Judgment Errors in Surgical Care.

BACKGROUND: Human error is impossible to eliminate, particularly in systems as complex as healthcare. The extent to which judgment errors in particular impact surgical patient care or lead to harm is unclear. STUDY DESIGN: The American College of Surgeons NSQIP (2018) procedures from a single institution with 30-day morbidity or mortality were examined. Medical records were reviewed and evaluated for judgment errors. Preoperative variables associated with judgment errors were examined using logistic regression. RESULTS: Of the surgical patients who experienced a morbidity or mortality, 18% (31 of 170) experienced an error in judgment during their hospitalization. Patients with hepatobiliary procedure (odds ratio [OR] 5.4 [95% CI 1.23 to 32.75], p = 0.002), insulin-dependent diabetes (OR 4.8 [95% CI 1.2 to 18.8], p = 0.025), severe COPD (OR 6.0 [95% CI 1.6 to 22.1], p = 0.007), or with infected wounds (OR 8.2 [95% CI 2.6 to 25.8], p < 0.001) were at increased risk for judgment errors. CONCLUSIONS: Specific procedure types and patients with certain preoperative variables had higher risk for judgment errors during their hospitalization. Errors in judgment adversely impacted the outcomes of surgical patients who experienced morbidity or mortality in this cohort. Preventing or mitigating errors and closely monitoring patients after an error in judgment is prudent and may improve surgical safety.

Acute Respiratory Failure Complicating Endoscopic Sleeve Gastroplasty: A Case Report.

Endoscopic sleeve gastroplasty (ESG) is a safe and minimally invasive procedure for the treatment of obesity. We report the case of a patient with obesity who underwent ESG complicated by postprocedural respiratory failure. During the procedure, she developed a Pao2/fraction of inspired oxygen (Fio2) ratio that necessitated postoperative mechanical ventilation. Chest radiography demonstrated massively dilated loops of bowel, cephalad displacement of both hemidiaphragms, lung volume reduction, and atelectasis. With absorption of luminal carbon dioxide, she was weaned from mechanical ventilation to supplemental oxygen, and she recovered completely. This case highlights postoperative respiratory failure associated with mechanical loading of the respiratory system following ESG.

Monitoring performance in laparoscopic gastric bypass surgery using risk-adjusted cumulative sum at 2 high-volume centers.

BACKGROUND: Traditional surgical outcomes are measured retrospectively and intermittently, limiting opportunities for early intervention. OBJECTIVES: The objective of this study was to use risk-adjusted cumulative sum (RA-CUSUM) to track perioperative surgical outcomes for laparoscopic gastric bypass. We hypothesized that RA-CUSUM could identify performance variations between surgeons. SETTING: Two mid-Atlantic quaternary care academic centers. METHODS: Patient-level data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were abstracted for laparoscopic gastric bypasses performed by 3 surgeons at 2 high-volume centers from 2014 to 2021. Estimated probabilities of serious complications, reoperation, and readmission were derived from the MBSAQIP risk calculator. RA-CUSUM curves were generated to signal observed-to-expected odds ratios (ORs) of 1.5 (poor performance) and .5 (superior performance). Control limits were set based on a false positive rate of 5% (α = .05). RESULTS: We included 1192 patients: Surgeon A = 767, Surgeon B = 188, and Surgeon C = 237. Overall rates of serious complications, 30-day reoperations, and 30-day readmissions were 3.9%, 2.5%, and 5.2% respectively, with expected rates of 4.7%, 2.2%, and 5.8%. RA-CUSUM signaled lower-than-expected (OR < .5) rates of readmission and serious complication in Surgeon A, and higher-than-expected (OR > 1.5) readmission rate in Surgeon C. Surgeon A further demonstrated an early period of higher-than-expected (OR > 1.5) reoperation rate before April 2015, followed by superior performance thereafter (OR < .5). Surgeon B's performance generally reflected expected standards throughout the study period. CONCLUSIONS: RA-CUSUM adjusts for clinical risk factors and identifies performance outliers in real-time. This approach to analyzing surgical outcomes is applicable to quality improvement, root-cause analysis, and surgeon incentivization.

Errors in Surgery: A Case Control Study.

OBJECTIVE: While errors can harm patients they remain poorly studied. This study characterized errors in the care of surgical patients and examined the association of errors with morbidity and mortality. BACKGROUND: Errors have been reported to cause <10% or >60% of adverse events. Such discordant results underscore the need for further exploration of the relationship between error and adverse events. METHODS: Patients with operations performed at a single institution and abstracted into the American College of Surgeons National Surgical Quality Improvement Program from January 1, 2018, to December 31, 2018 were examined. This matched case control study comprised cases who experienced a postoperative morbidity or mortality. Controls included patients without morbidity or mortality, matched 2:1 using age (±10 years), sex, and Current Procedural Terminology (CPT) group. Two faculty surgeons independently reviewed records for each case and control patient to identify diagnostic, technical, judgment, medication, system, or omission errors. A conditional multivariable logistic regression model examined the association between error and morbidity. RESULTS: Of 1899 patients, 170 were defined as cases who experienced a morbidity or mortality. The majority of cases (n=93; 55%) had at least 1 error; of the 329 matched control patients, 112 had at least 1 error (34%). Technical errors occurred most often among both cases (40%) and controls (23%). Logistic regression demonstrated a strong independent relationship between error and morbidity (odds ratio=2.67, 95% confidence interval: 1.64-4.35, P <0.001). CONCLUSION: Errors in surgical care were associated with postoperative morbidity. Reducing errors requires measurement of errors.

Bariatric surgery reduces long-term rates of cardiac events and need for coronary revascularization: a propensity-matched analysis.

BACKGROUND: Obesity and obesity-related comorbidities are associated with increased risk of coronary artery disease (CAD). Bariatric surgery results in durable weight loss and improvement in numerous CAD risk factors, yet limited data exist on CAD-related outcomes. We hypothesized that bariatric surgery would lead to decreased risk of CAD and reduced rates of coronary revascularization procedures. METHODS: All patients who underwent bariatric surgery at a single medical center from 1985 to 2015 were identified. A control population of morbidly obese patients who did not undergo bariatric surgery was identified using an institutional clinical data repository over the same study period, propensity score matched 1:1 on patient demographics and comorbidities including cardiac history. Univariate analyses were performed to compare outcomes in the surgery and non-surgery groups. RESULTS: A total of 3410 bariatric surgery patients and 45,750 non-surgical patients were identified. After 1:1 propensity-score matching, a total of 3242 patients in each group were found to be well balanced in baseline characteristics and risk factors. With a median follow-up of greater than 6 years, the surgery group had significantly lower rates of myocardial infarction (1.8% vs. 10.0%; RR 0.18), coronary catheterization (1.9% vs. 8.8%; RR 0.22), percutaneous coronary intervention (0.4% vs. 7.8%; RR 0.05), and coronary artery bypass grafting (0.6% vs. 2.3%; RR 0.26). Similar benefits were observed for subgroups of patients with and without diabetes. CONCLUSIONS: Bariatric surgery was associated with a significant reduction in the incidence of myocardial infarction as well as lower rates of coronary revascularization in a propensity-matched cohort of morbidly obese patients. Though the retrospective nature of this study may have introduced a degree of selection bias, these outcomes support increased utilization of bariatric surgery for the prevention of heart disease.

The impact of bariatric surgery on qualitative and quantitative breast density.

BACKGROUND: Obesity and breast density are associated with breast cancer in postmenopausal women. Bariatric surgery effectively treats morbid obesity, with sustainable weight loss and reductions in cancer incidence. We evaluated changes in qualitative and quantitative density; hypothesizing breast density would increase following bariatric surgery. METHODS: Women undergoing bariatric surgery from 1990 to 2015 were identified, excluding patients without a mammogram performed both before and after surgery. Changes in body mass index (BMI), time between mammograms and surgery, and American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) scores were assessed. VolparaDensity™ automated software calculated volumetric breast density (VBD), fibroglandular volume (FGV), and total breast volume for the 82 women with digital data available. Differences between pre- and postsurgery values were assessed. RESULTS: One hundred eighty women were included. Median age at surgery was 50.0 years, with 8.8 months between presurgery mammogram and surgery and 62.3 months between surgery and postsurgery mammogram. Median BMI significantly decreased over the study period (46.0 vs 35.4 kg/m2 ; P < 0.001). No change in BI-RADS scores was seen between the pre- and postsurgery mammograms. Eighty-two women had VolparaDensity™ data available. While VBD increased in these patients, FGV and total breast volume both decreased following bariatric surgery. CONCLUSIONS: Increased VBD, decreased FGV, and decreased total breast volume were seen following bariatric surgery-induced weight loss. There was no difference in qualitative breast density, highlighting the discrepancy between BI-RADS and VolparaDensity™ measurements. Further investigation will be required to determine how differential changes in components of breast density may affect breast cancer risk.

Socioeconomically Distressed Communities Associated With Long-term Mortality After Bariatric Surgery.

BACKGROUND: Surgical outcomes are affected by socioeconomic status, yet these factors are poorly accounted for in clinical databases. We sought to determine if the Distressed Communities Index (DCI), a composite ranking by zip code that quantifies socioeconomic risk, was associated with long-term survival after bariatric surgery. METHODS: All patients undergoing Roux-en-Y gastric bypass (1985-2004) at a single institution were paired with DCI. Scores range from 0 (no distress) to 100 (severe distress) and account for unemployment, education, poverty, median income, housing vacancies, job growth, and business establishment growth. Distressed communities, defined as DCI ≥75, were compared with all other patients. Regression modeling was used to evaluate the effect of DCI on 10-year bariatric outcomes, whereas Cox Proportional Hazards and Kaplan-Meier analysis examined long-term survival. RESULTS: Gastric bypass patients (n = 681) come from more distressed communities compared with the general public (DCI 60.5 ± 23.8 versus 50 ± 10; P < 0.0001). A total of 221 (32.3%) patients came from distressed communities (DCI ≥75). These patients had similar preoperative characteristics, including BMI (51.5 versus 51.7 kg/m2; P = 0.63). Socioeconomic status did not affect 10-year bariatric outcomes, including percent reduction in excess body mass index (57% versus 58%; P = 0.93). However, patients from distressed communities had decreased risk-adjusted long-term survival (hazard ratio, 1.38; P = 0.043). CONCLUSIONS: Patients with low socioeconomic status, as determined by the DCI, have equivalent outcomes after bariatric surgery despite worse long-term survival. Future quality improvement efforts should focus on these persistent disparities in health care.

Bowel Obstruction and Hydronephrosis Due to an Over-the-Scope Clip.

An over-the-scope clip is a type of endoscopically placed clip used to treat gastrointestinal perforation, bleeding, or fistula. After the defect heals, the clip usually passes uneventfully through the gastrointestinal tract. An uncommon complication of over-the-scope clip placement is intestinal obstruction caused by luminal stenosis at the site of clip placement. Intestinal obstruction can rarely cause other downstream complications such as hydronephrosis from extrinsic compression of the urinary tract. We report a rare case of bilateral hydronephrosis caused by bowel obstruction from a migrated endoscopically placed clip.

Overall and Estrogen Receptor-Positive Breast Cancer Incidences Are Decreased Following Bariatric Surgery.

INTRODUCTION: Bariatric surgery treats morbid obesity resulting in long-lasting weight loss. Elevated body mass index (BMI) increases breast cancer risk. We hypothesized that patients undergoing bariatric surgery would have decreased overall and estrogen receptor (ER)-positive breast cancer incidences compared to a propensity-matched non-surgical cohort. METHODS: The bariatric population included all female patients who underwent weight loss surgery at a single institution from 1985 to 2015. Patients from all outpatient visits were propensity score matched 1:1 with bariatric patients using BMI, comorbidities, demographics, and insurance status. The primary outcome was breast cancer incidence. Univariate analyses compared the groups. RESULTS: A total of 4860 patients were included, with 2430 in both groups. Median follow-up time from date of surgery or morbid obesity diagnosis was 5.7 years. There were no differences in age or comorbidities aside from gastroesophageal reflux disease. Seventeen (0.7%) patients in the surgery group were subsequently diagnosed with breast cancer versus 32 (1.3%) in the non-surgery group (p = 0.03). The non-surgery group had more ER-positive tumors [4 (36.4%) vs. 22 (71.0%); p = 0.04]. CONCLUSION: Female patients who underwent bariatric surgery were less frequently diagnosed with any breast cancer and ER-positive breast cancer versus a propensity-matched cohort suggesting a possible oncologic benefit to weight loss surgery.

Ten-year outcomes of Roux-en-Y gastric bypass are equivalent in patients with Medicare disability and non-Medicare patients.

BACKGROUND: Bariatric surgery is the most effective intervention for achieving durable weight loss and improvement of comorbidities in patients with obesity. Limited data exist on the impact of Medicare status in patients undergoing Roux-en-Y gastric bypass. We hypothesized that there is no difference in outcomes between Medicare beneficiaries and non-Medicare patients at the 10-year follow-up. METHODS: All patients who underwent Roux-en-Y gastric bypass with 10-year follow-up at a single medical center from 1985 to 2005 were stratified by Medicare insurance status. Outcomes included 10-year percent reduction in excess body mass index and comorbidity resolution. RESULTS: Of 617 patients who underwent Roux-en-Y gastric bypass with 10-year follow-up, 117 (19%) were insured under Medicare. Medicare patients were older (43 vs 40 years, P = .01) and had a greater preoperative body mass index (53.2 vs 51.0 kg/m2, P = .03) than non-Medicare patients, but there were no differences in preoperative median comorbidity index scores (3 [interquartile range 1-4] vs 2 [interquartile range 1-5], P = .33). At 10 years, weight loss (58.3% vs 57.0 percent reduction in excess body mass index, P = .16) and the decrease in median comorbidity index (1 [interquartile range 0-3] vs 1 [interquartile range 0-3], P = .85) were equivalent between groups. CONCLUSIONS: Roux-en-Y gastric bypass is equally beneficial in Medicare Disability and non-Medicare patients at 10 years. These findings support the continued and expanded coverage of bariatric surgery operations by Medicare.

Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study.

Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m-2. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P > 0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis (P < 0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intraoperative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.

Laparoscopic Sleeve Gastrectomy Is Associated with Lower 30-Day Morbidity Versus Laparoscopic Gastric Bypass: an Analysis of the American College of Surgeons NSQIP.

PURPOSE: Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity as a single-stage operation for the treatment of morbid obesity, as patients undergoing LSG have been shown to achieve similar weight loss and resolution of obesity-related comorbidities in comparison to those undergoing Roux-en-Y gastric bypass (RYGB), the "gold standard" bariatric operation. Although LSG poses fewer technical challenges than RYGB, little is known about differences in short-term outcomes among patients undergoing LSG and RYGB. We hypothesized that LSG is associated with lower 30-day risk-adjusted serious morbidity. METHODS: Preoperative characteristics and 30-day outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) Participant Use Files (PUF) 2010-2014 were selected for all patients who underwent LSG or RYGB. Descriptive comparisons were performed using chi-square and Wilcoxon's rank-sum tests as appropriate. The primary outcome was a risk-adjusted composite measure of 30-day serious morbidity and mortality. RESULTS: We analyzed records for 47,982 (42.0%) and 66,380 (58.0%) patients undergoing LSG and RYGB, respectively. On univariate analysis, LSG patients had a lower rate of organ space infection (0.45% vs. 0.68%, p < 0.001), lower rate of bleeding requiring transfusions (1.00% vs. 1.60%, p < 0.001), lower rate of sepsis (0.34% vs. 0.49%, p < 0.001), and septic shock (0.12% vs. 0.22%, p < 0.001) and required fewer unplanned reoperations (1.34% vs. 2.56%, p < 0.001) than RYGB patients. Both groups had similar rates of deep venous thrombosis (0.33% vs. 0.28%, p = 0.15) and pulmonary embolism (0.17% vs. 0.21%, p = 0.15). Mortality was lower among LSG patients (0.09% vs. 0.14%, p = 0.01). On multivariate analysis, RYGB was associated with higher risk-adjusted 30-day serious morbidity than LSG (odds ratio 1.61; 95% CI 1.52-1.71, p < 0.001). Older age, female gender, higher BMI, and insulin-dependent diabetes were also associated with risk of serious morbidity (C-statistic = 0.60). CONCLUSION: Serious morbidity following bariatric surgery is uncommon; however, LSG may be associated with modest protection from adverse 30-day outcomes in comparison to RYGB. Our conclusion is limited by the difference in baseline risk factors of the populations studied.

Roux-en-Y gastric bypass is safe in elderly patients: a propensity-score matched analysis.

BACKGROUND: Numerous studies have established the effectiveness of Roux-en-Y gastric bypass (RYGB) for weight loss and co-morbidity amelioration. However, its safety and efficacy in elderly patients remains controversial. OBJECTIVES: To evaluate outcomes in patients aged ≥60 years who underwent RYGB compared with nonsurgical controls with the hypothesis that RYGB provides weight loss benefits without differences in survival. SETTING: University-affiliated tertiary center. METHODS: All patients who underwent RYGB from 1985 to 2015 were identified and divided into elderly (age ≥60) and nonelderly (age <60) groups. A nonsurgical elderly control population was identified using a clinical data repository of outpatient visits to propensity match elderly patients 4:1 on demographic characteristics, co-morbidities, and relevant preoperative substance/medication use. Unpaired appropriate univariate analyses compared each stratified group. Kaplan-Meier survival curves were fitted based on social security death data. RESULTS: A total of 2306 patients underwent RYGB. The 107 elderly patients had lower median body mass index (47.0 versus 49.9; P = .007) and higher rates of co-morbidities. Rates of complications did not differ between elderly and nonelderly patients. Elderly surgical patients were propensity matched 4:1 (10,044 controls) yielding 428 well-matched nonsurgical controls. The elderly group demonstrated significant percent reduction in excess body mass index compared with the control group (81.8% versus 10.3%; P < .001). Kaplan-Meier survival analysis with log-rank test demonstrated no difference in midterm survival (P = .63). CONCLUSIONS: A significant weight reduction benefit was identified after RYGB in elderly patients without a difference in midterm survival compared with propensity-matched controls, suggesting RYGB is a safe and efficacious weight loss strategy in the elderly.

Resident-Specific Morbidity Reduced Following ACS NSQIP Data-Driven Quality Program.

BACKGROUND: The Accreditation Council for Graduate Medical Education Milestone Project for general surgery provided a more robust method for developing and tracking residents' competence. This framework enhanced systematic and progressive development of residents' competencies in surgical quality improvement. STUDY DESIGN: A 22-month interactive, educational program based on resident-specific surgical outcomes data culminated in a quality improvement project for postgraduate year 4 surgery residents. Self- assessment, quality knowledge test, and resident-specific American College of Surgeons National Surgical Quality Improvement Program Quality In-Training Initiative morbidity were compared before and after the intervention. RESULTS: Quality in-training initiative morbidity decreased from 25% (82/325) to 18% (93/517), p = 0.015 despite residents performing more complex cases. All participants achieved level 4 competency (4/4) within the general surgery milestones improvement of care, practice-based learning and improvement competency. Institutional American College of Surgeons National Surgical Quality Improvement Program general surgery morbidity improved from the ninth to the sixth decile. Quality assessment and improvement self-assessment postintervention scores (M = 23.80, SD = 4.97) were not significantly higher than preintervention scores (M = 19.20, SD = 5.26), p = 0.061. Quality Improvement Knowledge Application Tool postintervention test scores (M = 17.4, SD = 4.88), were not significantly higher than pretest scores (M = 13.2, SD = 1.92), p = 0.12. CONCLUSION: Sharing validated resident-specific clinical data with participants was associated with improved surgical outcomes. Participating fourth year surgical residents achieved the highest score, a level 4, in the practice based learning and improvement competency of the improvement of care practice domain and observed significantly reduced surgical morbidity for cases in which they participated.

Benefit of feeding tube placement for refractory malnutrition after bariatric surgery.

BACKGROUND: Bariatric surgery provides durable weight loss and decreases the incidence of co-morbid conditions for people with obesity. Most patients benefit from resultant weight loss, but some are at risk for postoperative refractory malnutrition, a serious but poorly understood complication. OBJECTIVE: To evaluate differences in bariatric surgery patients who received a feeding tube postoperatively for malnutrition compared with other indications. SETTING: Retrospective cohort study at an academic bariatric surgery center (1985-2015). METHODS: All bariatric surgery patients that received a feeding tube postoperatively over a 30-year period were identified. Data abstraction from the medical record was performed to assess demographic characteristics, operative details, tube indication, and resultant body mass index (BMI) changes. RESULTS: From a total of 3487 patients who underwent bariatric surgery during the study period, 139 (3.9%) required placement of a feeding tube postoperatively. Refractory malnutrition was the indication in 24 patients, all after Roux-en-Y gastric bypass. There were no significant differences between these patients and other bariatric surgery patients in terms of mean age (40.6±9.9 versus 43.1±13.4 years, P = .4) and preoperative BMI (47.5±10.5 versus 51.0±9.6 kg/m2, P = .1). The median time from surgery to tube placement for malnutrition patients was 4 years. Compared with other feeding tube indications, malnutrition patients had higher percent excess BMI lost after surgery (126.2±31.9 versus 52.5±44.3%, P<.0001). After tube placement, malnutrition patients had a significant increase in mean BMI compared with other indications (14.5±20.9 versus-13.0±14.0%, P< .001). CONCLUSION: Patients with refractory malnutrition benefit from feeding tube placement, which results in a significant increase in BMI.

Adoption of robotics in a general surgery residency program: at what cost?

BACKGROUND: Robotic technology is increasingly being utilized by general surgeons. However, the impact of introducing robotics to surgical residency has not been examined. This study aims to assess the financial costs and training impact of introducing robotics at an academic general surgery residency program. METHODS: All patients who underwent laparoscopic or robotic cholecystectomy, ventral hernia repair (VHR), and inguinal hernia repair (IHR) at our institution from 2011-2015 were identified. The effect of robotic surgery on laparoscopic case volume was assessed with linear regression analysis. Resident participation, operative time, hospital costs, and patient charges were also evaluated. RESULTS: We identified 2260 laparoscopic and 139 robotic operations. As the volume of robotic cases increased, the number of laparoscopic cases steadily decreased. Residents participated in all laparoscopic cases and 70% of robotic cases but operated from the robot console in only 21% of cases. Mean operative time was increased for robotic cholecystectomy (+22%), IHR (+55%), and VHR (+61%). Financial analysis revealed higher median hospital costs per case for robotic cholecystectomy (+$411), IHR (+$887), and VHR (+$1124) as well as substantial associated fixed costs. CONCLUSIONS: Introduction of robotic surgery had considerable negative impact on laparoscopic case volume and significantly decreased resident participation. Increased operative time and hospital costs are substantial. An institution must be cognizant of these effects when considering implementing robotics in departments with a general surgery residency program.

Hypoglycemia Following Bariatric Surgery: Our 31-Year Experience.

PURPOSE: The purposes of this study are to identify the cumulative incidence of post-bariatric surgery hypoglycemia (PBSH), describe its symptomatology, and characterize treatment patterns at a large academic institution. MATERIALS AND METHODS: All patients who underwent bariatric surgery at a single institution from 1985 to 2015 were identified using a clinical database, administrative billing data identified patients who were treated for hypoglycemia, and chart reviews were performed to make a diagnosis of PBSH based on Whipple's triad. PBSH cases were reviewed including patient diabetes history, symptomatology, and treatment measures. Univariate analyses were performed to identify correlations based on symptomatology, laboratory values, and treatments utilized. RESULTS: Ninety (2.6%) of 3487 patients were diagnosed with PBSH with preoperative median age of 43 years, mean BMI of 50.0 kg/m2, and median glycated hemoglobin of 6.0%. Median time-to-first hypoglycemic event was 40.6 months. No factors were identified which predict symptom severity or resolution. The 24 (27%) patients who received pharmacotherapy to treat hypoglycemia were younger, had lower nadir blood glucose levels, and more frequent symptoms. Sixty-nine (79%) cases eventually resolved. CONCLUSIONS: PBSH onset and severity are highly variable. Successful management of these patients can prove difficult and should include dietary therapy, the selective use of pharmacotherapy and surgery, and the use of a multidisciplinary team including bariatric surgeons and endocrinologists.

Simultaneous conversion of gastric band to sleeve gastrectomy is associated with increased postoperative complications: an analysis of the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has gained popularity for the treatment of morbid obesity as gastric banding (BAND) has fallen out of favor. As a result, simultaneous conversion (CONV) of BAND to LSG is commonly performed. We hypothesized that CONV is associated with higher 30-day risk-adjusted serious morbidity. METHODS: Preoperative characteristics and 30-day outcomes from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files 2010-2014 were selected for patients who underwent LSG. Patients undergoing CONV were identified. Descriptive comparisons were performed using Chi-square and Wilcoxon rank-sum tests as appropriate. Multivariate logistic regression was performed to assess the association between CONV and a composite measure of 30-day serious morbidity and mortality. RESULTS: Overall, 35,307 patients met criteria for inclusion, of which 943 (2.7%) underwent CONV. The median age of patients undergoing CONV was higher (46 vs 44 years, p < 0.001) and a greater percentage of CONV patients was female (84.8 vs 77.9%, p < 0.001) than LSG patients. CONV patients had lower rates of common comorbidities, including diabetes (14.9 vs 23.1%, p < 0.001), hypertension (41.9 vs 48.6%, p < 0.001), and tobacco use (7.2 vs 9.8%, p < 0.001), as well as lower median BMI (41 vs 44, p < 0.001). Individual unadjusted outcomes of serious 30-day complications were similar between both groups, as was a composite measure of serious morbidity (CONV 4.3% vs LSG 3.6%, p = 0.1). However, after controlling for demographics, comorbidities, and concurrent band removal, CONV was associated with increased odds of serious 30-day morbidity (1.44, 95% CI 1.03-1.97) (c-statistic: 0.60). CONCLUSIONS: Serious morbidity following LSG is uncommon; however, CONV is associated with a modest increase in risk-adjusted adverse 30-day outcomes. Patients being evaluated for CONV should be counseled about the added risks versus LSG alone. Further research is warranted to identify whether the incremental risks of CONV may be modifiable.

Roux-en-Y Gastric Bypass Following Nissen Fundoplication: Higher Risk Same Reward.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) effectively treats obesity and gastroesophageal reflux disease (GERD). As more surgeons recommend RYGB to treat GERD in patients with obesity, there are concerns about this approach in patients with previous non-bariatric foregut surgery. This study aims to evaluate the effect of previous non-bariatric foregut surgery on subsequent RYGB. METHODS: Retrospective review of 2089 patients undergoing RYGB between January 1985 and June 2015 was conducted to identify all patients with previous non-bariatric foregut surgery. Perioperative and postoperative data was collected by retrospective chart review. RESULTS: A total of 11 patients with prior non-bariatric foregut surgery underwent RYGB with median time between operations of 95.6 months. Of note, 7/11 (63.6%) had previous Nissen fundoplication. Conversion to open operation was required in 3/7 (42.9%) with previous Nissen compared to 1/4 (25%) in those without previous Nissen. The average length of stay (LOS) was 3.9 ± 0.9 days, significantly longer than our institutional average for RYGB of 3.2 ± 3.2 days (p = 0.02). Mean percentage of excess body mass index loss (%EBMIL) was 64.7 ± 23.5 at 4-year median follow-up, comparable to our institution's previously reported data. No mortalities were attributed to RYGB and the overall complication rate was 18.2%, compared to our institutional complication rate for RYGB of 8.5% (p = 0.253). CONCLUSION: Despite increased technical difficulty and increase perioperative morbidity, patients undergoing RYGB with previous non-bariatric foregut surgery had long-term symptom resolution and robust weight loss. This indicates that in the right hands, RYGB after non-bariatric foregut surgery may be performed safely and effectively.