Readiness to Embrace Artificial Intelligence Among Medical Doctors and Students: Questionnaire-Based Study.

BACKGROUND: Similar to understanding how blood pressure is measured by a sphygmomanometer, physicians will soon have to understand how an artificial intelligence-based application has come to the conclusion that a patient has hypertension, diabetes, or cancer. Although there are an increasing number of use cases where artificial intelligence is or can be applied to improve medical outcomes, the extent to which medical doctors and students are ready to work and leverage this paradigm is unclear. OBJECTIVE: This research aims to capture medical students' and doctors' level of familiarity toward artificial intelligence in medicine as well as their challenges, barriers, and potential risks linked to the democratization of this new paradigm. METHODS: A web-based questionnaire comprising five dimensions-demographics, concepts and definitions, training and education, implementation, and risks-was systematically designed from a literature search. It was completed by 207 participants in total, of which 105 (50.7%) medical doctors and 102 (49.3%) medical students trained in all continents, with most of them in Europe, the Middle East, Asia, and North America. RESULTS: The results revealed no significant difference in the familiarity of artificial intelligence between medical doctors and students (P=.91), except that medical students perceived artificial intelligence in medicine to lead to higher risks for patients and the field of medicine in general (P<.001). We also identified a rather low level of familiarity with artificial intelligence (medical students=2.11/5; medical doctors=2.06/5) as well as a low attendance to education or training. Only 2.9% (3/105) of medical doctors attended a course on artificial intelligence within the previous year, compared with 9.8% (10/102) of medical students. The complexity of the field of medicine was considered one of the biggest challenges (medical doctors=3.5/5; medical students=3.8/5), whereas the reduction of physicians' skills was the most important risk (medical doctors=3.3; medical students=3.6; P=.03). CONCLUSIONS: The question is not whether artificial intelligence will be used in medicine, but when it will become a standard practice for optimizing health care. The low level of familiarity with artificial intelligence identified in this study calls for the implementation of specific education and training in medical schools and hospitals to ensure that medical professionals can leverage this new paradigm and improve health outcomes.

Incidental Gastrointestinal Stromal Tumors (GIST) During Laparoscopic Sleeve Gastrectomy Procedures: a Retrospective Study.

PURPOSE: Gastrointestinal stromal tumors (GIST) are the most frequently occurring form of mesenchymal tumors in the gastrointestinal tract. Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric operation in which a portion of the gastric body and fundus is removed and sent for pathological examination. Increasingly, bariatric surgeons have incidentally identified neoplasms in the excised portion of the stomach. The aim of this study is to explore the incidence of GIST in obese patients undergoing LSG. MATERIAL AND METHODS: This is a single-center, single-surgeon retrospective case series which included 305 obese patients who underwent LSG. All excised stomach specimens were sent for pathologic analysis.. In the case of pathologically verified GIST (n = 6; 1.97%), detailed analysis was performed. RESULTS: In 305 LSG procedures, six cases of GIST (1.97%) were identified. The tumors were measured between 1 and 7 mm and were all low grade with negative resection margins. The mean BMI was 46.38 ± 3.94 kg/m2 (range: 41.61-51.77). The mean age at time of surgery was 55.33 ± 12.9 years (range: 37-73 years). All cases were asymptomatic and showed no evidence of metastatic disease. CONCLUSION: The incidental rate of GIST in the excised portion of the stomach in our 305 obese patients who underwent LSG is 6/305 (1.97%). This adds relevant data to the overall goal of determining whether obesity is a risk factor for GIST. Radical surgical resection of these tumors with adequate disease-free margins performed on a low-grade malignancy serves as a definitive oncological treatment, especially when there is an intact pseudocapsule.

Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience.

INTRODUCTION: Many centers have reported excellent short-term efficacy of per-oral endoscopic myotomy (POEM) for the treatment of achalasia. However, long-term data are limited and there are few studies comparing the efficacy of POEM versus Heller Myotomy (HM). AIMS: To compare the long-term clinical efficacy of POEM versus HM. METHODS: Using a retrospective, parallel cohort design, all cases of POEM or HM for achalasia between 2010 and 2015 were assessed. Clinical failure was defined as (a) Eckardt Score > 3 for at least 4 weeks, (b) achalasia-related hospitalization, or (c) repeat intervention. All index manometries were classified via Chicago Classification v3. Pre-procedural clinical, manometric, radiographic data, and procedural data were reviewed. RESULTS: 98 patients were identified (55 POEM, 43 Heller) with mean follow-up of 3.94 years, and 5.44 years, respectively. 83.7% of HM patients underwent associated anti-reflux wrap (Toupet or Dor). Baseline clinical, demographic, radiographic, and manometric data were similar between the groups. There was no statistical difference in overall long-term success (POEM 72.7%, HM 65.1% p = 0.417, although higher rates of success were seen in Type III Achalasia in POEM vs Heller (53.3% vs 44.4%, p < 0.05). Type III Achalasia was the only variable associated with failure on a univariate COX analysis and no covariants were identified on a multivariate Cox regression. There was no statistical difference in GERD symptoms, esophagitis, or major procedural complications. CONCLUSION: POEM and HM have similar long-term (4-year) efficacy with similar adverse event and reflux rates. POEM was associated with greater efficacy in Type III Achalasia.

Guidelines for gastrostomy tube placement and enteral nutrition in patients with severe, refractory hypoglycemia after gastric bypass.

BACKGROUND: Postbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients. OBJECTIVES: To provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management. SETTING: Stanford University Hospital and Clinics. METHODS: Based on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners. RESULTS: A team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia. CONCLUSIONS: G-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.

A rare case of gastric perforation by a 5-year-old Intra-gastric Balloon in situ: Case report and review of literature.

INTRODUCTION: Insertion of an Intra gastric Balloon (IGB) has widely been used as a minimally invasive procedure for the treatment of obesity. Gastric balloons are usually inserted for a period of six months only. They have a high safety profile and one of their rare, reported, serious complications include gastric or esophageal perforation, which are usually early and require immediate operative management. PRESENTATION OF CASE: We report a 26-year-old lady who presented to the ED with signs and symptoms of acute abdomen and five-year history of endoscopic placement of Intra-gastric Balloon. Emergent endoscopic removal of the balloon revealed a large pressure ulcer at gastric incisura with central necrosis. Laparoscopy confirmed gastric perforation along lesser curvature with extensive soilage of peritoneal cavity. Extensive irrigation and drainage and Graham omental patch repair were carried out laparoscopically, and the perforation sealed satisfactorily. She recovered well from surgery and within days she was tolerating a diet. Broad spectrum IV antibiotics were given for 10 days. DISCUSSION: Gastric perforation is a rare complication reported in 0.1% of patients undergoing IGB insertion. It can ensue as early as days after placement or late at weeks to months. In our review of literature, we found the maximum time frame in which a patient presented with an IGB induced gastric perforation was at 22 months. This makes our case unique as the patient was able to tolerate it for 5 years (60 months) before presenting to the emergency with this sinister complication. CONCLUSION: Very late Gastric perforations in patients with IGB placement are rare. An upper gastrointestinal endoscopy should be arranged as soon as possible to remove the balloon and assess the stomach visualize the perforation followed by a laparoscopic approach to repair the defect if expertise is available.

"I Must Try Harder": Design Implications for Mobile Apps and Wearables Contributing to Self-Efficacy of Patients With Chronic Conditions.

BACKGROUND: Diverse wellness-promoting mobile health technologies, including mobile apps and wearable trackers, became increasingly popular due to their ability to support patients' self-management of health conditions. However, the patient's acceptance and use depend on the perceived experience and the app appropriateness to the patient's context and needs. We have some understating of the experience and factors influencing the use of these technologies in the general public, but we have a limited understanding of these issues in patients. OBJECTIVE: By presenting results from an explorative study, this paper aims to identify implications for the design of mobile apps and wearables to effectively support patients' efforts in self-management of health with a special emphasis on support for self-efficacy of activities contributing to health. METHODS: An explorative mixed-method study involving 200 chronically ill patients of Stanford Medical Center (Stanford, CA, United States) was conducted between mid-2016 and end of 2018. Amongst these, 20 patients were involved in a 4-weeks study, in which we collected the underlying wearable device use logs (e.g., Fitbit) and subjective use experience [via an Ecological Momentary Assessment (EMA)], as well as patients' momentary perception of general self-efficacy in their natural environments and different daily contexts. RESULTS: The results indicate that mobile apps for health and wearables have the potential to enable better self-management and improve patients' wellbeing but must be further refined to address different human aspects of their use. Specifically, the apps/wearables should be easier to use, more personalized and context-aware for the patient's overall routine and lifestyle choices, as well as with respect to the momentary patient state (e.g., location, type of people around) and health(care) needs. Additionally, apps and devices should be more battery efficient and accurate; providing timely, non-judgmental feedback and personalized advice to the patients anywhere-anytime-anyhow. These results are mapped on major sources of the individuals' self-efficacy. CONCLUSION: Our results show how the apps/wearables that are aimed at supporting the patients' self-management should be designed to leverage and further improve the patients' general self-efficacy and self-efficacy of activities contributing to chronic disease management.

Increasing Completion Rate and Benefits of Checklists: Prospective Evaluation of Surgical Safety Checklists With Smart Glasses.

BACKGROUND: Studies have demonstrated that surgical safety checklists (SSCs) can significantly reduce surgical complications and mortality rates. Such lists rely on traditional posters or paper, and their contents are generic regarding the type of surgery being performed. SSC completion rates and uniformity of content have been reported as modest and widely variable. OBJECTIVE: This study aimed to investigate the feasibility and potential of using smart glasses in the operating room to increase the benefits of SSCs by improving usability through contextualized content and, ideally, resulting in improved completion rates. METHODS: We prospectively evaluated and compared 80 preoperative time-out events with SSCs at a major academic medical center between June 2016 and February 2017. Participants were assigned to either a conventional checklist approach (poster, memory, or both) or a smart glasses app running on Google Glass. RESULTS: Four different surgeons conducted 41 checklists using conventional methods (ie, memory or poster) and 39 using the smart glasses app. The average checklist completion rate using conventional methods was 76%. Smart glasses allowed a completion rate of up to 100% with a decrease in average checklist duration of 18%. CONCLUSIONS: Compared with alternatives such as posters, paper, and memory, smart glasses checklists are easier to use and follow. The glasses allowed surgeons to use contextualized time-out checklists, which increased the completion rate to 100% and reduced the checklist execution time and time required to prepare the equipment during surgical cases.

Reprocessing and reuse of single-use medical devices: perceptions and concerns of relevant stakeholders toward current practices.

BACKGROUND: Research and history have largely shown the covert billion-dollar global market of single-use medical device (SUD) reprocessing and reuse to be a safe endeavor, but awareness and perceptions of the practice both within and outside of healthcare have received limited attention. METHODS: Responses for patients, physicians, and medical practitioners were attained on both online and article-based surveys, in which attitudes and perceptions of SUD reprocessing and reuse were expressed in an assortment of closed-ended questions and partially closed-ended questions. RESULTS: Of the 214 participants, a collective 77% were unaware that the Food and Drug Administration allows SUD reprocessing and reuse. This included 65% of physicians and 84% of patients, which were significantly different proportions (P = 0.005). A significantly greater proportion of patients than physicians (92 vs. 68%) also felt that hospitals bear the responsibility of informing patients of the practice as part of their care (P < 0.001). CONCLUSION: There is a profound lack of awareness of SUD reprocessing and reuse among all relevant stakeholders. In addition, the overwhelming desire for transparency among patients further forces the debate of whether current, covert methods should be altered, in addition to the question of who bears this responsibility. Despite research and history having shown the practice to be safe, apprehension and misconceptions remain. Survey results suggest that education may be able to subdue such patient concerns.

Heterogeneity of weight loss after gastric bypass, sleeve gastrectomy, and adjustable gastric banding.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding all lead to substantial weight loss in obese patients. Long-term weight loss can be highly variable beyond 1-year postsurgery. This study examines and compares the frequency distribution of weight loss and lack of treatment effect rates after laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding. METHODS: A total of 1,331 consecutive patients at a single academic institution were reviewed from a prospectively collected database. Preoperative data collected included demographics, body mass index, and percent excess weight loss. Postoperative BMI and %EWL were collected at 12, 24, and 36 months. Percent excess weight loss was analyzed by the percentiles of excess weight lost, and the distribution of percent excess weight loss was evaluated in 10% increments. Lack of a successful treatment effect was defined as <25% excess weight loss. RESULTS: Of the 1,331 patients, 72.4% (963) underwent laparoscopic Roux-en-Y gastric bypass, 18.3% (243) laparoscopic sleeve gastrectomy, and 9.4%(125) laparoscopic adjustable gastric banding. Mean percent excess weight loss was greatest for laparoscopic Roux-en-Y gastric bypass, followed by laparoscopic sleeve gastrectomy, and then by laparoscopic adjustable gastric banding at every time point: at 2 years mean percent excess weight loss was 77.9± 24.4 for laparoscopic Roux-en-Y gastric bypass, 50.8 ± 25.8 for laparoscopic sleeve gastrectomy, and 40.8± 25.9 for laparoscopic adjustable gastric banding (P < .0001). The rates of a successful treatment effect s for laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding were 0.9%, 5.2%, and 24.3% at 1 year; 0.3%, 11.1%, and 26.0% at 2 years; and 1.0%, 25.3%, and 30.2% at 3 years. At 1 year, the odds ratio of lack of a successful treatment effect of laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass was 6.305 (2.125-19.08; P = .0004), the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic Roux-en-Y gastric bypass was 36.552 (15.64-95.71; P < .0001), and the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic sleeve gastrectomy was 5.791 (2.519-14.599; P < .0001). At 2 years, the odds ratio for laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass increased to 70.7 (9.4-531.7; P < .0001), the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic Roux-en-Y gastric bypass increased to 128.1 (16.8-974.3; P < .0001), and the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic sleeve gastrectomy decreased to 1.8 (0.9-3.6; P = .09). CONCLUSION: This study emphasizes the existing variability in weight loss across bariatric procedures as well as in the lack of a treatment effect for each procedure. Although laparoscopic adjustable gastric banding has the greatest rate of a lack of a successful treatment effect, the rate remained stable over 3 years postoperatively. Laparoscopic sleeve gastrectomy showed a doubling in the rate of a lack of a successful treatment effect every year reaching 25% at year 3. The rates for lack of a successful treatment effect for laparoscopic Roux-en-Y gastric bypass remained stable at about 1% for the first 3 years postoperatively.

Magnetic Surgery: Results From First Prospective Clinical Trial in 50 Patients.

OBJECTIVE: To evaluate a new magnetic surgical system during reduced-port laparoscopic cholecystectomy in a prospective, multicenter clinical trial. BACKGROUND: Laparoscopic instrumentation coupled by magnetic fields may enhance surgeon performance by allowing for shaft-less retraction and mobilization. The movements can be performed under direct visualization, generating different angles of traction and reducing the number of trocars to perform the procedure. This may reduce well-known associated complications of trocars, including incisional pain, scarring, infection, bowel, and vascular injuries, among others. METHODS: A prospective, multicenter, single-arm, open-label study was performed to assess the safety and performance of a magnetic surgical system (Levita Magnetics' Surgical System). The investigational device was used during a 3-port laparoscopic technique. The primary endpoints evaluated were safety and feasibility of the device to adequately mobilize the gallbladder to achieve effective exposure of the targeted surgical site. Patients were followed for 30 days postprocedure. RESULTS: Between January 2014 and March 2015, 50 patients presenting with benign gallbladder disease were recruited. Forty-five women and 5 men with an average age of 39 years (18-59), average body mass index of 27 kg/m (20.4-34.1) and an average abdominal wall thickness of 2.6 cm (1.8-4.6). The procedures were successfully performed in all 50 patients. No device-related serious adverse events were reported. Surgeons rated as "excellent" (90%) or "sufficient" (10%) the exposure of the surgical site. CONCLUSIONS: This clinical trial shows that this new magnetic surgical system is safe and effective in reduced-port laparoscopic cholecystectomy.

Bowel endometriosis: diagnosis and management.

The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short- and long-term complications.

Buttressing of the EEA stapler during gastrojejunal anastomosis decreases rate of bleeding-related complications for laparoscopic gastric bypass.

BACKGROUND: Bariatric surgery is a well-tolerated and effective treatment for severe obesity. Newer surgical techniques and equipment have improved safety standards surrounding bariatric surgery. In particular, buttressing of the staple line in sleeve gastrectomy has decreased rates of clinically significant postoperative bleeding. The present study investigates the effectiveness of buttressing the circular stapled anastomosis during laparoscopic Roux-en-Y gastric bypass (LRYGB). SETTING: Academic, accredited hospital. METHODS: A total of 253 patients undergoing LRYGB at a single academic institution were included in this retrospective study between 2014 and 2015. Buttressing material was used in 125 of these cases. Demographic information was collected from both groups preoperatively. Surgical characteristics were also obtained analyzed using unpaired t or χ2 tests. RESULTS: Patients in both buttressing and nonbuttressing groups were on average 46 years old and predominantly female (79.2% versus 74.2% female, respectively), with a body mass index of approximately 48 kg/m2. Postoperative weight loss did not significantly differ between groups at any time point (buttressing versus nonbuttressing percentage of excess weight loss: 39.5% versus 41.5% at 3 mo, P = .3860; 56.4% versus 56.7% at 6 mo, P = .9341). There were no significant differences for operating time, length of stay, readmissions, or reoperations. Complications due to strictures were found to be lower for the buttressing group (0% buttressing versus 2.3% nonbuttressing, P = .0851). Specific rates of bleeding-related complications were significantly lower for the group in which buttressing was used (0% buttressing versus 3.1% nonbuttressing, P = .0463). CONCLUSION: Buttressing of the gastrojejunal anastomosis during LRYGB significantly reduces bleeding-related complications and increases tolerability of the procedure.

Adipose tissue macrophages impair preadipocyte differentiation in humans.

AIM: The physiologic mechanisms underlying the relationship between obesity and insulin resistance are not fully understood. Impaired adipocyte differentiation and localized inflammation characterize adipose tissue from obese, insulin-resistant humans. The directionality of this relationship is not known, however. The aim of the current study was to investigate whether adipose tissue inflammation is causally-related to impaired adipocyte differentiation. METHODS: Abdominal subcutaneous(SAT) and visceral(VAT) adipose tissue was obtained from 20 human participants undergoing bariatric surgery. Preadipocytes were isolated, and cultured in the presence or absence of CD14+ macrophages obtained from the same adipose tissue sample. Adipocyte differentiation was quantified after 14 days via immunofluorescence, Oil-Red O, and adipogenic gene expression. Cytokine secretion by mature adipocytes cultured with or without CD14+macrophages was quantified. RESULTS: Adipocyte differentiation was significantly lower in VAT than SAT by all measures (p<0.001). With macrophage removal, SAT preadipocyte differentiation increased significantly as measured by immunofluorescence and gene expression, whereas VAT preadipocyte differentiation was unchanged. Adipocyte-secreted proinflammatory cytokines were higher and adiponectin lower in media from VAT vs SAT: macrophage removal reduced inflammatory cytokine and increased adiponectin secretion from both SAT and VAT adipocytes. Differentiation of preadipocytes from SAT but not VAT correlated inversely with systemic insulin resistance. CONCLUSIONS: The current results reveal that proinflammatory immune cells in human SAT are causally-related to impaired preadipocyte differentiation, which in turn is associated with systemic insulin resistance. In VAT, preadipocyte differentiation is poor even in the absence of tissue macrophages, pointing to inherent differences in fat storage potential between the two depots.

Capnoperitoneum During Peroral Endoscopic Myotomy-Recognition and Management: A Case Report.

Peroral endoscopic myotomy (POEM) is a minimally invasive procedure for treating esophageal achalasia. During POEM, carbon dioxide is insufflated under pressure into the esophagus and stomach, which can cause clinically significant capnoperitoneum, capnomediastinum, or capnothorax. We present a case in which gas accumulation in the abdomen during POEM had adverse effects on ventilation. Once the cause was recognized, needle decompression of the abdomen led to immediate improvement in ventilation.

Influence of Weight Loss Attempts on Bariatric Surgery Outcomes.

Many payors require an additional attempt at nonsurgical weight loss before approval of bariatric procedures. This study evaluates this requirement by characterizing the prior weight loss attempts (WLAs) undergone by bariatric surgery patients and correlating those attempts to postoperative weight loss outcomes. Number and duration of WLAs were obtained from a preoperative clinic assessment. Body mass index (BMI) and percentage of excess weight loss (%EWL) were used to assess weight loss. Kruskal-Wallis and Spearman Correlation tests were performed to analyze data using GraphPad Prism 6. Mean number of WLAs before surgery was 3.5 ± 0.2 attempts, with an average duration of 15.2 ± 1.1 years. There was a significant negative correlation between duration of WLAs and preoperative BMI (r = -0.2637, P = 0.0025). No significant difference was found for preoperative BMI or mean 12-month %EWL among any WLA groups. The number and duration of dietary attempts before surgery do not significantly affect long-term weight loss outcomes after bariatric surgery. Given these data, an additional preoperative WLA may not be efficacious in improving patients' chances at weight loss.

Characterizing Readmissions After Bariatric Surgery.

INTRODUCTION: Readmissions are an important quality metric for surgery. Here, we compare characteristics of readmissions across laparoscopic Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG), and adjustable gastric band (LAGB). METHODS: Demographic, intraoperative, anthropometric, and laboratory data were prospectively obtained for 1775 patients at a single academic institution. All instances of readmissions within 1 year were recorded. Data were analyzed using STATA, release 12. RESULTS: For the 1775 patients, 113 (6.37 %) were readmitted. Mean time to readmission was 52.1 days. Of all the readmissions, 64.6 % were within 30 days, 22.1 % from 30 to 90 days, 1.77 % from 90 to 180 days, and 11.5 % from 180 to 365 days. Incidence of 30-day readmissions varied across surgeries (LRYGB: 7.17 %; LAGB: 3.05 %; LSG: 4.25 %, p = 0.04). Time to readmission varied as well, with 90.0 % of LSG and 80.0 % of LABG patients within the first 30 days, versus 60.8 % of LRYGB (p = 0.02). The most common causes of readmissions were gastrointestinal issues related to index procedure (34.5 %) and did not vary across surgeries. In multivariable logistic regression, index hospital length of stay (LOS) was associated with readmission (OR = 1.07, 95 % CI 1.02-1.13, p = 0.01). CONCLUSIONS: Readmissions after bariatric surgery are associated with high index hospital LOS, and a measureable proportion of procedure-related readmissions can occur up to 1 year, especially for LRYGB.

National prevalence, causes, and risk factors for bariatric surgery readmissions.

BACKGROUND: Readmissions are often used as a quality metric particularly in bariatric surgery. METHODS: Laparoscopic Roux en Y gastric bypass, laparoscopic adjustable gastric banding, and laparoscopic sleeve gastrectomy were identified using Current Procedure Terminology codes in the 2012 National Surgical Quality Improvement Program public use file. RESULTS: A total of 18,296 patients were included, 10,080 (55.1%) were laparoscopic Roux en Y gastric bypass, 1,829 (10.0%) were laparoscopic adjustable gastric banding, and 6,387 (34.9%) were laparoscopic sleeve gastrectomy. Among all patients, 955 (5.22%) were readmitted. Patients with readmissions had a higher proportion of body mass index greater than 50 (30.2% vs 24.6%, P < .001), higher index operative time (132 minutes vs 115, P < .001) and greater proportion with length of stay greater than 4 days (9.57% vs 3.36%, P < .001). Readmitted patients were more likely to have diabetes (31.1% vs 27.7%, P = .02), chronic obstructive pulmonary disease (2.63% vs 1.72%, P = .04), and hypertension (54.5% vs 50.8%, P = .03). Overall, 40.6% of readmitted patients had a complication. Common readmissions were gastrointestinal-related (45.0%), dietary (33.5%), and bleeding (6.57%). Readmission was independently associated with African-American race (odds ratio [OR] = 1.53, P = .02), complication (OR = 11.3, 95%, P < .001), and resident involvement (OR = .53, P = .04). CONCLUSIONS: A 30-day readmission after bariatric surgery is prevalent and closely associated with complications.

A postoperative nutritional consult improves bariatric surgery outcomes.

BACKGROUND: Bariatric surgery is the most effective treatment for obesity. Guidelines for optimizing postoperative care are emerging, and roles of the surgeon and registered dietician (RD) have opportunities for coordination. OBJECTIVES: The study objective was to better define the appropriate guidelines for postoperative care by investigating whether a combined surgeon and RD follow-up for the initial postoperative visit within 2 to 6 weeks after surgery improves patient outcomes. SETTING: The setting was an accredited bariatric hospital in an academic setting. METHODS: A retrospective analysis of a prospective database was performed on patients who underwent bariatric surgery and were followed up by either a surgeon alone or by a surgeon and RD for initial postoperative visit. RESULTS: There were 302 patients in the surgeon follow-up group and 268 in the RD follow-up. Patients in the RD follow-up group had significantly fewer readmissions due to dietary-related problems (9 versus 0; P = .004), more favorable 3-month change in serum thiamine (-30.5 versus-4.04; P = .002), high-density lipoprotein (-3.42 versus-1.67; P = .053), and triglycerides (-17.5 versus-31.5; P = .03), and trended lower number of minor complications (16 versus 6; P = .08). No significant differences in percent excess weight loss were observed at all time points after surgery. Multivariate logistic models controlling for demographic features found that RD follow-up predicted 3-month increase in thiamine (odds ratio = 2.49; P<.000) and high-density lipoprotein cholesterol (OR = 1.73; P = .01), and decrease in total cholesterol (OR = 1.58; P = .03) and triglycerides (OR = 1.55; P = .03). CONCLUSIONS: Follow-up with a surgeon and RD for the initial postoperative visit may help improve patient outcomes.

Do adverse childhood experiences affect surgical weight loss outcomes?

Bariatric surgery is an effective and enduring treatment for obesity; however, variation in weight loss may occur following surgery. Many factors beyond technical considerations may influence postoperative outcomes. A better understanding of the influence of adverse childhood experiences (ACE) on surgical weight loss may improve preoperative care. Demographic and preoperative and postoperative data were prospectively obtained for 223 patients undergoing bariatric surgery. All cases were completed laparoscopically without serious complication. Patients completed the ACE questionnaire, which assesses childhood maltreatment. Patients had an average age of 48 years and 77 % were female. There was a significant reduction from preoperative to 12-month postoperative BMI (45 to 31 kg/m(2), p ≤ 0.01). The average ACE score was 2.9 and these patients were more likely than population norms to have an ACE score ≥4 (35.9 vs. 12.5 %, p < 0.001). There was a positive correlation between the number of preoperative comorbidities and preoperative ACE score (R = 0.112, p = 0.09). Patients with a high ACE score (≥6) vs. patients low ACE scores had a higher postoperative BMI at 6-months (36.9 vs. 33.4 kg/m(2), p = 0.03) and 12-months postoperatively (34.5 vs. 30.5 kg/m(2), p = 0.07). High ACE patients had higher total cholesterol (191 vs. 169 mg/dL, p = 0.02) and LDL cholesterol (116 vs. 94 mg/dL, p = 0.02) than low ACE patients 12-months postoperatively. A high preoperative ACE score decreases weight loss following bariatric surgery and may warrant an increased preoperative counseling.