performed bariatric surgery on patients with severe obesity and ESHF. Outcomes of interest included incidence of patients listed for heart transplantation after bariatric surgery, proportion of patients that successfully received transplant, the change in BMI after bariatric surgery, and 30-day complications. Pooled estimates were calculated using a random-effects meta-analysis of proportions. Eleven studies with 98 patients were included. Mean preoperative BMI was 44.9 (2.1) kg/m2 and BMI after surgery was 33.2 (2.3) kg/m2 with an absolute BMI reduction of 26.1%. After bariatric surgery, 71% [95% confidence interval (CI), 55-86%] of patients with ESHF were listed for transplantation. The mean time from bariatric surgery to receiving a heart transplant was 14.9 (4.0) months. Of the listed patients, 57% (95% CI, 39-74%) successfully received heart transplant. The rate of 30-day mortality after bariatric surgery was 0%, and the 30-day major and minor complications after bariatric surgery was 28% (95% CI, 10-49%). Bariatric surgery can facilitate sustained weight loss in obese patients with ESHF, improving heart transplant candidacy and the incidence of transplantation.

The Impact of Psychiatric History and Peri-operative Psychological Distress on Weight Loss Outcomes 1 Year After Bariatric Surgery.

BACKGROUND: To determine if self-reported baseline psychological distress moderates the association between lifetime psychiatric diagnosis and weight loss 1 year after bariatric surgery. An exploratory analysis assessed change in psychological distress from baseline on weight loss at 1 year. METHODS: A retrospective cohort study using data from the Ontario Bariatric Registry for all individuals undergoing surgery between January 1, 2012, and December 31, 2018, with a complete baseline psychological assessment and 1-year post-operative weight recorded (N = 11,159). Multiple linear regressions assessed the relationship between psychiatric diagnosis and percentage of excess body mass index loss (%EBMIL) at 1-year post-surgery, controlling for baseline body mass index, socio-demographics, medical co-morbidities, and surgical complications. Baseline psychological distress, measured with the EQ-5D-5L anxiety/depression rating, was examined as a moderator of this relationship. %EBMIL was separately regressed on change in psychological distress from baseline to 1 year, controlling for psychiatric diagnosis. RESULTS: In the adjusted model, psychiatric diagnosis was associated with lower %EBMIL at 1 year (B = - 1.00, P = .008). Baseline psychological distress was not a moderator, but had a significant main effect on %EBMIL (B = - .84, P = .001). Those who experienced a decrease in psychological distress at 1 year, or remained low throughout, fared better than those who increased or had persistently high symptoms. CONCLUSIONS: These findings support use of a self-report assessment for psychological distress prior to bariatric surgery. Addressing active psychological distress prior to and/or following surgery may increase the likelihood of successful outcomes.

Outcomes of bariatric surgery in elderly patients: a registry-based cohort study with 3-year follow-up.

BACKGROUND: Elderly patients undergo bariatric surgery less frequently than younger patients. Short- and medium-term outcomes after bariatric surgery in the elderly population remain largely unknown. The objective of the present retrospective, registry-based cohort study was to compare short- and medium-term outcomes between patients <65 and ≥65 years undergoing bariatric surgery, hypothesizing similar outcomes between groups. METHODS: In this retrospective, registry-based cohort study, the Ontario Bariatric Registry was used to compare data of patients <65 and ≥65 years who underwent Roux-en-Y gastric bypass and sleeve gastrectomy between January 2010 and August 2019 in all accredited bariatric centers of excellence in Ontario, Canada. Primary outcomes were overall postoperative complications. Secondary outcomes included early (<30 days) complications, readmissions, reoperations, mortality, weight loss and comorbidities improvement at 1 and 3 year after surgery. RESULTS: Data of 22,981 patients <65 and 532 patients ≥65 years were analyzed. Overall postoperative complications were similar between patients <65 and ≥65 years (3388/22,981 [14.7%] vs. 73/532 [13.7%], p = 0.537). Early (<30 days) postoperative complications, readmissions, reoperations, and mortality rates were also similar between groups. Both groups had significant weight loss and comorbidities improvement at 1- and 3-year follow-up. Patients <65 years had superior weight loss (+3.5%, 95% CI: 1.6-5.4, p < 0.001) and higher rates of remission for diabetes mellitus (63.8% vs. 39.3%, p < 0.001), hypertension (37.9% vs. 14.5%, p < 0.001), dyslipidemia (28.2% vs. 9.5%, p < 0.001) and gastroesophageal reflux (65.1% vs. 24.0 %, p < 0.001) compared to patients ≥65 years at 3 year. CONCLUSIONS: Patients <65 and ≥65 years had similar perioperative morbidity and mortality after bariatric surgery. Even though patients <65 years had overall better medium-term outcomes, bariatric surgery is safe and yields significant weight loss and comorbidities improvement in patients ≥65 years.

Risk factors for abdominal reoperations in bariatric patients.

BACKGROUND: With a growing bariatric population, a better understanding of the patient and health provider-related factors associated with later reoperations could help providers enhance follow-up and develop reliable benchmarking targets. OBJECTIVES: To investigate the patient and provider-related risk factors associated with abdominal reoperations in bariatric patients. SETTING: This is a cohort study using data from a large clinical registry of Ontario bariatric patients between 2010 and 2016. METHODS: A multilevel mixed effect logistic regression model using hospital and surgeon identifiers as random effects was performed to adjust for clustering of patients. The primary outcome was any abdominal operation performed within 2 years of primary bariatric surgery. RESULTS: Among a cohort of 10,946 bariatric patients (86.6% receiving gastric bypass surgery), 15.8% underwent an abdominal operation within 2 years and about a third of these were urgent. The multilevel analysis demonstrated that 98% of patient variation among reoperations was a result of patient characteristics rather than disparities between surgeons or center experience. Type of procedure was not a significant factor after adjustment for surgeon and hospital level experience (OR [odds ratio] .85, 95% CI [confidence interval] .70-1.03). Concurrent abdominal wall (OR 2.40, 95% CI 1.26-4.59), hiatal hernia repairs (OR 1.29, 95% CI 1.02-1.62), and previously higher health care users (OR 1.30, 95% CI 1.15-1.46) were most significantly associated with reoperations. CONCLUSION: Reoperations are significantly more common among certain bariatric patients, especially those undergoing concurrent hernia procedures. Reoperations were not associated with provider-related factors and may not be a suitable target for health provider benchmarking.

Comparison of 4-Year Health Care Expenditures Associated With Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy.

Importance: Data on the long-term health care expenditures associated with bariatric surgery consisting of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are lacking. Objective: To compare 4-year health care expenditures after RYGB vs sleeve gastrectomy, identify factors independently associated with 4-year health care expenditures, and compare the procedures in terms of subsequent hospitalizations, bariatric procedures, and all-cause mortality. Design, Setting, and Participants: In this propensity score-matched cohort study, all residents of Ontario, Canada, who underwent publicly funded surgery with RYGB (n = 6301) or sleeve gastrectomy (n = 926) from March 1, 2010, to March 31, 2015, and consented to participate in the Ontario Bariatric Registry were eligible for the study. Follow-up was completed on March 31, 2019, and data were analyzed from May 5, 2020, to May 20, 2021. Interventions: RYGB and sleeve gastrectomy. Main Outcomes and Measures: Publicly funded health care expenditures, subsequent hospitalizations, bariatric procedures, and mortality during the 4 years after RYGB or sleeve gastrectomy. Results: The 1:1 matched study cohorts consisted of 1624 patients (812 per cohort) with a mean (SD) age of 48.0 (10.6) years, and 1242 women (76.5%). The mean body mass index (calculated as weight in kilograms divided by height in square meters) was 51.9 (8.3) for the RYGB cohort and 51.9 (8.9) for the sleeve gastrectomy cohort. The 4-year cumulative costs were not statistically significantly different between RYGB and sleeve gastrectomy (mean [SD], $33 682 [$31 169] vs $33 948 [$32 633], respectively; P = .86). Having a history of coronary artery disease was associated with a 35% increase in overall health care expenditures; chronic kidney disease, a 54% increase; and mental health admissions, a 67% increase. There were no statistically significant differences in all-cause mortality between RYGB and sleeve gastrectomy (1.5% vs 2.2%, respectively; P = .26) or the total number of hospitalizations (754 vs 669, respectively; P = .11) during the 4-year follow-up period. However, nonelective hospitalizations occurred more frequently with RYGB vs sleeve gastrectomy (472 vs 339, respectively; P = .002). Roux-en-Y gastric bypass was associated with relatively fewer subsequent bariatric procedures during the 4-year follow-up period (9 vs 40, respectively; P < .001). Conclusions and Relevance: In this Canadian population-based study, key results indicated that 4-year health care expenditures, all-cause mortality, and number of hospital admissions associated with RYGB did not significantly differ from those for sleeve gastrectomy. The rate of subsequent bariatric surgery was lower with RYGB. This study identified important patient-level drivers of health care expenditures that need to be further investigated.

From telementorship to automation.

The effective integration of robotic technology and surgical tools has played a vital role in advancing surgical care by enabling telepresence in surgery to provide mentorship and surgical care across long distances in the absence of surgeons. This article describes our experiences with advancing surgical education and innovation through telementoring community surgeons, establishing the world's first telerobotic surgical service, and the integration of Artificial Intelligence and robotics to provide remote surgical care and training.

Early postoperative follow-up reduces risk of late severe nutritional complications after Roux-En-Y gastric bypass: a population based study.

BACKGROUND: Severe nutritional complications can occur following Roux-en-Y gastric bypass (RYGB). Adherence to follow-up visits can reduce the risk of many bariatric surgery complications, but whether this applies to severe nutritional complications is unknown. OBJECTIVES: Determine the association between adherence to follow-up visits after RYGB and risk of severe nutritional complications. SETTING: Multicenter publicly-funded Ontario Bariatric Network. METHODS: Retrospective cohort study of Ontario adults participating in the Ontario Bariatric Registry who underwent RYGB between January 1, 2009, and December 31, 2015. The primary outcome was a severe nutritional complication (hospital admission with malnutrition or nutrient deficiency) occurring 1 year or more after RYGB. The primary exposure was adherence to postoperative follow-up visits, occurring at 3, 6, and 12 months postoperatively, and categorized as perfect (3 visits), partial (1-2 visits), or none. Cox proportional hazards modeling quantified the association between adherence to follow-up visits and the primary outcome using hazard ratios (HR). RESULTS: In total, 9105 adults (84% female, age 44.7 ± 10.3 yr) met study criteria. Mean preoperative body mass index (BMI) was 48.6 kg/m2. First year follow-up attendance was: 51.7% perfect, 31.6% partial, and 16.7% none. Median time in the study was 3.4 years. Severe nutritional complications occurred in 1.1% of patients. Compared with perfect follow-up, patients with no follow-up (HR 3.09, 95% CI 1.74-5.50) and partial follow-up (HR 1.94, 95% CI 1.25-3.03) had an increased risk of severe nutritional complications. CONCLUSION: Adherence to follow-up visits during the first year after RYGB is independently associated with reduction in the risk of subsequent severe nutritional complications.

Comparison of single- versus double-anastomosis duodenal switch: a single-center experience with 2-year follow-up.

BACKGROUND: Single-anastomosis duodenal switch (SADS) has emerged in recent years as an alternative to the standard double-anastomosis duodenal switch (DADS). The objective of this study was to compare short- and medium-term outcomes between SADS and DADS. METHODS: Data collected in the Ontario Bariatric Registry between 2010 and 2019 were used for this retrospective study to determine outcomes of patients undergoing primary laparoscopic SADS versus DADS at a Canadian tertiary hospital and bariatric center of excellence. The primary outcome was weight loss at 1 and 2 years after surgery. Short-term secondary outcomes included operative times, intra- and early postoperative complications, hospital length of stay (LOS), and 30-day readmissions. Medium-term secondary outcomes included late postoperative complications as well as nutritional deficiencies and persistent diarrhea at 1 and 2 years after surgery. Subgroup analyses were performed to compare patients undergoing one- and two-stage procedures. RESULTS: Data of 107 patients who underwent SADS (n = 25) or DADS (n = 82) were included in the study. Follow-up data were available for 59/107 (55.1%) patients at 1 year and 47/107 (43.9%) at 2 years after surgery. Patients in the SADS and DADS groups had similar %TBWL at 1 year (23.6 versus 26.2, P = 0.617) and 2 years (24.8 versus 30.2, P = 0.116) after surgery. Short- and medium-term outcomes were similar between groups. There was no difference between patients undergoing one- versus two-stage procedures. CONCLUSION: This study showed that patients undergoing SADS and DADS had similar weight loss at 1 and 2 years. Early and late postoperative morbidity, operative times, early readmissions, and LOS were also similar between groups. Further studies with longer follow-up are required to confirm these results.

Association Between Bariatric Surgery and Major Adverse Diabetes Outcomes in Patients With Diabetes and Obesity.

Importance: There are high-quality randomized clinical trial data demonstrating the effect of bariatric surgery on type 2 diabetes remission, but these studies are not powered to study mortality in this patient group. Large observational studies are warranted to study the association of bariatric surgery with mortality in patients with type 2 diabetes. Objective: To determine the association between bariatric surgery and all-cause mortality among patients with type 2 diabetes and severe obesity. Design, Setting, and Participants: This retrospective, population-based matched cohort study included patients with type 2 diabetes and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) 35 or greater who underwent bariatric surgery from January 2010 to December 2016 in Ontario, Canada. Multiple linked administrative databases were used to define confounders, including age, baseline BMI, sex, comorbidities, duration of diabetes diagnosis, health care utilization, socioeconomic status, smoking status, substance abuse, cancer screening, and psychiatric history. Potential controls were identified from a primary care electronic medical record database. Data were analyzed in 2020. Exposure: Bariatric surgery (gastric bypass and sleeve gastrectomy) and nonsurgical management of obesity provided by the primary care physician. Main Outcomes and Measures: The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality and nonfatal morbidities. Groups were compared through a multivariable Cox proportional Hazards model. Results: A total of 6910 patients (mean [SD] age at baseline, 52.04 [9.45] years; 4950 [71.6%] women) were included, with 3455 patients who underwent bariatric surgery and 3455 match controls and a median (interquartile range) follow-up time of 4.6 (3.22-6.35) years. In the surgery group, 83 patients (2.4%) died, compared with 178 individuals (5.2%) in the control group (hazard ratio [HR] 0.53 [95% CI, 0.41-0.69]; P < .001). Bariatric surgery was associated with a 68% lower cardiovascular mortality (HR, 0.32 [95% CI, 0.15-0.66]; P = .002) and a 34% lower rate of composite cardiac events (HR, 0.68 [95% CI, 0.55-0.85]; P < .001). Risk of nonfatal renal events was also 42% lower in the surgical group compared with the control group (HR, 0.58 [95% CI, 0.35-0.95], P = .03). Of the groups that had the highest absolute benefit associated with bariatric surgery, men had an absolute risk reduction (ARR) of 3.7% (95% CI, 1.7%-5.7%), individuals with more than 15 years of diabetes had an ARR of 4.3% (95% CI, 0.8%-7.8%), and individuals aged 55 years or older had an ARR of 4.7% (95% CI, 3.0%-6.4%). Conclusions and Relevance: These findings suggest that bariatric surgery was associated with reduced all-cause mortality and diabetes-specific cardiac and renal outcomes in patients with type 2 diabetes and severe obesity.