Sociodemographic factors leading to preventable emergency department visits after bariatric surgery: a single-institution analysis.

BACKGROUND: An important quality benchmark after bariatric surgery is 30-day emergency department (ED) visits. OBJECTIVES: We aimed to identify risk factors for ED visits not requiring readmission and thus deemed preventable. SETTING: University Hospital. METHODS: Patients who underwent a minimally invasive sleeve gastrectomy between 2017 and 2022 at a single institution were identified. Among these patients, those who presented to the ED within 30 days after surgery were matched 3:1 to controls. Sociodemographic and clinical variables were collected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database and the electronic medical record. Univariate conditional logistic regression analysis was performed to determine predictive factors of ED visits. RESULTS: Overall, 648 patients underwent sleeve gastrectomy, of which 53 (8.2%) presented to the ED within 30 days postoperatively without requiring readmission. Patients who presented to the ED were more likely to be unemployed (42% versus 24%, P = .04) and have government insurance (68% versus 41%, P = .001). Significant risk factors included lower versus upper socioeconomic bracket (odds ratio [OR] 3.6, P = .042), primary care physician (PCP) outside the health system versus within (OR 2.15, P = .032), greater number of PCP visits within the past year (OR 1.27, P < .001), and greater number of postoperative clinic phone calls (OR 2.04, P < .001). The number of ED visits within 1 year before surgery was a significant risk factor, with an OR of 1.44 for each visit (P < .001). CONCLUSIONS: Modifiable and unmodifiable risk factors contribute to ED visits after bariatric surgery. Identifying these risk factors can aid in the development of quality improvement initiatives.

A comprehensive analysis of health care Inequities in randomized clinical trials following bariatric surgeries.

BACKGROUND: Obesity is a global epidemic, leading to an increasing focus on interventions like bariatric surgeries. Despite this, there's a noticeable gap in understanding the demographic distribution of patients in clinical trials for bariatric surgery. METHODS: We conducted a comprehensive analysis of 117 registered randomized clinical trials related to bariatric surgery on ClinicalTrials.gov. We extracted demographic information, including age, sex, race, and ethnicity, and performed descriptive statistical analyses. RESULTS: The analysis covered 8,418 participants. The mean age was 43.8 years, with a substantial majority (93.8 â€‹%) falling within the 18-65 age group. Females comprised 74.9 â€‹% of participants, surpassing real-world estimates. Racially, 65.3 â€‹% of participants were White, while African Americans represented 18.5 â€‹%, Asians 1.2 â€‹%, Native Hawaiians 0.2 â€‹%, and American Indians 0.1 â€‹%, indicating an underrepresentation of diverse racial groups, notably lower compared to real-world demographic data. In terms of ethnicity, only 17.6 â€‹% were Hispanic. CONCLUSIONS: This study reveals significant demographic disparities in patients undergoing bariatric surgeries in clinical trials. This suggests a lack of generalizability, emphasizing the need for inclusive recruitment strategies to enhance health equity.

Sleeve Gastrectomy Protects Against Hypertension in Rats due to Changes in the Gut Microbiome.

INTRODUCTION: Sleeve gastrectomy (SG), results in improvement in hypertension. We have previously published that rodent SG improves hypertension independent of weight loss associated with unique shifts in the gut microbiome. We tested if the gut microbiome directly improves blood pressure by performing fecal material transfer (FMT) from post-SG rats to surgery-naïve animals. METHODS: We performed SG or Sham surgery in male, Zucker rats (n = 6-7) with obesity. Stool was collected postop from surgical donors for treatment of recipient rats. Three nonsurgical groups received daily, oral consumption of SG stool, sham stool, or vehicle alone (Nutella) for 10 wk (n = 7-8). FMT treatment was assessed for effects on body weight, food intake, oral glucose tolerance, and blood pressure. Genomic deoxyribonucleic acid of stool from donor and recipient groups were sequenced by 16S ribosomal ribonucleic acid and analyzed for diversity, abundance, and importance. RESULTS: Ten weeks of SG-FMT treatment significantly lowered systolic blood pressures in surgery-naïve, recipient rats compared to vehicle treatment alone (126.8 ± 13.3 mmHg versus 151.8 ± 12.2 mmHg, P = 0.001). SG-FMT treatment also significantly altered beta diversity metrics compared to Sham-FMT and vehicle treatment. In random forest analysis, amplicon sequence variant level significantly predicted FMT group, P = 0.01. CONCLUSIONS: We have found a direct link between gut microbial changes after SG and regulation of blood pressure. Future mechanistic studies are required to learn what specific gut microbial changes are required to induce improvements in obesity-associated hypertension and translation to clinical, metabolic surgery.

Diet in Food Insecurity: A Mediator of Metabolic Health?

Objective: Food insecurity (FI) is associated with poor metabolic health. It is assumed that energy intake and diet quality underlie this association. We tested the hypothesis that dietary factors (quantity and quality) mediate the association of FI with excess weight, waist circumference and glycemic control [glycohemoglobin (A1C)]. Methods: A mediation analysis was performed on data from the National Health And Nutrition Examination Survey using FI as an independent variable; body mass index (BMI), waist circumference, and A1C as metabolic outcome variables and total energy intake, macronutrients, and diet quality measured by the Healthy Eating Index-2015 (HEI-2015) as potential mediators. Results: Despite a greater prevalence of obesity in participants experiencing FI, daily reported energy intake was similar in food-secure and -insecure subjects. In adjusted analyses of the overall cohort, none of the examined dietary factors mediated associations between FI and metabolic outcomes. In race-stratified analyses, total sugar consumption was a partial mediator of BMI in non-Hispanic Whites, while diet quality measures (HEI-2015 total score and added sugar subscore) were partial mediators of waist circumference and BMI, respectively, for those in the "other" ethnic group. Conclusion: Dietary factors are not the main factors underlying the association of FI with metabolic health. Future studies should investigate whether other social determinants of health commonly present in the context of FI play a role in this association.

Bariatric Surgeon Ergonomics: A Comparison of Laparoscopy and Robotics.

INTRODUCTION: Bariatric surgery is routinely performed using laparoscopic and robotic approaches. Musculoskeletal injuries are prevalent among both robotic and laparoscopic bariatric surgeons. Studies evaluating ergonomic differences between laparoscopic and robotic bariatric surgery are limited. This study aims to analyze the ergonomic, physical, and mental workload differences among surgeons performing robotic and laparoscopic bariatric surgery. MATERIALS AND METHODS: All primary laparoscopic and robotic bariatric surgeries, Roux-en-Y gastric bypass, and sleeve gastrectomy between May and August 2022 were included in this study. Objective ergonomic analysis was performed by an observer evaluating each surgeon intraoperatively according to the validated Rapid Entire Body Assessment tool, with a higher score indicating more ergonomic strain. After each operation, surgeons subjectively evaluated their physical workload using the body part discomfort scale, and their mental workload using the surgery task load index. RESULTS: Five bariatric surgeons participated in this study. In total, 50 operative cases were observed, 37 laparoscopic and 13 robotic. The median total Rapid Entire Body Assessmentscore as a primary surgeon was significantly higher in laparoscopic (6.0) compared to robotic (3.0) cases (P < 0.01). The laparoscopic and robotic approaches had no significant differences in the surgeons' physical (body part discomfort scale) or mental workload (surgery task load index). CONCLUSIONS: This study identified low-risk ergonomic stress in surgeons performing bariatric surgery robotically compared to medium-risk stress laparoscopically. Since ergonomic stress can exist even without the perception of physical or mental stress, this highlights the importance of external observations to optimize ergonomics for surgeons in the operating room.

The Association of Preoperative Food Insecurity With Early Postoperative Outcomes After Bariatric Surgery.

INTRODUCTION: To assess the rate of food insecurity in patients undergoing bariatric surgery. To compare the rates of 30-d postoperative complications based on food security status. METHODS: Patients undergoing primary Roux-en-Y gastric bypass or sleeve gastrectomy between 7/2020 - 3/2022 were screened for food insecurity via telephone using questions from the Accountable Health Communities Health-Related Social Needs Screening Tool. Screens were matched to patient data and 30-d outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. RESULTS: In total, 213 (59%) of the 359 bariatric surgery patients were screened with 81 (38%) screening positive for food insecurity. Evaluation of preoperative variables based on food security status showed comparable age, body mass index, and comorbidity status. Food insecure patients were found to have an increased length of stay following surgery compared to food secure patients (P = 0.003). Food insecurity was not associated with higher rates of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program reported 30-d postoperative complications including emergency department/urgent care visits (P = 0.34) and hospital readmissions (P = 0.94). CONCLUSIONS: Food insecurity was prevalent at 38% of the bariatric surgical population. Food insecure patients had a statistically longer length of stay after primary bariatric surgery but were not associated with an increased risk of 30-d complications. Future studies are needed to determine the mid-term and long-term effects of food insecurity status on bariatric surgical outcomes and the potential impact of food insecurity on length of stay.

Bariatric Surgeon Perspective on Revisional Bariatric Surgery (RBS) for Weight Recurrence.

BACKGROUND: Weight recurrence (WR) after bariatric surgery occurs in nearly 20% of patients. Revisional bariatric surgery (RBS) may benefit this population but remains controversial among surgeons. OBJECTIVES: Explore surgeon perspectives and practices for patients with WR after primary bariatric surgery (PBS). SETTING: Web-based survey of bariatric surgeons. METHODS: A 21-item survey was piloted and posted on social media closed groups (Facebook) utilized by bariatric surgeons. Survey items included demographic information, questions pertaining to the definition of suboptimal and satisfactory response to bariatric surgery, and general questions related to different WR management options. RESULTS: One hundred ten surgeons from 19 countries responded to the survey. Ninety-eight percent responded that WR was multifactorial, including behavioral and biological factors. Failure of PBS was defined as excess weight loss < 50% by 31.4%, as excess weight loss <25% by 12.8%, and as comorbidity recurrence by 17.4%. Surgeon responses differed significantly by gender (P = .036). 29.4% believed RBS was not successful, while 14.1% were unsure. Nevertheless, 73% reported that they would perform RBS if sufficient evidence of benefit existed. Most frequently performed revisional procedures included conversion of sleeve gastrectomy to Roux-en-Y gastric bypass (RYGB), adjustable gastric band to RYGB, and RYGB revision (21.9% versus 18.2% versus 15.3%, respectively). CONCLUSIONS: This survey demonstrates significant variability in surgeon perception regarding causes and the effectiveness of RBS. Moreover, they disagree on what constitutes a nonsatisfactory response to PBS and to whom they offer RBS. These findings may relate to limited available clinical evidence on best management options for this patient population. Clinical trials investigating the comparative effectiveness of various treatment options are needed.

A single, peri-operative antibiotic can persistently alter the post-operative gut microbiome after Roux-en-Y gastric bypass.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) significantly alters the gut microbiome and may be a mechanism for post-operative cardiovascular disease improvement. We have previously found an association between the class of peri-operative, intravenous antibiotic administered at the time of RYGB and the resolution rate of hypertension suggesting the gut microbiome as a mechanism. In this study, we performed a prospective study of RYGB to determine if a single intravenous antibiotic could alter the gastrointestinal microbial composition. METHODS: Patients undergoing RYGB were randomized to a single, peri-operative antibiotic of intravenous cefazolin (n = 8) or clindamycin (n = 8). Stool samples were collected from four-time points: 2 weeks pre-op (- 2w), 2 days pre-op (- 2d), 2 weeks post-op (+ 2w) and 3 months post-op (+ 3m). Stool samples were processed for genomic DNA followed by Illumina 16S rRNA gene sequencing and shotgun metagenomic sequencing (MGS). RESULTS: A total of 60 stool samples (- 2w, n = 16; - 2d, n = 15; + 2w, n = 16; + 3m, n = 13) from 16 patients were analyzed. 87.5% of patients were female with an average age of 48.6 ± 12.2 years and pre-operative BMI of 50.9 ± 23.3 kg/m2. RYGB induced statistically significant differences in alpha and beta diversity. There were statistically significant differences in alpha diversity at + 2w and beta diversity at + 3m due to antibiotic treatment. MGS revealed significantly distinct gut microbiota with 11 discriminatory metagenomic assembled genomes driven by antibiotic treatment at 3 months post-op, including increased Bifidobacterium spp. with clindamycin. CONCLUSION: RYGB induces significant changes in the gut microbiome at 2 weeks that are maintained 3 months after surgery. However, the single peri-operative dose of antibiotic administered at the time of RYGB induces unique and persisting changes to the gut microbiome that are antibiotic-specific. Increased Bifidobacterium spp. with clindamycin administration may improve the metabolic efficacy of RYGB when considering gut-microbiome driven mechanisms for blood pressure resolution.

Sleeve Gastrectomy Improves High-Fat Diet-Associated Hepatic Steatosis Independent of the Glucagon-like-Petpide-1 Receptor in Rats.

BACKGROUND: The gastrointestinal hormone glucagon-like peptide-1 (GLP-1) is increased after sleeve gastrectomy (SG). Rat and clinical studies support, while mouse studies refute, a role for GLP-1R signaling after SG. Therefore, we developed a global GLP-1R knockout (KO) rat to test the hypothesis that a functional GLP-1R is critical to induce weight loss and metabolic disease improvement after SG. METHODOLOGY: A 4 bp deletion was created in exon 2 of the GLP-1R gene on a Lewis strain background to create a global GLP-1R KO rat. KO and Lewis rats were placed on a high-fat or low-fat diet and phenotyped followed by SG or Sham surgery and assessed for the effect of GLP-1R KO on surgical and metabolic efficacy. RESULTS: Loss of the GLP-1R created an obesity-prone rodent without changes in energy expenditure. Both male and female KO rats had significantly greater insulin concentrations after an oral glucose gavage, augmented by a high-fat diet, compared to Lewis rats despite similar glucose concentrations. GLP-1R KO caused hepatomegaly and increased triglyceride deposition compared to Lewis rats. We found no difference between SG GLP-1R KO and Lewis groups when considering efficacy on body weight, glucose tolerance, and a robustly preserved improvement in fatty liver disease. CONCLUSIONS: Loss of the GLP-1R in rats resulted in increased adiposity, insulin resistance, and severe steatosis. A functional GLP-1R is not critical to the metabolic efficacy of SG in Lewis rats, similar to mouse studies, but importantly including steatosis, supporting a GLP-1R-independent mechanism for the improvement in fatty liver disease after SG.

Isolated left ventricular assist device implantation produces variable changes to patient body mass index.

BACKGROUND: Body mass index (BMI) is an important consideration for transplant-eligible left ventricular assist device (LVAD) recipients. LVAD therapy's impact on BMI is unclear. We evaluated BMI changes in patients who underwent LVAD implantation. The association between these patients' BMI and the transplant was studied. METHODS: This was a retrospective cohort study of patients who underwent LVAD implantation between January 1, 2012 and December 31, 2018 at our institution. Patients were stratified by preoperative BMI (kg/m2 ) into four groups: <30, 30-34.9, 34.9-39.9, and ≥40. BMI data were collected at 12 and 6 months prior to implantation, time of implantation, and 3- and 6- months postimplantation. RESULTS: A total of 107 patients underwent LVAD implantation at our institution. Data were available for 80 patients. Baseline characteristics included a mean age of 56.0 years, 69% male, and a mean implant BMI of 29.9 ± 6.8 kg/m2 . The mean BMI (kg/m2 ) for each of the BMI (kg/m2 ) groups <30, 30-34.9, 35-39.9, and ≥40 (n = 60, 25, 12, and 10, respectively) was 25.1, 32.5, 36.8, and 43.8, respectively. There was no consistent pattern with weight change across differing implant BMIs. No patient with a BMI of <30 gained sufficient weight to impact transplant candidacy. Twenty-three percent of patients with a BMI of 30-34.9 kg/m2 , 60% of patients with a BMI of 35-39.9 kg/m2 , and 87.5% of patients with a BMI of ≥40 kg/m2 had a 6-month BMI potentially affecting transplant. CONCLUSIONS: Associated weight changes during LVAD support may significantly impact transplant candidacy. Higher BMI groups may benefit from multimodal and multidisciplinary targeted weight-loss interventions.

Transversus abdominis plane blocks for complex abdominal wall reconstruction decrease hospital length of stay compared to epidurals.

BACKGROUND: Complex abdominal wall reconstruction for ventral and incisional hernias can be quite painful with prolonged length of stay (LOS). There are a variety of options to manage post-operative pain after a ventral hernia repair, including epidural catheters, transversus abdominis plane (TAP) blocks, and intravenous narcotic pain medications (IVPM). We hypothesized that TAP blocks with liposomal bupivacaine decrease the LOS compared to epidurals and IVPM. METHODS: A retrospective review of all patients who underwent an open ventral hernia repair with retromuscular mesh between 2016 and 2020 was conducted. LOS was used as the primary outcome. Secondary outcomes included post-operative pain and 90-day post-operative complications. RESULTS: An epidural was used in 66 patients, a TAP block with liposomal bupivacaine in 18 patients, and IVPM in 11 patients. The epidural group was noted to have a significantly longer duration of surgery (251.11 vs. 207.94 min; P < 0.05) and larger area of mesh (461.85 vs. 338.17 cm2; P < 0.05) when compared to the TAP block group. Hospital LOS was significantly shorter for the TAP block group compared to the epidural group (4.22 vs. 5.62 days; P < 0.05). There were no differences in post-operative complications between the groups. The epidural group reported significantly lower post-operative day one (POD1) pain scores measured on a 10-point scale, compared to the IVPM and TAP block groups (5.00 vs. 6.91 vs. 7.50; P < 0.05). CONCLUSION: Patients who received a TAP block for post-operative pain management had a significantly shorter length of stay compared to those patients who received an epidural. While the TAP block group reported higher POD1 pain scores, they did not have a significant difference in post-operative complications. TAP blocks with liposomal bupivacaine should be considered for post-operative pain control in complex ventral hernia repairs.

Guidelines for the performance of minimally invasive splenectomy.

BACKGROUND: Minimally invasive splenectomy (MIS) is increasingly favored for the treatment of benign and malignant diseases of the spleen over open access approaches. While many studies cite the superiority of MIS in terms of decreased morbidity and length of stay over a traditional open approach, the comparative effectiveness of specific technical and peri-operative approaches to MIS is unclear. OBJECTIVE: To develop evidence-based guidelines that support clinicians, patients, and others in decisions on the peri-operative performance of MIS. METHODS: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) including methodologists used the Grading of Recommendations Assessment, Development and Evaluation approach to grade the certainty of evidence and formulate recommendations. RESULTS: Informed by a systematic review of the evidence, the panel agreed on eight recommendations for the peri-operative performance of MIS for adults and children in elective situations addressing six key questions. CONCLUSIONS: Conditional recommendations were made in favor of lateral positioning for non-hematologic disease, intra-operative platelet administration for patients with idiopathic thrombocytopenic purpura instead of preoperative administration, and the use of mechanical devices to control the splenic hilum. Further, a conditional recommendation was made against routine intra-operative drain placement.

The Impact of Hemoglobin A1c on Post-operative Outcomes in Bariatric Surgery Patients.

INTRODUCTION: Pre-operative hemoglobin (Hb) A1c levels ≥ 8% can lead to increased post-operative complications. In bariatric surgery patients, attaining a pre-operative HbA1c < 8% can be a challenge. The purpose of this study was to identify the association of pre-operative HbA1c on post-operative outcomes in bariatric surgery patients. MATERIAL AND METHODS: A retrospective chart review was conducted on diabetic patients (HbA1c ≥ 6.5%) who underwent primary bariatric surgery at a single institution between the years 2013 and 2019. Patients were divided into two groups based on their pre-operative HbA1c levels of < 8% and ≥ 8%. Univariate analyses were performed to determine an association between pre-operative HbA1c levels and post-operative outcomes. RESULTS: There were 351 primary diabetic bariatric surgery patients, 270 HbA1c <8%, and 81 HbA1c ≥ 8%. Procedure selection was significantly different between the HbA1c < 8% and HbA1c ≥ 8% group (49.3% sleeve, 50.4% bypass and 0.4% band versus 43.2% sleeve, 53.1% bypass and 3.7% band respectively, P < 0.04). There was no statistically significant difference in any 30-day post-operative outcome between the two groups. Post-operative HbA1c was significantly less in the HbA1c < 8% group at 3-6 month (6.0% ± 0.9 versus 7.4% ± 1.4, P <0.001) and 6-12 month (6.0% ± 1.1 versus 7.2% ± 1.4, P <0.001) follow-up. CONCLUSIONS: This study demonstrated no difference in post-operative outcomes of primary bariatric surgery patients based on a HbA1c cut-off of 8%. This highlights that bariatric surgery can be considered and safely performed in patients with a pre-operative HbA1c ≥ 8%.