Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD).

BACKGROUND: Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD. METHODS: Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS: The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss. CONCLUSION: Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Pre-screening for bariatric surgery patients: comparative effectiveness of transnasal endoscopy versus esophagogastroduodenoscopy.

BACKGROUND: Endoscopic evaluation is frequently performed before bariatric surgery to identify foregut pathology that may alter procedure selection. Transnasal endoscopy (TNE) is an alternative to esophagogastroduodenoscopy (EGD). The objective of this study was to compare TNE to EGD. METHODS: Patients who underwent TNE or EGD before bariatric surgery from January 2012 through April 2019 were reviewed. Statistical analyses included Chi-square, Wilcoxon two-sample, and Fisher's exact tests. A p value < 0.05 was considered significant. RESULTS: Three hundred and forty-five patients underwent preoperative screening (63% EGD, 37% TNE) before bariatric surgery. Mean age and preoperative body mass index in the TNE and EGD groups were 46.2 ± 12.4 vs 45.5 ± 11.6 years (p = 0.58) and 46.5 ± 7.1 vs. 45.5 ± 6.1 kg/m2 (p = 0.25), respectively. Three TNEs were aborted, resulting in a success rate of 98%. Of patients who underwent EGD, 1 (0.5%) visited the emergency department (ED), and 7 (3%) called the nurse with post-procedure concerns. There were no ED visits or nurse calls from patients who underwent TNE. The median total time in the procedure room was 77 (57-97) min for EGD vs. 26 (8-33) min for TNE (p < 0.001). One patient who underwent TNE required subsequent EGD. Mean charge per patient for EGD and TNE was $5034.70 and $1464.00, respectively. CONCLUSIONS: TNE was associated with less post-procedure care, shorter procedure time and fewer charges compared to EGD. TNE could be considered an initial screening tool for patients undergoing bariatric surgery, while EGD could be used selectively in patients with abnormal TNE findings.

Lack of Correlation Between Subjective and Objective Measures of Gastroesophageal Reflux Disease: Call for a Novel Validated Assessment Tool.

Background. Objective measures including the DeMeester score, lower esophageal sphincter (LES) pressure, acid exposure time, and body mass index (BMI) are used to determine gastroesophageal reflux disease (GERD) severity and eligibility for various antireflux surgical procedures. The GERD Health-Related Quality of Life (GERD-HRQL) survey is widely used to evaluate patients' subjective severity of symptoms and GERD-related quality of life. The purpose of this project was to identify whether or not the subjective measure (GERD-HRQL) correlated with objective measures (DeMeester score, LES, acid exposure time, and BMI) of GERD severity. Methods. A retrospective review of the medical records of patients who underwent antireflux surgery from 2013-2018 was completed. Patients' GERD severity was measured preoperatively and postoperatively using the GERD-HRQL. Statistical analysis included the calculation of Spearman correlation coefficients, Wilcoxon rank sum, sign, and chi-square tests. Results. 151 patients were included in the study; 64% were female. The mean age and BMI were 54.6 ± 14.6 years and 30.1 ± 4.1 kg/m2, respectively. The mean preoperative DeMeester score was 43.1 ± 36.1, LES pressure was 19.9 ± 18.4 mmHg, and acid exposure time was 11.4 ± 9.6. Mean GERD-HRQL scores decreased from 27.3 ± 9.2 preoperative to 5.3 ± 4.5 postoperative; P < .0001. Preoperative GERD-HRQL scores were not correlated with the DeMeester score (r = .11; P = .389), LES pressure (r = -.20; P = .089), acid exposure time (r = .05; P = .755), BMI (r = .10; P = .329), or age (r = -.16; P = .118). Conclusions. Total GERD-HRQL scores significantly decreased from pre- to postoperative. There was no correlation between subjective and objective GERD scoring. These data indicate the need for both physiologic evaluation and subjective assessment of patient symptoms during preoperative workup. There is a need for a contemporary, validated GERD questionnaire that correlates with objective pH testing.

Magnetic Sphincter Augmentation Superior to Proton Pump Inhibitors for Regurgitation in a 1-Year Randomized Trial.

BACKGROUND & AIMS: Regurgitative gastroesophageal reflux disease (GERD) refractive to medical treatment is common and caused by mechanical failure of the anti-reflux barrier. We compared the effects of magnetic sphincter augmentation (MSA) with those of proton-pump inhibitors (PPIs) in a randomized trial. METHODS: Patients with moderate to severe regurgitation (assessed by the foregut symptom questionnaire) despite once-daily PPI therapy (n = 152) were randomly assigned to groups given twice-daily PPIs (n = 102) or laparoscopic MSA (n = 50) at 20 sites, from July 2015 through February 2017. Patients answered questions from the foregut-specific reflux disease questionnaire and GERD health-related quality of life survey about regurgitation, heartburn, dysphagia, bloating, diarrhea, flatulence, and medication use, at baseline and 6 and 12 months after treatment. Six months after PPI therapy, MSA was offered to patients with persistent moderate to severe regurgitation and excess reflux episodes during impedance or pH testing on medication. Regurgitation, foregut scores, esophageal acid exposure, and adverse events were evaluated at 1 year. RESULTS: Patients in the MSA group and those who crossed over to the MSA group after PPI therapy (n = 75) had similar outcomes. MSA resulted in control of regurgitation in 72/75 patients (96%); regurgitation control was independent of preoperative response to PPIs. Only 8/43 patients receiving PPIs (19%) reported control of regurgitation. Among the 75 patients who received MSA, 61 (81%) had improvements in GERD health-related quality of life improvement scores (greater than 50%) and 68 patients (91%) discontinued daily PPI use. Proportions of patients with dysphagia decreased from 15% to 7% (P < .005), bloating decreased from 55% to 25%, and esophageal acid exposure time decreased from 10.7% to 1.3% (P < .001) from study entry to 1-year after MSA (Combined P < .001). Seventy percent (48/69) of patients had pH normalization at study completion. MSA was not associated with any peri-operative events, device explants, erosions, or migrations. CONCLUSIONS: In a prospective study, we found MSA to reduce regurgitation in 95% of patients with moderate to severe regurgitation despite once-daily PPI therapy. MSA is superior to twice-daily PPIs therapy in reducing regurgitation. Relief of regurgitation is sustained over 12 months. ClinicalTrials.gov no: NCT02505945.

Objective Evidence of Reflux Control After Magnetic Sphincter Augmentation: One Year Results From a Post Approval Study.

OBJECTIVE: To report 1-year results from a 5-year mandated study. SUMMARY BACKGROUND DATA: In 2012, the United States Food and Drug Administration approved magnetic sphincter augmentation (MSA) with the LINX Reflux Management System (Torax Medical, Shoreview, MN), a novel device for the surgical treatment of gastroesophageal reflux disease (GERD). Continued assessment of safety and effectiveness has been monitored in a Post Approval Study. METHODS: Multicenter, prospective study of patients with pathologic acid reflux confirmed by esophageal pH testing undergoing MSA. Predefined clinical outcomes were assessed at the annual visit including a validated, disease-specific questionnaire, esophagogastricduodenoscopy and esophageal pH monitoring, and use of proton pump inhibitors. RESULTS: A total of 200 patients (102 males, 98 females) with a mean age of 48.5 years (range 19.7-71.6) were treated with MSA between March 2013 and August 2015. At 1 year, the mean total acid exposure time decreased from 10.0% at baseline to 3.6%, and 74.4% of patients had normal esophageal acid exposure time (% time pH<4 ≤5.3%). GERD Health-Related Quality of Life scores improved from a median score of 26.0 at baseline to 4.0 at 1 year, with 84% of patients meeting the predefined success criteria of at least a 50% reduction in total GERD Health-Related Quality of Life score compared with baseline. The device removal rate at 1 year was 2.5%. One erosion and no serious adverse events were reported. CONCLUSIONS: Safety and effectiveness of magnetic sphincter augmentation has been demonstrated outside of an investigational setting to further confirm MSA as treatment for GERD.

Laparoscopic magnetic sphincter augmentation versus double-dose proton pump inhibitors for management of moderate-to-severe regurgitation in GERD: a randomized controlled trial.

BACKGROUND AND AIMS: GERD patients frequently complain of regurgitation of gastric contents. Medical therapy with proton-pump inhibitors (PPIs) is frequently ineffective in alleviating regurgitation symptoms, because PPIs do nothing to restore a weak lower esophageal sphincter. Our aim was to compare effectiveness of increased PPI dosing with laparoscopic magnetic sphincter augmentation (MSA) in patients with moderate-to-severe regurgitation despite once-daily PPI therapy. METHODS: One hundred fifty-two patients with GERD, aged ≥21 years with moderate-to-severe regurgitation despite 8 weeks of once-daily PPI therapy, were prospectively enrolled at 21 U.S. sites. Participants were randomized 2:1 to treatment with twice-daily (BID) PPIs (N = 102) or to laparoscopic MSA (N = 50). Standardized foregut symptom questionnaires and ambulatory esophageal reflux monitoring were performed at baseline and at 6 months. Relief of regurgitation, improvement in foregut questionnaire scores, decrease in esophageal acid exposure and reflux events, discontinuation of PPIs, and adverse events were the measures of efficacy. RESULTS: Per protocol, 89% (42/47) of treated patients with MSA reported relief of regurgitation compared with 10% (10/101) of the BID PPI group (P < .001) at the 6-month primary endpoint. By intention-to-treat analysis, 84% (42/50) of patients in the MSA group and 10% (10/102) in the BID PPI group met this primary endpoint (P < .001). Eighty-one percent (38/47) of patients with MSA versus 8% (7/87) of patients with BID PPI had ≥50% improvement in GERD-health-related quality of life scores (P < .001), and 91% (43/47) remained off of PPI therapy. A normal number of reflux episodes and acid exposures was observed in 91% (40/44) and 89% (39/44) of MSA patients, respectively, compared with 58% (46/79) (P < .001) and 75% (59/79) (P = .065) of BID PPI patients at 6 months. No significant safety issues were observed. In MSA patients, 28% reported transient dysphagia; 4% reported ongoing dysphagia. CONCLUSION: Patients with GERD with moderate-to-severe regurgitation, especially despite once-daily PPI treatment, should be considered for minimally invasive treatment with MSA rather than increased PPI therapy. (Clinical trial registration number: NCT02505945.).

CLINICAL PRACTICE GUIDELINES FOR THE PERIOPERATIVE NUTRITION, METABOLIC, AND NONSURGICAL SUPPORT OF PATIENTS UNDERGOING BARIATRIC PROCEDURES - 2019 UPDATE: COSPONSORED BY AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY, THE OBESITY SOCIETY, AMERICAN SOCIETY FOR METABOLIC & BARIATRIC SURGERY, OBESITY MEDICINE ASSOCIATION, AND AMERICAN SOCIETY OF ANESTHESIOLOGISTS - EXECUTIVE SUMMARY.

Objective: The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society, American Society of Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. Methods: Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. Results: New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health-care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). Conclusion: Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. A1C = hemoglobin A1c; AACE = American Association of Clinical Endocrinologists; ABCD = adiposity-based chronic disease; ACE = American College of Endocrinology; ADA = American Diabetes Association; AHI = Apnea-Hypopnea Index; ASA = American Society of Anesthesiologists; ASMBS = American Society of Metabolic and Bariatric Surgery; BMI = body mass index; BPD = biliopancreatic diversion; BPD/DS = biliopancreatic diversion with duodenal switch; CI = confidence interval; CPAP = continuous positive airway pressure; CPG = clinical practice guideline; CRP = C-reactive protein; CT = computed tomography; CVD = cardiovascular disease; DBCD = dysglycemia-based chronic disease; DS = duodenal switch; DVT = deep venous thrombosis; DXA = dual-energy X-ray absorptiometry; EFA = essential fatty acid; EL = evidence level; EN = enteral nutrition; ERABS = enhanced recovery after bariatric surgery; FDA = U.S. Food and Drug Administration; G4G = Guidelines for Guidelines; GERD = gastroesophageal reflux disease; GI = gastrointestinal; HCP = health-care professional(s); HTN = hypertension; ICU = intensive care unit; IGB = intragastric balloon(s); IV = intravenous; LAGB = laparoscopic adjustable gastric band; LAGBP = laparoscopic adjustable gastric banded plication; LGP = laparoscopic greater curvature (gastric) plication; LRYGB = laparoscopic Roux-en-Y gastric bypass; LSG = laparoscopic sleeve gastrectomy; MetS = metabolic syndrome; NAFLD = nonalcoholic fatty liver disease; NASH = nonalcoholic steatohepatitis; NSAID = nonsteroidal anti-inflammatory drug; OA = osteoarthritis; OAGB = one-anastomosis gastric bypass; OMA = Obesity Medicine Association; OR = odds ratio; ORC = obesity-related complication(s); OSA = obstructive sleep apnea; PE = pulmonary embolism; PN = parenteral nutrition; PRM = pulmonary recruitment maneuver; RCT = randomized controlled trial; RD = registered dietician; RDA = recommended daily allowance; RYGB = Roux-en-Y gastric bypass; SG = sleeve gastrectomy; SIBO = small intestinal bacterial overgrowth; TOS = The Obesity Society; TSH = thyroid-stimulating hormone; T1D = type 1 diabetes; T2D = type 2 diabetes; VTE = venous thromboembolism; WE = Wernicke encephalopathy; WHO = World Health Organization.

A Different Kind of Craving: Incidence and Treatment of Pica After Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: Iron deficiency can occur in patients after Roux-en-y gastric bypass due to altered absorption. Pica, the compulsive craving and intake of non-nutritive substances, is a rare and poorly understood presentation of iron deficiency. To our knowledge, the rate of pica after RYGB has never been reported. METHODS: The medical records of patients who underwent laparoscopic RYGB from 2001 to 2011 were reviewed. Patients with pica or other abnormal cravings were identified. RESULTS: Pica was identified in 16/959 (1.7%) patients who underwent RYGB during the study period. The most common presenting sign was pagophagia. All patients with pica were female and had multiple risk factors for iron deficiency with 13/16 being premenopausal and 7/16 non-compliant with oral iron supplementation. Pica symptoms presented at a mean of 3.9 ± 1.9 years after RYGB. Iron deficiency was identified in all 16 patients, with a median ferritin level of 5.0 ng/mL (range 2-27). All 16 patients received intravenous iron and pica symptoms resolved. CONCLUSIONS: Pica is a rare phenomenon associated with iron deficiency and can occur despite oral iron supplementation. In our experience, intravenous iron can relieve symptoms. Patients considering bariatric surgery should be counseled on pica. Patients with unusual cravings should be evaluated for iron deficiency.

Impact of Obesity on Cesarean Delivery Outcomes.

BACKGROUND: The rate of cesarean delivery has increased over the last 2 decades. Obesity is a risk factor for complications during pregnancy and cesarean procedures. The objective of this study was to evaluate cesarean delivery outcomes in patients with vs without obesity, and determine the impact of obesity on complications. METHODS: The medical records of patients who underwent a cesarean delivery from 2010 to 2014 were reviewed. Patients were grouped by body mass index (BMI) into obese (≥30kg/m²) and non-obese (<30kg/m²) cohorts for comparison. RESULTS: Nine hundred seventy-one patients were included; 432 whom had obesity, and 539 did not have obesity. The rate of gestational diabetes was increased among patients with vs without obesity (15.3% vs 5.8%; P<0.001). Obesity was associated with an increased incidence of surgical site infections (8.1% vs 2.4%; P<0.001), yeast infection (2.8% vs 0.2%; P<0.001), and seroma (2.8% vs 0.4%; P=0.002). Obesity was an independent risk factor for surgical site infections, regardless of wound closure technique (adjusted odds ratio=3.24, 95% CI, 1.66-6.32; P<0.001). CONCLUSIONS: Obesity is a risk factor for wound infections after a cesarean delivery. As obesity rates increase, it is important to be aware of these risks after performing a cesarean delivery.

Long-term Outcomes of Patients Receiving a Magnetic Sphincter Augmentation Device for Gastroesophageal Reflux.

BACKGROUND & AIMS: Based on results from year 2 of a 5-year trial, in 2012 the US Food and Drug Administration approved the use of a magnetic device to augment lower esophageal sphincter function in patients with gastroesophageal reflux disease (GERD). We report the final results of 5 years of follow-up evaluation of patients who received this device. METHODS: We performed a prospective study of the safety and efficacy of a magnetic device in 100 adults with GERD for 6 months or more, who were partially responsive to daily proton pump inhibitors (PPIs) and had evidence of pathologic esophageal acid exposure, at 14 centers in the United States and The Netherlands. The magnetic device was placed using standard laparoscopic tools and techniques. Eighty-five subjects were followed up for 5 years to evaluate quality of life, reflux control, use of PPIs, and side effects. The GERD-health-related quality of life (GERD-HRQL) questionnaire was administered at baseline to patients on and off PPIs, and after placement of the device; patients served as their own controls. A partial response to PPIs was defined as a GERD-HRQL score of 10 or less on PPIs and a score of 15 or higher off PPIs, or a 6-point or more improvement when scores on vs off PPI were compared. RESULTS: Over the follow-up period, no device erosions, migrations, or malfunctions occurred. At baseline, the median GERD-HRQL scores were 27 in patients not taking PPIs and 11 in patients on PPIs; 5 years after device placement this score decreased to 4. All patients used PPIs at baseline; this value decreased to 15.3% at 5 years. Moderate or severe regurgitation occurred in 57% of subjects at baseline, but only 1.2% at 5 years. All patients reported the ability to belch and vomit if needed. Bothersome dysphagia was present in 5% at baseline and in 6% at 5 years. Bothersome gas-bloat was present in 52% at baseline and decreased to 8.3% at 5 years. CONCLUSIONS: Augmentation of the lower esophageal sphincter with a magnetic device provides significant and sustained control of reflux, with minimal side effects or complications. No new safety risks emerged over a 5-year follow-up period. These findings validate the long-term safety and efficacy of the magnetic sphincter augmentation device for patients with GERD. ClinicalTrials.gov no: NCT00776997.

Evaluating metabolic and bariatric surgery fellows' attitudes toward their training.

BACKGROUND: The American Society of Metabolic and Bariatric Surgeons (ASMBS) Leadership Academy is conducted at the ASMBS Weekend to prepare surgeons for practice, while in their fellowship. OBJECTIVES: The aim of this analysis is to gather the views of current fellows in training on issues regarding practice patterns and career development. SETTING: Survey at ASMBS Fellows Leadership Academy. METHODS: An online survey was conducted at the last 2 ASMBS Leadership Academy Meetings at the ASMBS Weekend. There were 14 questions. There were 61 respondents. Twenty-three respondents had incomplete surveys and were not included in the final analysis. There were 24 fellows surveyed at the Leadership Academy in November 2022, in San Antonio, TX and 37 in January 2022, in Las Vegas, NV. RESULTS: Fifty-eight percent of attendees were interviewing for employment after their fellowship with 3.64% already employed. Eighteen percent had employment secured upon completion of their fellowship. Of the academic fellows, 29.1% believe that private practice will no longer exist in 2030 and 10.9% of attendees believe that we will have Medicare for all by 2030. Fellows in academic programs ranked their fellowship as either "best decision of my life" or "great" (96.4%) and 3.6% ranked it as "useless (not good/not bad)." Ninety-three percent of attendees said they would do a bariatric fellowship again. Of those that said they would not, all were from a robotic fellowship program. Of those that would do a bariatric fellowship again, 80% stated they would do so at the same institution. CONCLUSIONS: The fellows that attended the ASMBS Leadership Academy overall were very pleased with their fellowship experience, and most would choose to do a MIS/bariatric fellowship again.

Use of Preoperative Endoscopic Capsule-Based pH Testing Before Bariatric Surgery.

BACKGROUND: Vertical sleeve gastrectomy is the most performed bariatric operation in the US; however, a significant number of patients suffer from persistent or new-onset reflux. No consensus for objective preoperative evaluation in these patients exists. We compared capsule-based pH testing vs GERD symptom scoring to determine extent of preoperative GERD to aid in procedure selection for bariatric surgery. STUDY DESIGN: An IRB-approved retrospective review of consecutive patients at a single institution was performed from April 2021 to December 2022. During initial consultation for bariatric surgery, a validated GERD symptom subjective survey was administered. All patients demonstrating interest in sleeve gastrectomy or had a history of reflux underwent upper endoscopy with capsule-based pH testing. RESULTS: Sixty-two patients underwent preoperative endoscopy with capsule-based pH testing and completed GERD symptom assessment survey(s). Median BMI was 43.4 kg/m 2 and 66.1% of patients were not taking a proton-pump inhibitor before performance of pH testing. There was negligible linear association between the objective DeMeester score obtained by capsule-based pH probe and GERD symptom survey scores. Median GERD symptom survey scores did not differ between patients with and without a diagnosis of GERD based on pH testing (all p values >0.11). CONCLUSIONS: An objective method for identifying severe GERD in the preoperative assessment may aid in the decision tree for procedure selection and informed consent process. Patients with significant preoperative GERD may be at higher risk for future GERD-related sleeve complications. Capsule-based pH testing may prove to be superior to subjective symptom scoring systems in this patient population.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Changing trends and outcomes in the use of percutaneous cholecystostomy tubes for acute cholecystitis.

BACKGROUND: Percutaneous cholecystostomy tube (PCT) placement serves as a treatment option for acute cholecystitis in elderly and critically ill patients. The objective of this study was to compare PCT and cholecystectomy outcomes over time. METHODS: PCTs placed from April 1, 1998, to December 31, 2009 (time period 2) were retrospectively reviewed. Patients who underwent cholecystectomies served as matched controls. Institutional data from March 1, 1989, to March 31, 1998 (time period 1) were reviewed to compare trends. RESULTS: A total of 143 patients successfully underwent PCT placement in time period 2. When compared with patients undergoing cholecystectomy, PCT patients had a higher rate of cardiovascular disease (66% vs 26%, P = 0.001), diabetes (27% vs 13%, P = 0.001), and a higher mean Charlson comorbidity index (3.27 vs 1.07, P = 0.001). Compared with the first time period, patients undergoing PCT in the second time period had lower American Society of Anesthesiologist's classifications (American Society of Anesthesiologist's class I, II: 0% vs 18%, P = 0.001). Thirty-day mortality decreased from 36% to 12% in patients undergoing PCT (P = 0.001). CONCLUSIONS: Among patients with acute cholecystitis, percutaneous cholecystostomy tubes were placed in older patients with increased comorbidities compared to cholecystectomy. Mortality rates after PCT decreased over time.

Updates on Surgical Treatment for Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a common condition that is on the rise. Obesity is one risk factor that has increased in parallel with the rise of GERD. Typical symptoms include heartburn, regurgitation, dysphagia, cough, and chest pain. Patients with typical symptoms are empirically treated with proton pump inhibitors (PPIs). If the diagnosis is not clear, further evaluation is performed with endoscopy, pH monitoring, and esophageal manometry. Untreated GERD increases the risk of esophagitis, esophageal stricture, Barrett's esophagus, and esophageal adenocarcinoma. Treatment begins with lifestyle modification and medical therapy. If these fail, surgical and endoscopic surgical techniques are available, to provide treatment, symptom relief, and reduce long-term PPI use.

When the COVID-19 pandemic collides with the obesity epidemic in the United States: a national survey.

BACKGROUND: COVID-19 has disrupted life and put a spotlight on obesity as a risk factor for severe COVID-19 outcomes. Five years ago, we performed a survey exploring ways Americans view obesity and its treatment. We repeated the survey in the COVID-19 era to explore the impact of this once-in-a-century public health crisis on public perception and behavior surrounding obesity. OBJECTIVE: To explore if America's views on obesity have changed after more than 2 years of living through COVID-19. SETTING: The national survey was conducted by the National Opinion Research Center (NORC) from December 10 to 28, 2021. METHODS: We revisited some of the questions posed in a survey 5 years ago and added questions asking whether COVID-19 has changed views on obesity. We surveyed 1714 Americans sampled from a probability-based, nationally representative panel. Responses of Americans to questions about obesity were compared with the same or similar questions asked 5 years ago. RESULTS: COVID-19 has led to a change in how Americans view risks of obesity and benefits of treatment. Nearly one third (29%) of Americans became more worried about having obesity, and this is more pervasive among Black and Hispanic Americans (45%). This heightened concern led an estimated 28 million people to explore treatments not considered before the pandemic, including 6.4 million who thought about bariatric surgery or taking prescription obesity drugs. CONCLUSIONS: COVID-19 may have heightened Americans' worry about obesity. This may present an opportunity for conversations about treatments, including metabolic surgery.

Outcomes of Bariatric Surgery With Concomitant Hiatal Hernia Repair Using an Absorbable Tissue Matrix.

BACKGROUND: Hiatal hernias are a common finding in patients who undergo bariatric surgery with an incidence of about 20% of all bariatric patients. Controversy exists on the utility of a biosynthetic tissue matrix (BTM) usage in combination with crural repair. This study was designed to explore the safety and benefits of the use of a BTM during concomitant hiatal hernia repair with bariatric surgical procedures. METHODS: This was a retrospective chart review of bariatric surgical patients who underwent a concomitant hiatal hernia repair at a single practice at a tertiary academic medical center from January 2014 to February 2019. RESULTS: A total of 420 patients were reviewed. Hiatal BTM reinforcement, recurrence, and postoperative proton pump inhibitor use were reported by type of operation. Recurrence was higher in gastric bypass patients who underwent hiatal hernia repair with suture cruroplasty alone vs. those who also underwent hiatal BTM reinforcement (7.1% vs. 3.7%, P = .52) and significantly higher in gastric sleeve patients who underwent hiatal hernia repair with suture cruroplasty alone vs. those who also underwent hiatal BTM reinforcement (7.1% vs. .5%, P = .01). No patient required reoperation for hiatal hernia recurrence. DISCUSSION: Performing Roux-en-Y gastric bypass or vertical sleeve gastrectomy with concomitant hiatal hernia repair is safe and durable. Employing crural reinforcement with BTM may be of benefit in reducing recurrence rates of hiatal hernia, particularly in sleeve gastrectomy patients.

Epic Sepsis Model Inpatient Predictive Analytic Tool: A Validation Study.

Earlier treatment of sepsis leads to decreased mortality. Epic is an electronic medical record providing a predictive alert system for sepsis, the Epic Sepsis Model (ESM) Inpatient Predictive Analytic Tool. External validation of this system is lacking. This study aims to evaluate the ESM as a sepsis screening tool and determine whether an association exists between ESM alert system implementation and subsequent sepsis-related mortality. DESIGN: Before-and-after study comparing baseline and intervention period. SETTING: Urban 746-bed academic level 1 trauma center. PATIENTS: Adult acute care inpatients discharged between January 12, 2018, and July 31, 2019. INTERVENTIONS: During the before period, ESM was turned on in the background, but nurses and providers were not alerted of results. The system was then activated to alert providers of scores greater than or equal to 5, a set point determined using receiver operating characteristic curve analysis (area under the curve, 0.834; p < 0.001). MEASUREMENTS AND MAIN RESULTS: Primary outcome was mortality during hospitalization; secondary outcomes were sepsis order set utilization, length of stay, and timing of administration of sepsis-appropriate antibiotics. Of the 11,512 inpatient encounters assessed by ESM, 10.2% (1,171) had sepsis based on diagnosis codes. As a screening test, the ESM had sensitivity, specificity, positive predictive value, and negative predictive value rates of 86.0%, 80.8%, 33.8%, and 98.11%, respectively. After ESM implementation, unadjusted mortality rates in patients with ESM score greater than or equal to 5 and who had not yet received sepsis-appropriate antibiotics declined from 24.3% to 15.9%; multivariable analysis yielded an odds ratio of sepsis-related mortality (95% CI) of 0.56 (0.39-0.80). CONCLUSIONS: In this single-center before-and-after study, utilization of the ESM score as a screening test was associated with a 44% reduction in the odds of sepsis-related mortality. Due to wide utilization of Epic, this is a potentially promising tool to improve sepsis mortality in the United States. This study is hypothesis generating, and further work with more rigorous study design is needed.

An analysis of enhanced recovery pathways for bariatric surgery-preoperative fasting, carbohydrate loading, and aspiration risk: a position statement from the International Society for the Perioperative Care of Patients with Obesity.

Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).