Patient Outcomes in Laparoscopic Appendectomy With Acute Surgical Care Model Compared to Traditional Call.

INTRODUCTION: Shift-based models for acute surgical care (ACS), where surgical emergencies are treated by a dedicated team of surgeons working shifts, without a concurrent elective practice, are becoming more common nationwide. We compared the outcomes for appendectomy, one of the most common emergency surgical procedures, between the traditional (TRAD) call and ACS model at the same institution during the same time frame. METHODS: A retrospective review of patients who underwent laparoscopic appendectomy for acute appendicitis during 2017-2018. ACS and TRAD-patient demographics, clinical presentation, operative details, and outcomes were compared using independent sample t-tests, Wilcoxon rank-sum tests and Fisher's exact or χ2 tests. Multiple exploratory regression models were constructed to examine the effects of confounding variables. RESULTS: Demographics, clinical presentation, and complication rates were similar between groups except for a longer duration of symptoms prior to arrival in the TRAD group (Δ = 0.5 d, P = 0.006). Time from admission to operating room (Δ = -1.85 h, P = 0.003), length of hospital stay (Δ = -2.0 d, P < 0.001), and total cost (Δ = $ -2477.02, P < 0.001) were significantly lower in the ACS group compared to the TRAD group. Furthermore, perforation rates were lower in ACS (8.3% versus 28.6%, P = 0.003). Differences for the outcomes remained significant even after controlling for duration of symptoms prior to arrival (P < 0.05). CONCLUSIONS: Acute appendicitis managed using the ACS shift-based model seems to be associated with reduced time to operation, hospital stay, and overall cost, with equivalent success rates, compared to TRAD.

Correction to: Bariatric efficiency at an academic tertiary care center.

This article was updated to correct Adel Alhaj Saleh's name, incorrectly displayed as Adel A. Saleh. It is correct as displayed here: Adel (first name) Alhaj Saleh (last name).

Bariatric efficiency at an academic tertiary care center.

BACKGROUND: Operating room (OR) efficiency requires coordinated teamwork between the staff surgeon, anesthesia team, circulating nurse, surgical technician, and surgical trainee or assistant. Bariatric cases present unique challenges including difficult airways, challenging intravenous access, use of specialized surgical equipment, and synchronized exchange of orogastric tubes. The high contribution margin of these complex bariatric procedures rests on OR efficiency. OBJECTIVE: To compare the efficiency of bariatric surgeries performed by a single surgeon at a tertiary academic medical center with its inherent variability of OR staff to that of a private hospital with a standardized surgical team. METHODS: All laparoscopic Roux-en-Y gastric bypasses (LRYGB) performed by a single surgeon at University Hospitals Cleveland Medical Center (UHCMC) and a Community Affiliate (CA) from 2013 to 2015 were retrospectively reviewed. Patient demographics and preoperative comorbidities were compared. The variability of OR staff at each site was described. Four primary endpoints of the different OR phases were measured at the 2 locations and analyzed using standard statistical methods. RESULTS: The OR data of 74 cases of LRYGB at UHCMC and 106 cases at the CA were analyzed. Patient cohorts were comparable by age (45 ± 12 vs. 45 ± 10; p = 0.88), sex (82% vs. 79% female; p = 0.62), BMI (47.16 ± 7.33 vs. 45.91 ± 6.85; p = 0.25), and comorbidities. At CA, the teams who participated in LRYGB cases were fairly constant (8 circulating and scrub nurses, 4 anesthetists, 3 anesthesiologists), whereas at UHCMC there was great variability in the number of staff with 108 staff (39 circulating nurses, 57 scrub nurses/technicians, 59 anesthetists or anesthesia residents, 24 anesthesiologists) participated in LRYGB cases. There was no statistical difference between the total mean OR time and surgical time of the cases performed at the 2 sites (203 ± 59 min vs. 188 ± 39 min; p = 0.06; 152 ± 56 min; 145 ± 37 min; p = 0.36). However, the pre- and post-case times were longer at UHCMC compared to the CA (38 ± 9 min vs. 33 ± 6 min; p < 0.0001; 13 ± 6 min vs. 10 ± 3 min; p = 0.01). CONCLUSION: The academic center has much greater variability in staff for these complex bariatric procedures. There was a trend toward longer OR times at the tertiary center as demonstrated by the difference in pre- and post-case times, but the consistent surgeon and assistant allowed for consistent surgical case time regardless of the setting. The implication of variability in OR staff can be overcome by the surgeon directing the procedure itself. The opportunity for improving the efficiency of bariatric surgery should focus on the perioperative care of the patient in OR that requires everyone to be familiar with the procedure.

Safety of Revision Sleeve Gastrectomy Compared to Roux-Y Gastric Bypass After Failed Gastric Banding: Analysis of the MBSAQIP.

OBJECTIVE: The aim of this study was to assess the safety of revisional surgery to laparoscopic sleeve gastrectomy (LSG) compared to laparoscopic Roux-Y gastric bypass (LRYGB) after failed laparoscopic adjustable gastric banding (LAGB). BACKGROUND: The number of reoperations after failed gastric banding rapidly increased in the United States during the last several years. A common approach is band removal with conversion to another weight loss procedure such as gastric bypass or sleeve gastrectomy in a single procedure. The safety profile of those procedures remains controversial. METHODS: Preoperative characteristics and 30-day outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files 2015 were selected for all patients who underwent a 1-stage conversion of LAGB to LSG (conv-LSG) or LRYGB (conv-LRYGB). Conv-LSG cases were matched (1:1) with conv-LRYGB patients by age (±1 year), body mass index (±1 kg/m(2)), sex, and comorbidities including diabetes, hypertension, hyperlipidemia, venous stasis, and sleep apnea. RESULTS: A total of 2708 patients (1354 matched pairs) were included in the study. The groups were closely matched as intended. The mean operative time in conv-LRYGB was significantly longer in comparison to conv-LSG patients (151 ±â€Š58 vs 113 ±â€Š45 minutes, P < 0.001). No mortality was observed in either group. Patients after conv-LRYGB had a clinically increased anastomotic leakage rate (2.07% vs 1.18%, P = 0.070) and significantly increased bleed rate (2.66% vs 0.44%, P < 0.001). Thirty-day readmission rate was significantly higher in conv-LRYGB patients (7.46% vs 3.69%, P < 0.001), as was 30-day reoperation rate (3.25% vs 1.26%, P < 0.001). The length of hospital stay was longer in conv-LRYGB. CONCLUSIONS: A single-stage conversion of failed LAGB leads to greater morbidity and higher complication rates when converted to LRYGB versus LSG in the first 30 days postoperatively. These differences are particularly notable with regards to bleed events, 30-day reoperation, 30-day readmission, operative time, and hospital stay.

Improved Outcomes in Treating Acute Biliary Disorders With a Shift-Based Acute Care Surgery Model.

BACKGROUND: As Acute Care Surgery and shift-based models increase in popularity, there is evidence of better outcomes for many types of emergency general surgery patients. We explored the difference in outcomes for patients with acute biliary disorders, treated by either Acute Care Surgery (ACS) model or traditional call model (TRAD) during the same period. METHODS: Retrospective review of patients undergoing laparoscopic cholecystectomy for acute biliary disease 2017-2018. Demographics, clinical presentation, operative details, and outcomes were compared. RESULTS: Demographics, clinical presentation, and complication rates were similar between groups. Time from surgical consult to operating room (Δ = -15.34 hours [-24.57, -6.12], P = .001), length of stay (Δ = -1.4 days [-2.45, -.35], P = .009), and total charges were significantly decreased in ACS group compared to TRAD (Δ$2797.76 [-4883.12, -712.41], P = .009). CONCLUSIONS: Acute biliary disease can be managed successfully in an ACS shift-based model with reduced overall hospital charges and equivalent outcomes.

Variations in insulin requirements can be an early indicator of sepsis in burn patients.

INTRODUCTION: A >25% increase in daily insulin dosing is suggestive of possible sepsis in burn patients, however, no conclusive evidence is available regarding the time point at which insulin dosing begins to increase. The purpose of this study is to determine the exact time point at which the insulin requirement increases among non-diabetic burn patients with sepsis. METHODS: A retrospective chart review in non-diabetic burn patients with ≥20% total body surface area burned (TBSA) during 2010-2018 who received a blood culture for suspected sepsis. Absolute insulin dosing at intervals (0, 24, 48, 72, and 96 h prior to blood culture) were Box-Cox transformed and compared vs.-96 h reference using mixed-effects models accounting for within-patient dependencies. RESULTS: Fifty-eight patients (84% males, age 44 ± 17 years, TBSA% 49 ± 17.5) were included. When cube root of daily insulin dosing was regressed on each time point in a mixed-effects model, statistically significant increase in insulin dosing compared to baseline was observed for -48 (p = 0.018), -24 (p = 0.011), and 0 h (p = 0.008). CONCLUSION: Daily insulin dosing increases 48 h prior to development of other clinical signs of sepsis and can be used as a sensitive early marker.

Comparing outcomes between patients transferred from a critical access hospital versus directly from scene to a level 1 trauma center.

OBJECTIVES: The aim of this retrospective study was to compare the outcomes of trauma patients directly transported to a level I trauma center (SCENE) versus those who were stabilized at a critical access hospital (CAH) and subsequently transferred. METHODS: Patients were grouped based on their transfer status, interventions performed at CAH and outcomes. Google Maps was used to calculate the distances from the location of injury (LOI). Each transfer group data was analyzed separately to examine associations of different factors on the outcomes. Outcomes were compared using univariate and multivariate analyses and propensity score matching analysis. RESULTS: There were 262 patients in SCENE and 684 in CAH. Compared to SCENE, CAH had higher rates of blunt injury and a greater distance from LOI, whereas lower ISS score and length of stay (LOS) (p < 0.05). The majority of CAH group survived compared to SCENE (p = 0.007). For both groups, baseline factors (e.g., age) were associated with outcomes (p < 0.05). Interestingly, longer LOS in the CAH was associated with an increase in survival (p = 0.009), whereas an increased number of CT/MRI performed was associated with increased LOS (p < 0.05)., and an increased number of procedures was associated with longer LOS and ICU stay (p < 0.05). After matching, the two groups had no significant differences in survival, LOS, or ICU stay (p > 0.05). CONCLUSION: Equivalent overall clinical outcomes were seen in both groups, suggesting that existing trauma system protocols in the West Texas region are functioning well to select appropriate patients for each transfer modality. LEVEL OF EVIDENCE III: Retrospective Analysis.

Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer.

INTRODUCTION: Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI). METHODS: This was a secondary analysis of a multicenter, case-control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts. RESULTS: A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53). CONCLUSION: For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary. STUDY TYPE: Original article, case series. LEVEL OF EVIDENCE: III.

In-hospital perforation risk in acute appendicitis: Age matters.

BACKGROUND: Controversy exists regarding how quickly an adult with appendicitis requires surgery to prevent perforation, and recent literature on antibiotic use as definitive treatment has complicated this question further. Since perforation is associated with worse outcomes, particularly in the elderly, efforts to prevent this complication are warranted. We studied risk factors for in-hospital perforation in patients diagnosed by admission CT with non-perforated acute appendicitis. METHODS: We evaluated baseline demographics, symptom duration, and time from admission to antibiotics and surgery. Outcome measure was perforation diagnosed intra-operatively by attending surgeon. RESULTS: Of 700 patients, 84 (12%) sustained in-hospital perforation; time from admission to operation or antibiotics were not associated. Duration of symptoms >24 h (aOR = 2.23, 95% CI = 1.33-3.72, p < 0.001) increased perforation risk. Patient age over 46 years (aOR = 4.54, 95% CI = 2.04-10.06, p < 0.001) was also associated with higher risk that increased with increasing age. CONCLUSION: Time to operation and antibiotic timing were not associated with in-hospital perforation in a general adult population. However, these findings suggest a possible benefit to expedient surgery in older patients.

Surgical management of advanced hidradenitis suppurativa via a one-stage procedure: A single-center experience.

BACKGROUND: Hidradenitis suppurativa (HS) is a debilitating skin condition; in severe forms it requires excision and skin grafting for cure. This is commonly performed as a multi-stage procedure; we explored single-stage operation as a more efficient alternative. METHODS: Retrospective review 2007-2018 evaluating outcomes of patients undergoing single-stage surgery. RESULTS: 139 one-stage procedures were performed: 35 excision and primary closure, 104 split-thickness skin grafting (STSG). Success rate was higher for STSG at 75% versus 60% with primary closure. Of failed primary closures, 57% required revision by grafting due to recurrence. Axilla procedures were most successful at 91% compared to 70%, 54%, and 50% for inguinal, gluteal, and perineal areas, respectively. Infection was the most common complication (17%), with 38% requiring readmission. CONCLUSION: Compared to prior literature on multi-stage HS treatment, one-stage operations are a feasible, cost-effective alternative. STSG should remain the procedure of choice, even when primary closure appears feasible.

Actions of annatto-extracted tocotrienol supplementation on obese postmenopausal women: study protocol for a double-blinded, placebo-controlled, randomised trial.

INTRODUCTION: Obesity is a major health concern in postmenopausal women, and chronic low-grade inflammation contributes to the development of obesity. Cellular studies and high-fat-diet-induced obese mouse model mimicking obesity show the antiobesity effect of annatto-extracted tocotrienols (TT) with antioxidant capability. We aim to assess the safety and efficacy of TT consumption for lipid-related parameters in obese postmenopausal women. METHODS AND ANALYSIS: Eligible obese postmenopausal women will be randomly assigned to placebo group (430 mg olive oil) and TT group (DeltaGold Tocotrienol 70%) for 24 weeks. In the present study, the primary outcome is total/regional fat mass and visceral adipose tissue. The secondary outcomes include lipid profile in serum, mRNA expression of fatty acid synthase and carnitine palmitoyltransferase 1A in fat tissue, oxylipins and endocannabinoids in plasma and adipose tissue, abundance and composition of intestinal microbiome in faeces, high-sensitivity C-reactive protein (hs-CRP) in serum and leptin in serum. Every participant will be evaluated at 0 (prior to starting intervention) and 24 weeks of intervention, except for serum lipid profile and hs-CRP at 0, 12 and 24 weeks. 'Intent-to-treat' principle is employed for data analysis. Hierarchical linear modelling is used to estimate the effects of dietary TT supplementation while properly accounting for dependency of data and identified covariates. To our knowledge, this is the first randomised, placebo-controlled, double-blinded study to determine dietary TT supplementation on an obese population. If successful, this study will guide the future efficacy TT interventions and TT can be implemented as an alternative for obese population in antiobesity management. ETHICS AND DISSEMINATION: This study has been approved by the Bioethics Committee of the Texas Tech University Health Sciences Center, Lubbock. An informed consent form will be signed by a participant before enrolling in the study. The results from this trial will be actively disseminated through academic conference presentation and peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03705845.

Prophylactic Probiotics in Burn Patients: Risk versus Reward.

Probiotics are often used in critically ill patients to prevent antibiotic-associated complications, including Clostridium difficile colitis. However, clinical evidence of their efficacy is lacking. The objective of this study is to assess the impact of prophylactic probiotic administration on bowel function, gut microbial diversity, and nutritional markers in adult burn patients. A retrospective cohort study was done on 108 burn patients aged 18 to 89. Patients were given >1 million colony-forming units per day of Lactobacillus acidophilus and Lactobacillus rhamnosus. Testing for C. difficile was used as a surrogate marker for the presence of diarrhea. Serum C-reactive protein and prealbumin values were measured. Additionally, the gut microbial diversity of eight patients was tracked via 16S quantitative PCR before and throughout the course of a standard probiotic regimen. Patients receiving oral probiotics had more reported diarrhea in the first and second weeks of treatment. In the second week, C-reactive protein levels were increased, while serum prealbumin levels were lower in patients receiving probiotics, suggesting potential malabsorption. Additionally, there was no difference in C. difficile infection, sepsis rates, emesis, or gastric residuals, indicating an absence of therapeutic benefit for probiotic administration in burn patients. Furthermore, it was determined that no discernible benefit to gut microbial diversity was conferred by probiotic therapy. Prophylactic probiotics in burn patients are not associated with improvements in patient outcomes and may in fact be associated with an increased incidence of diarrhea and malabsorption. Additional research is needed before routine use in burn patients.

Laparoscopic omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study.

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.

Jejuno-gastric intussusception: A case report of unusual cause of food intolerance after roux-En-Y gastric bypass.

INTRODUCTION: Morbid obesity is increasing worldwide as a result, weight loss procedures such as Roux- En-Y gastric bypass (RYGB) are increasing as well. RYGB has multiple complications including intussusception, most of the cases are jejuno-jejunal. Only one case reported to be Jejuno-gastric intussusception (JGI) but through the remnant and not the gastro-jejunostomy anastomosis (GJ). CASE REPORT: A 50-year-old female presented to the emergency department complaining of diffuse abdominal pain, nausea, and vomiting. Her surgical history is significant for an RYGB 17 years ago. Nausea and food intolerance were the most prominent symptoms. CT scan of the abdomen and upper GI series were normal. Only Esophagogastroduodenoscopy (EGD) showed JGI through GJ, with friable mucosa and a small gastro-gastric fistula. Patient underwent successful reconstruction of GJ and had no symptoms afterwards. CONCLUSION: JGI is a rare of cause of abdominal pain, nausea and vomiting after RYGB. Early diagnosis is crucial, a thorough work up is needed to make diagnosis of JGI including EGD. Revision of GJ anastomosis is necessary to address this phenomenon.

Application of HARM Score to Measure Surgical Quality and Outcomes in Bariatric Patients.

BACKGROUND: The HospitAl stay, Readmission, and Mortality rates (HARM) score is a quality indicator that is easily determined from routine administrative data. However, the HARM score has not yet been applied to patients undergoing bariatric surgery. OBJECTIVE: The aims of the present study were to adjust the HARM score to the bariatric population and to validate the ability of the modified HARM score to serve as an inexpensive tool to measure the quality of bariatric surgery. METHODS: A MBSAQIP 2015 PUF database was reviewed. For each discharge, a 1 to 10 score was calculated on the basis of length of stay (LOS), discharge status, and 30-day readmissions. We adjusted the LOS categories to the distribution of LOS in the MBSQIP database. The new LOS categories were used to calculate the modified HARM score, referred to as the BARiatric HARM (BAR-HARM) score. The association between HARM and BAR-HARM scores and complication rate was assessed. RESULTS: A total of 197,141 cases were evaluated: 98.8% were elective and 1.2% were emergent admissions. The mean individual patient BAR-HARM score was 1.75 ± 1.04 for elective cases, and 2.02 ± 1.45 for emergency cases. The complication rates for the respective BAR-HARM categories ≤ 2, > 2 to 3, > 3 to 4, and > 4 were 3.95, 27.53, 40.14, and 79.97% (p < 0.001). CONCLUSIONS: The quality of bariatric surgery can be reliably and validly assessed using the BAR-HARM score, which is a modification of the HARM score.

Safety of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in elderly patients - analysis of the MBSAQIP.

BACKGROUND: An increase in the prevalence of obesity and longer life expectancy has resulted in an increased number of candidates over the age of 60 who are pursuing a bariatric procedure. OBJECTIVE: The aim of this study was to assess the safety of laparoscopic Roux-Y gastric bypass (LRYGB) compared to laparoscopic sleeve gastrectomy (LSG) in patients aged 60 years or older. SETTING: University Hospital, United States METHODS: Preoperative characteristics and 30-day outcomes from the MBSAQIP 2015 were selected for all patients aged 60 years or older who underwent a LSG or LRYGB. LRYGB cases were closely matched (1:1) with LSG patients by age (±1 year), BMI (±1 kg/m2), gender, preoperative steroid or immunosuppressant use, preoperative functional health status and comorbidities including: diabetes, gastroesophageal reflux disease, hypertension, hyperlipidemia, venous stasis, sleep apnea and history of severe chronic obstructive pulmonary disease. RESULTS: A 3371 matched pairs were included in the study. The mean operative time in LRYGB was significantly longer in comparison to LSG patients (122 vs 84 min., P<0.001). Patients after LRYGB had a significantly increased anastomotic leakage rate (1.01% vs 0.47 %, p = 0.011), 30-day readmission rate (6.08% vs 3.74%, p < 0.001) and 30-day reoperation rate (2.49% vs 0.89%, p < 0.001) The length of hospital stay was longer in LRYGB. Mortality and bleed rate was comparable. CONCLUSIONS: LRYGB and LSG in patients aged 60 years or older are relatively safe in the short term with an acceptable complication rate and low mortality. However, LRYGB is more challenging and is associated with significantly increased rates of leakage events, 30-day reoperation, 30-day readmission, longer operative time and longer hospital stay.

Does Sleeve Shape Make a Difference in Outcomes?

INTRODUCTION: Sleeve gastrectomy (SG) is one of the most common procedures performed for weight loss. Many seek the "perfect sleeve" with the notion that the type of calibrating device affects sleeve shape, and this in turn will affect outcomes and complications. Two major concerns after SG are amount of weight loss and acid reflux. Our aim was to determine if the various calibration methods could impact sleeve shape and thereby allow for better outcomes of weight loss and reflux. METHODS: A retrospective chart review was performed of 210 patients who underwent SG and had postoperative upper gastrointestinal (UGI) study from 2011 to 2015 in a single center by a single (fellowship-trained) bariatric surgeon. Data regarding demographics, calibrating devices and clinical outcomes at 1 year (weight loss and de novo acid reflux) were collected. UGIs were reviewed by two radiologists blinded to the clinical outcomes. Sleeve shape was classified according to a previously described classification as tubular, dumbbell, upper pouch, or lower pouch. The types of calibrating devices used to guide the sleeve size intraoperatively were endoscopy, large-bore orogastric tube, and fenestrated suction tube. RESULTS: One hundred ninety-nine patients met inclusion criteria (11 had no esophagram). Demographics revealed age 45.76 ± 10.6 years, BMI 47 ± 8.6 kg/m2, and 82% female. Calibration devices used were endoscopic guidance (7.6%), large bore orogastric tube (41.4%), and fenestrated suction tube (50.5%). Sleeve shape was reported as 32.6% tubular, 20.6% dumbbell, 39.2% lower pouch, and 7.5% upper pouch (100% interrater reliability). No correlation was seen with type of calibration used. Of patients, 62.0% had > 50% excess weight loss at 1 year. Twenty-three percent of patients remained on PPI at 1 year (of which 43.3% did not have reflux preoperatively). The lower pouch shape showed a trend toward less reflux and more weight loss. CONCLUSION: This study showed no clear association between uniformity of sleeve shape and the type of calibration device used. The study showed a trend toward decreased reflux and improved weight loss with the lower pouch shape, regardless of calibration device.