Racial variation in baseline characteristics and wait times among patients undergoing bariatric surgery.

BACKGROUND: Although bariatric surgery is the most effective treatment for obesity and weight-related comorbid diseases, utilization rates are disproportionately low among non-white patients. We sought to understand if variation in baseline characteristics or access to care exists between white and non-white patients. METHODS: Using a statewide bariatric-specific data registry, we evaluated all patients who underwent bariatric surgery between 2006 and 2020 and completed a preoperative baseline questionnaire, which included a question about self-identification of race. Patient characteristics, co-morbidities, and time from initial preoperative clinic evaluation to date of surgery were compared among racial groups. RESULTS: A total of 73,141 patients met inclusion criteria with 18,741 (25.5%) self-identified as non-white. These included Black/African American (n = 11,904), Hispanic (n = 3448), Asian (n = 121), Native Hawaiian/Pacific Islander (n = 41), Middle Eastern (n = 164), Multiple (n = 2047) and other (n = 608). Non-white males were the least represented group, accounting for only 4% of all bariatric cases performed. Non-white patients were more likely to be younger (43.0 years vs. 46.6 years, p < 0.0001), disabled (16% vs. 11.4%, p < 0.0001) and have Medicaid (8.4% vs. 3.8%, p < 0.0001) when compared to white patients, despite having higher rates of college education (78.0% vs. 76.6, p < 0.0001). In addition, median time from initial evaluation to surgery was also longer among non-white patients (157 days vs. 127 days, p < 0.0001), despite having higher rates of patients with a body mass index above 50 kg/m2 (39.0% vs. 33.2%, p < 0.0001). CONCLUSIONS: Non-white patients undergoing bariatric surgery represent an extremely diverse group of patients with more socioeconomic disadvantages and longer wait times when compared to white patients despite presenting with higher rates of severe obesity. Current guidelines and referral patterns for bariatric surgery may not be equitable and need further examination when considering the management of obesity within diverse populations to reduce disparities in care-of which non-white males are particularly at risk.

Evaluating outcomes among surgeons who changed their technique for gastric bypass: a state-wide analysis from 2011 to 2021.

INTRODUCTION: Technical variation exists when performing the gastrojejunostomy during Roux-en-Y gastric bypass (RYGB). However, it is unclear whether changing technique results in improved outcomes or patient harm. METHODS: Surgeons participating in a state-wide bariatric surgery quality collaborative who completed a survey on how they perform a typical RYGB in 2011 and again in 2021 were included in the analysis (n = 31). Risk-adjusted 30-day complication rates and case characteristics for cases in 2011 were compared to those in 2021 among surgeons who changed their gastrojejunostomy technique from end-to-end anastomosis (EEA) to either a linear staple or handsewn anastomosis (LSA/HSA). In addition, case characteristics and outcomes among surgeons who maintained an EEA technique throughout the study period were assessed. RESULTS: A total of 15 surgeons (48.3%) changed their technique from EEA to LSA/HSA while 7 surgeons (22.3%) did not. Nine surgeons did LSA or HSA the entire period and therefore were not included. Surgeons who changed their technique had significantly lower rates of surgical complications in 2021 when compared to 2011 (1.9% vs 5.1%, p = 0.0015), including lower rates of wound complications (0.5% vs 2.1%, p = 0.0030) and stricture (0.1% vs 0.5%, p = 0.0533). Likewise, surgeons who did not change their EEA technique, also experienced a decrease in surgical complications (1.8% vs 5.8%, p < 0.0001), wound complications (0.7% vs 2.1%, p < 0.0001) and strictures (0.2% vs 1.2%, p = 0.0006). Surgeons who changed their technique had a significantly higher mean annual robotic bariatric volume in 2021 (30.0 cases vs 4.9 cases, p < 0.0001) when compared to those who did not. CONCLUSIONS: Surgeons who changed their gastrojejunostomy technique from circular stapled to handsewn demonstrated greater utilization of the robotic platform than those who did not and experienced a similar decrease in adverse events during the study period, despite altering their technique. Surgeons who chose to modify their operative technique may be more likely to adopt newer technologies.

Association of program-specific variation in bariatric surgery volume for Medicaid patients and access to care: a tale of inequality?

BACKGROUND: Although patients with lower socioeconomic status are at higher risk of obesity, bariatric surgery utilization among patients with Medicaid is low and may be due to program-specific variation in access. Our goal was to compare bariatric surgery programs by percentage of Medicaid cases and to determine if variation in distribution of patients with Medicaid could be linked to adverse outcomes. METHODS: Using a state-wide bariatric-specific data registry that included 43 programs performing 97,207 cases between 2006 and 2020, we identified all patients with Medicaid insurance (n = 4780, 4.9%). Bariatric surgery programs were stratified into quartiles according to the percentage of Medicaid cases performed and we compared program-specific characteristics as well as baseline patient characteristics, risk-adjusted complication rates and wait times between top and bottom quartiles. RESULTS: Program-specific distribution of Medicaid cases varied between 0.69 and 22.4%. Programs in the top quartile (n = 11) performed 18,885 cases in total, with a mean of 13% for Medicaid patients, while programs in the bottom quartile (n = 11) performed 32,447 cases in total, with a mean of 1%. Patients undergoing surgery at programs in the top quartile were more likely to be Black (20.2% vs 13.5%, p < 0.0001), have diabetes (35.1% vs 29.5%, p < 0.0001), hypertension (55.1% vs 49.6%, p < 0.0001) and hyperlipidemia (47.6% vs 45.2%, p < 0.0001). Top quartile programs also had higher complication rates (8.4% vs 6.6%, p < 0.0001), extended length of stay (5.6% vs 4.0%, p < 0.0001), Emergency Department visits (8.1% vs 6.5%, p < 0.0001) and readmissions (4.7% vs 3.9%, p < 0.0001). Median time from initial evaluation to surgery date was also significantly longer among top quartile programs (200 vs 122 days, p < 0.0001). CONCLUSIONS: Bariatric surgery programs that perform a higher proportion of Medicaid cases tend to care for patients with greater disease severity who experience delays in care and also require more resource utilization. Improving bariatric surgery utilization among patients with lower socioeconomic status may benefit from insurance standardization and program-centered incentives to improve access and equitable distribution of care.

Depression as a risk factor for adverse outcomes and increased healthcare utilization in bariatric surgery patients.

INTRODUCTION: Depression is strongly associated with obesity and is common among patients undergoing bariatric surgery. Little is known about the impact of depression on early postoperative outcomes or its association with substance use. METHODS: The Michigan Bariatric Surgery Collaborative is a statewide quality improvement program that maintains a large clinical registry. We evaluated patients undergoing primary Roux-en-Y gastric bypass or sleeve gastrectomy between 2017 and 2022. Patients self-reported symptoms of depression (PHQ-8) and use of alcohol (AUDIT-C), smoking, prescription opiates, and marijuana at baseline. Preoperative PHQ-8 scores stratified patients based on severity: no depression (0-4), mild (5-9), moderate (10-14), or severe (15-24). We compared 30-day outcomes and substance use between patients with and without depression. RESULTS: Among 44,301 patients, 30.8% had some level of depression, with 19.8% mild, 7.5% moderate, and 3.5% severe. Patients with depression were more likely to have an extended length of stay (LOS) (> 3 days) than those without depression (no depression 2.1% vs. severe depression 3.0%, p = 0.0452). There were no significant differences between no depression and severe depression groups in rates of complications (5.7% vs. 5.2%, p = 0.1564), reoperations (0.9%, vs. 0.8%, p = 0.7394), ED visits (7.7% vs. 7.8%, p = 0.5353), or readmissions (3.2% vs. 3.9%, p = 0.3034). Patients with severe depression had significantly higher rates of smoking (9.7% vs. 12.5%, p < 0.0001), alcohol use disorder (8.6% vs. 14.0%, p < 0.0001), opiate use (14.5% vs. 22.4%, p < 0.0001) and marijuana use (8.4%, vs. 15.5%, p = 0.0008). CONCLUSIONS: This study demonstrated that nearly one-third of patients undergoing bariatric surgery have depression, with over 10% in the moderate to severe range. There was a significant association between preoperative depressive symptoms and extended LOS after bariatric surgery, as well as higher rates of smoking and use of marijuana, prescription opiates and alcohol. There was no significant effect on adverse events or other measures of healthcare utilization.

Evaluating the Impact of Surgeon Self-awareness by Comparing Self Versus Peer Ratings of Surgical Skill and Outcomes for Bariatric Surgery.

OBJECTIVE: To evaluate variation in self versus peer-assessments of surgical skill using surgical videos and compare surgeon-specific outcomes with bariatric surgery. SUMMARY BACKGROUND DATA: Prior studies have demonstrated that surgeons with lower peer-reviewed ratings of surgical skill had higher complication rates after bariatric surgery. METHODS: This is a retrospective cohort study of 25 surgeons who voluntarily submitted a video of a typical laparoscopic sleeve gastrectomy (SG) between 2015 and 2016. Videos were self and peer-rated using a validated instrument based on a 5-point Likert scale (5= "master surgeon" and 1= "surgeon-in-training"). Risk adjusted 30-day complication rates were compared between surgeons who over-rated and under-rated their skill based on data from 24,186 SG cases and 12,888 gastric bypass (GBP) cases. RESULTS: individual overall self-rating of surgical skill varied between 2.5 and 5. Surgeons in the top quartile for self:peer ratings (n = 6, ratio 1.58) had lower overall mean peer-scores (2.98 vs 3.79, P = 0.0150) than surgeons in the lowest quartile (n = 6, ratio 0.94). Complication rates between top and bottom quartiles were similar after SG, however leak rates were higher with gastric bypass among surgeons who over-rated their skill with SG (0.65 vs 0.27, P = 0.0181). Surgeon experience was similar between comparison groups. CONCLUSIONS AND RELEVANCE: Self-perceptions of surgical skill varied widely. Surgeons who over-rated their skill had higher leak rates for more complex procedures. Video assessments can help identify surgeons with poor self-awareness who may benefit from a surgical coaching program.

Evaluation of Patient Reported Gastroesophageal Reflux Severity at Baseline and at 1-year After Bariatric Surgery.

OBJECTIVE: To assess patient-reported gastroesophageal reflux disease (GERD) severity before and after SG and Roux-en-Y gastric bypass (RYGB). SUMMARY OF BACKGROUND DATA: Development of new-onset or worsening GERD symptoms after bariatric surgery varies by procedure, but there is a lack of patient-reported data to help guide decision-making. Methods: Retrospective cohort study of patients undergoing bariatric surgery in a statewide quality collaborative between 2013 and 2017. We used a validated GERD survey with symptom scores ranging from 0 (no symptoms) to 5 (severe daily symptoms) and included patients who completed surveys both at baseline and 1-year after surgery (n = 10,451). We compared the rates of improved and worsened GERD symptoms after SG and RYGB. RESULTS: Within our study cohort, 8680 (83%) underwent SG and 1771 (17%) underwent RYGB. Mean baseline score for all patients was 0.94. Patients undergoing SG experienced similar improvement in GERD symptoms when compared to RYGB (30.4% vs 30.8%, P = 0.7015). However, SG patients also reported higher rates of worsening symptoms (17.8% vs 7.5%, P < 0.0001) even though they were more likely to undergo concurrent hiatal hernia repair (35.1% vs 20.0%, P<0.0001). More than half of patients (53.5%) did not report a change in their score. CONCLUSIONS: Although SG patients reported higher rates of worsening GERD symptoms when compared to RYGB, the majority of patients (>80%) in this study experienced improvement or no change in GERD regardless of procedure. Using clinically relevant patient-reported outcomes can help guide decisions about procedure choice in bariatric surgery for patients with GERD.

Patient characteristics and outcomes among bariatric surgery patients with high narcotic overdose scores.

BACKGROUND: Obesity-related chronic pain can increase the risk of narcotic abuse in bariatric surgery patients. However, assessment of overdose risk has not been evaluated to date. METHODS: A NARxCHECK® overdose score ("Narx score") was obtained preoperatively on all patients undergoing bariatric surgery (n = 306) between 2018 and 2020 at a single-center academic bariatric surgery program. The 3-digit score ranges from 000 to 999 and is based on patient risk factors found within the Prescription Drug Monitoring Program. A Narx score ≥ 200 indicates tenfold increased risk of narcotic overdose. Patient characteristics, comorbidities, and emergency room (ER) visits were compared between patients in the upper (≥ 200) and lower (000) terciles of Narx scores. Morphine milligram equivalent (MME) prescribed at discharge and refills was also evaluated. RESULTS: Patients in the upper tercile represented 32% (n = 99) of the study population, and compared to the lower tercile (n = 101, 33%), were more likely to have depression (63.6% vs 38.6%, p = 0.0004), anxiety (47.5% vs 30.7%, p = 0.0150), and bipolar disorder (6.1% vs 0.0%, p = 0.0120). Median MME prescribed at discharge was the same between both groups (75); however, high-risk patients were more likely to be prescribed more than 10 tablets of a secondary opioid (83.3% vs 0.0%, p = 0.0111), which was prescribed by another provider in 67% of cases. ER visits among patients who did not have a complication or require a readmission was also higher among high-risk patients (7.8% vs 0.0%, p = 0.0043). There were no deaths or incidents of mental health-related ER visits in either group. CONCLUSION: Patients with a Narx score ≥ 200 were more likely to have mental health disorders and have potentially avoidable ER visits in the setting of standardized opioid prescribing practices. Narx scores can help reduce ER visits by identifying at-risk patients who may benefit from additional clinic or telehealth follow-up.

Impact of hiatal hernia repair technique on patient-reported gastroesophageal reflux symptoms following laparoscopic sleeve gastrectomy.

INTRODUCTION: Repairing a hiatal hernia at the time of laparoscopic sleeve gastrectomy (SG) can reduce or even prevent gastroesophageal reflux disease (GERD) symptoms in the post-operative period. Several different hiatal hernia repair techniques have been described but their impact on GERD symptoms after SG is unclear. METHODS: Surgeons (n = 74) participating in a statewide quality collaborative were surveyed on their typical technique for repair of hiatal hernias during SG. Options included posterior repair with mesh (PRM), posterior repair (PR), and anterior repair (AR). Patients who underwent SG with concurrent hiatal hernia repair (n = 7883) were compared according to their surgeon's reported technique. Patient characteristics, baseline and 1-year GERD health-related quality of life surveys, weight loss and 30-day risk-adjusted complications were analyzed. RESULTS: The most common technique reported by surgeons for hiatal hernia repair was PR (n = 64, 85.3%), followed by PRM (n = 7, 9.3%) and AR (n = 4, 5.3%). Patients who underwent SG by surgeons who perform AR had lower rates of baseline GERD diagnosis (AR 55.3%, PR 59.5%, PRM 64.8%, p < 0.01), but were more likely to experience worsening GERD symptoms at 1 year (AR 29.8%, PR 28.7%, PRM 28.2%, p < 0.0001), despite similar weight loss (AR 29.8%, PR 28.7%, PRM 28.2%, p = 0.08). Satisfaction with GERD symptoms at 1 year was high (AR 73.2%, PR 76.3%, PRM 75.7%, p = 0.43), and risk-adjusted 30-day outcomes were similar among all groups. CONCLUSIONS: Patients undergoing SG with concurrent hiatal hernia repair by surgeons who typically perform an AR were more likely to report worsening GERD at 1 year despite excellent weight loss. Surgeons who typically performed an AR had nearly one-half of their patients report increased GERD severity after surgery despite similar weight loss. While GERD symptom control may be multifactorial, technical approach to hiatal hernia repair at the time of SG may play a role and a posterior repair is recommended.

Evaluating the Effect of Surgical Skill on Outcomes for Laparoscopic Sleeve Gastrectomy: A Video-based Study.

BACKGROUND: Prior studies have demonstrated a correlation between surgical skill and complication rates after laparoscopic Roux-en-Y gastric bypass. However, the impact of surgical skill on a similar but less technically challenging procedure such as sleeve gastrectomy (SG) is unknown. METHODS: Practicing bariatric surgeons (n = 25) participating in a statewide quality improvement collaborative submitted an unedited deidentified video of a representative laparoscopic SG. Videos were obtained between 2015 and 2016 and were rated by bariatric surgeons in a blinded fashion using a validated instrument that assesses surgical skill. Overall scores were based on a 5-point Likert scale with 5 representing a "master surgeon" and 1 representing a "surgeon-in-training." Risk-adjusted 30-day complication rates, 1-year weight loss among cases performed during the study period, and operative technique were compared between surgeons rated in the top and bottom quartiles according to skill. RESULTS: Surgeon ratings for skill varied between 2.73 and 4.60. Ratings for skill did not correlate with overall 30-day risk-adjusted complication rates (Pearson correlation coefficient, 0.213, P = 0.303). However, surgeons with higher skill ratings had lower rates of specific surgical complications, including postoperative obstruction (0.13% vs 0.3%, P = 0.017), hemorrhage (0.85% vs 1.27%, P = 0.005), and reoperation (0.24% vs 0.92%, P < 0.0001). Surgeons ranked in the top quartile for skill had faster operating times for SG (59.0 vs 82.1 min, P < 0.0001) and higher annual case volumes for both SG and any bariatric procedure (224.3 cases/yr vs 73.4 cases/yr, P = 0.009 and 244.9 cases/yr and 93.9 cases/yr, P = 0.009) when compared with surgeons in the bottom quartile. When comparing operative technique, top rated surgeons were noted to have a higher likelihood of using buttressing (83.3% vs 0%, P = 0.0041) and intraoperative endoscopy (83.3% vs 0%, P = 0.0041). CONCLUSIONS: Peer ratings for surgical skill varied for laparoscopic sleeve gastrectomy but did not have a significant impact on overall complication rates. Top rated surgeons had lower rates of obstruction, hemorrhage, and reoperation; however, severe morbidity remained extremely low among all surgeons.

Upper gastrointestinal series after sleeve gastrectomy is unnecessary to evaluate for gastric sleeve stenosis.

BACKGROUND: There has been an increase in sleeve gastrectomy (SG) procedures being performed worldwide, and a paralleled rise in prevalence of gastric sleeve stenosis (GSS). Symptoms include dysphagia, reflux, and obstructive symptoms. Upper gastrointestinal series (UGIS) is commonly performed in the diagnostic algorithm prior to referral for endoscopic dilation; however, little is known about its utility in making a diagnosis. Our aim was to evaluate positive predictive value (PPV) and negative predictive value (NPV) of UGIS in detection of GSS. METHODS: We performed a retrospective analysis of a prospectively collected database at a tertiary center for patients referred with nausea/vomiting or obstructive symptoms following SG between 2017 and 2019. All patients underwent upper endoscopy (EGD) for evaluation of GSS. Serial balloon dilations were performed for GSS with increasing balloon size and/or filling pressure until symptom resolution or referral for surgical revision. Primary outcomes were PPV and NPV for UGIS in predicting GSS. Secondary outcomes included EGD findings and symptom response to dilation. RESULTS: Thirty consecutive patients were included in the analyses. The most common presenting symptoms were nausea (66.7%), vomiting (60.0%) reflux (66.7%), and abdominal pain (54.8%). Twenty-two (73.3%) patients underwent UGIS prior to EGD. On diagnostic EGD, 27 (87.1%) patients were diagnosed with GSS. The sensitivity and NPV of UGIS to detect GSS was 30.0%, and 12.5%, respectively. All 6 patients with GSS on UGIS also had GSS on endoscopic evaluation (specificity = 100%, PPV = 100%). Twenty-six (86.6%) patients had resolution of symptoms with a mean 1.97 ± 1.13 dilations. CONCLUSION: UGIS following SG has low NPV to evaluate for GSS. Independent of the UGIS findings, majority of patients found to have GSS on EGD had symptom improvement with dilations. The utility of UGIS is limited for diagnosing GSS and when suspicion for GSS is high, patients should be referred directly for EGD.

Comparison of early outcomes between Roux-en-Y gastric bypass and sleeve gastrectomy among patients with body mass index ≥ 60 kg/m2.

BACKGROUND: There is no consensus on the ideal bariatric operation to choose for patients with extremely high body mass index (BMI). The aim of this study was to compare the perioperative complications, weight loss, and comorbidity remission between laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) among patients with BMI ≥ 60 kg/m2. METHODS: Data from a statewide bariatric surgery registry were used to identify all patients with BMI ≥ 60 kg/m2 undergoing LRYGB or LSG between January 2006 and June 2019. Risk and reliability adjustment were used to compare outcomes between the two groups. RESULTS: A total of 6015 patients were identified and 2505 (41.6%) underwent LRYGB and 3510 (58.4%) underwent LSG. The overall mean age was 43.1 ± 11.2 years with a mean preoperative BMI of 66.7 ± 6.4 kg/m2. Females accounted for 69.3% and the majority were either white (68.5%) or black (21.2%). LRYGB was associated with a higher rate of adjusted 30-day postoperative serious complications (4.0% vs 2.2%; p < 0.01) including anastomotic leak, obstruction, and bleeding. Resource utilization was also higher with LRYGB (23.7% vs 14.8%; p < 0.01) and included more emergency department visits, readmissions, reoperations, and length of stay ≥ 4 days. The overall 1-year follow-up rate was 38.8%. The adjusted percent total weight loss at 1 year was significantly higher following LRYGB compared to LSG (36.6 ± 9.3 vs 31.3 ± 9.3%; p < 0.01). LRYGB was associated with a higher rate of treatment discontinuation for diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. CONCLUSIONS: In patients with BMI ≥ 60 kg/m2, LRYGB was associated with better weight loss and medication discontinuation 1 year following surgery at the expense of an increase in perioperative complications and resource utilization compared to LSG.

Incidence and Efficacy of Stent Placement in Leak Management After Bariatric Surgery: An MBSAQIP Analysis.

OBJECTIVE: The aim of this study was to evaluate the rates of use and efficacy of stent placement for postoperative leak following bariatric surgery. SUMMARY OF BACKGROUND DATA: Endoscopically placed stents can successfully treat anastomotic and staple line leaks after bariatric surgery. However, the extent to which stents are used in the management of bariatric complications and rates of reoperation remain unknown. METHODS: Data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use files were analyzed for patients who experienced anastomotic or staple line leaks after bariatric surgery, and then evaluated for use of an endoscopically placed stent. Patient and procedure-level data were compared between those who underwent stent placement versus those who required reoperation. Multivariable logistic regression was used to compare outcomes between groups. RESULTS: A total of 354,865 bariatric cases were captured in 2015 to 2016. One thousand one hundred thirty patients (0.3%) required intervention for a leak, of whom 275 (24%) were treated with an endoscopically placed stent. One hundred seven (39%) of the patients who received stents required reoperation as part of their care pathway. Patient characteristics were statistically similar when comparing leaks managed with stents to those treated with reoperation alone. Those treated with stents, however, had a higher likelihood of readmission (odds ratio 2.59, 95% confidence interval -1.59 to 4.20). CONCLUSION: Placement of stents for management of leaks after bariatric surgery is common throughout the United States. The use of stents can be effective; however, it does not prevent reoperation and is associated with an increased likelihood of readmission. Both technique and resource utilization should be considered when choosing a management pathway for leaks.

Surgeon variation in severity of reflux symptoms after sleeve gastrectomy.

BACKGROUND: Prior studies have demonstrated an increase in gastroesophageal reflux after laparoscopic sleeve gastrectomy (LSG). However, it is unknown whether symptom severity varies or if outcomes are surgeon-specific. METHODS: A validated reflux symptom survey was obtained at baseline and at 1 year after primary LSG on 7358 patients participating in a state-wide quality improvement collaborative between 2013 and 2018. Patients with worsening symptoms after surgery were divided into terciles based on the degree of increase in survey score (0 = no symptoms, 50 = max symptoms). Surgeon-level data was obtained on 52 bariatric surgeons performing at least 25 LSG cases/year during the study period. Surgeon characteristics, operative experience, and risk-adjusted 30-day complication rates were compared between surgeons in the highest tercile for moderate worsening of symptoms vs those in the lowest. RESULTS: A total of 2294 (31.2%) patients had worsening symptoms of reflux after sleeve gastrectomy. Overall mean increase in severity score was 6.11 (range 1 to 48) and patients with minimal, mild, and moderate symptoms had a mean increase of 1.4, 4.2, and 13.8, respectively. There were no significant differences in surgeon-specific characteristics when comparing surgeons in the highest tercile for moderate worsening of symptoms (44.7% of patients) vs those in the lowest tercile (18.7% of patients). In addition, there were no significant differences in risk-adjusted rates of overall complications (3.70% vs. 4.33%, p = 0.686), endoscopic dilations (2.83% vs. 1.91%, p = 0.417), or concurrent hiatal hernia repair (34.3% vs. 27.0%, p = 0.415) between surgeons in the highest and lowest terciles. CONCLUSIONS: We found that 1/3 of patients had worsening symptoms of reflux after LSG and that severity of symptoms varied. Surgeons with the highest rates of worsening reflux had similar operative experience and complication rates than those with the lowest. Further assessment of operative technique and skill may be informative.

Factors Associated With Long Wait Times for Bariatric Surgery.

BACKGROUND: Despite its proven safety and efficacy, bariatric surgery is an underutilized therapy for severe obesity. Wait times for surgery are largely unexplored in the United States and may impact access to care. OBJECTIVE: To determine the amount of time between initial bariatric surgery clinic visit and operative date and identify factors associated with longer wait times. METHODS: A statewide clinical data registry was queried from 2006 to 2016 and 60,791 patients undergoing primary bariatric surgery were identified. Demographics, comorbidities, 30-day complications, and 1-year patient-reported outcomes were compared between shortest and longest wait time quartiles. Analyses were performed using Chi-square, t-test, and logistic regression. RESULTS: Median wait times for bariatric surgery increased from 86 to 159 days during the study period. Median wait times were ≤67 days for the shortest wait time quartile and ≥204 days for the longest wait time quartile. Factors independently associated with longer wait times included Medicaid insurance [odds ratio (OR) 3.02; 95% confidence interval (CI): 2.58-3.53], sleep apnea (OR 1.49; 95% CI: 1.41-1.58), psychological disorder (OR 1.25; 95% CI: 1.18-1.32), hyperlipidemia (OR 1.21; 95% CI: 1.14-1.28), smoking history (OR 1.11; 95% CI: 1.05-1.17), and white race (OR 0.665; 95% CI: 0.614-0.720). Preoperative weight loss, risk adjusted complication rates, postoperative self-reported weight loss, and comorbidity remission were similar between groups. CONCLUSIONS: Over the past decade, eligible patients are experiencing longer wait times when pursuing bariatric surgery. Complex patients with Medicaid insurance are experiencing the longest delay despite similar outcomes and preoperative weight loss. Policies that delay surgery should be re-examined.

Assessing the effect of the critical view of safety criteria on simulated operative decision-making: a pilot study.

BACKGROUND: Despite well-established criteria for identifying the critical view of safety (CVS) during laparoscopic cholecystectomy, its impact on intraoperative decision-making among trainees is unclear. METHODS: General surgery interns (n = 10) viewed a training module on the CVS criteria and then independently reviewed 20 cholecystectomy videos lasting 1 min each edited at various points of CVS dissection to include examples of both adequate and inadequate dissections. Participants were asked to identify the following CVS criteria for each video-(1) clearance of fat from the hepatocystic triangle; (2) exposure of the cystic plate; and (3) two and only two structures entering the gallbladder-and then decide if the structures were safe to divide. RESULTS: Inter-rater agreement for each CVS criteria varied: (1) (k = 0.2510), (2) (k = 0.2771), and (3) (k = 0.4298) as did the decision to divide critical structures (k = 0.371). Individual mean rate of dividing structures ranged 5-50% and did not correlate with the total number of CVS criteria identified by each participant (Spearman's rho = 0.247, p = 0.492). Division of structures with incomplete CVS identification occurred in 15% of cases and was isolated to one participant in the majority of cases (88%). Among these cases, omission of the cystic plate dissection occurred in every instance. CONCLUSIONS: Identification of CVS criteria was not uniform with the least amount of agreement on adequate hepatocystic and cystic plate dissection. Individual variation also exists between identification of CVS criteria and likelihood to divide structures. Video-based assessments that include intraoperative decision-making can help assess individual perceptions of safe practices without the risk of harm to the patient.

Effect of new persistent opioid use on physiologic and psychologic outcomes following bariatric surgery.

INTRODUCTION: New persistent opioid use following surgery is a common iatrogenic complication, developing in roughly 6% of patients after elective surgery. Despite increased awareness of misuse and associated morbidity, opioids remain the cornerstone of pain management in bariatric surgery. The potential impact of new persistent opioid use on long-term postoperative outcomes is unknown. We sought to determine the relationship between new persistent opioid use and 1-year postoperative outcomes for patients undergoing bariatric surgery. METHODS: Using data from the MBSC registry, we identified patients undergoing primary bariatric surgery between 2006 and 2016. Using previously validated patient-reported survey methodology, we evaluated patient opioid use preoperatively and at 1 year following surgery. New persistent use was defined as a previously opioid-naïve patient who self-reported opioid use 1 year after surgery. We used multivariable logistic regression models to evaluate the association between new persistent opioid use, risk-adjusted weight loss, and psychologic outcomes (psychological wellbeing, body image, and depression). RESULTS: 27,799 patients underwent primary bariatric surgery between 2006 and 2016. Among opioid-naïve patients, the rate of new persistent opioid use was 6.3%. At 1-year after surgery, patients with new persistent opioid user lost significantly less excess body weight compared to those without new persistent use (57.6% vs. 60.3%; p < 0.0001). Patients with new persistent opioid use had significantly worse psychological wellbeing (35.0 vs. 33.1; p < 0.0001), body image (19.9 vs. 18.0; p < 0.0001), and depression scores (2.4 vs. 5.0; p < 0.0001). New persistent opioid users also reported less overall satisfaction with their bariatric surgery (75.1% vs. 85.7%; p < 0.0001). CONCLUSIONS: New persistent opioid use is common following bariatric surgery and associated with significantly worse physiologic and psychologic outcomes. More effective screening and postoperative surveillance tools are needed to identify these patients, who likely require more aggressive counseling and treatment to maximize the benefits of bariatric surgery.

Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study.

BACKGROUND: Considerable technical variation exists when performing laparoscopic sleeve gastrectomy (LSG). However, little is known about which techniques are associated with optimal outcomes. OBJECTIVE: To compare technical variation among surgeons with the lowest complication rates and whose patients achieved the most weight loss. METHODS: Practicing bariatric surgeons (n = 30) voluntarily submitted a video of a typical LSG performed between 2015 and 2016. Technique-specific data captured from videos and a questionnaire included bougie size, stapler vendor, number of staple loads, use of staple line reinforcement, fibrin sealant, intraoperative leak test, endoscopy, and drain placement. Surgeon-specific outcomes were obtained from cases performed by surgeons during the study period (n = 7023) using a state-wide bariatric-specific data registry. Surgeons were ranked based on 30-day risk-adjusted surgical complication rates ("safety") and excess body weight loss (EBWL) % ("efficacy") at 1 year after surgery. Technique-specific variables were compared between surgeons ranked in the top and bottom quartile for both safety and efficacy. RESULTS: Surgical complication rates ranged from 0 to 4.32% while EBWL varied from 45.3 to 65.3%. There was no correlation between surgeon rankings for safety and efficacy (Pearson's r = 0.063, p = 0.741). Surgeons ranked in the top quartile for safety and efficacy had significantly shorter mean operative times than surgeons ranked in the bottom quartile (65 min vs. 69 min, p < 0.0001). Surgeons with the highest leak rates were more likely to use buttressing (85.7% vs 40.0%, p = 0.032), otherwise operative techniques varied considerably. CONCLUSIONS: Technical variation appears to have minimal effect on the safety or efficacy of sleeve gastrectomy among surgeons participating in a state-wide quality improvement collaborative. Top ranked surgeons did have faster mean operative times indicating that there may be other metrics of technical quality that correlate to optimal outcomes.

Training in Minimally Invasive Pancreatic Resections: a paradigm shift away from "See one, Do one, Teach one".

BACKGROUND: Increased incorporation of minimally invasive pancreatic resections (MIPR) has emerged into hepato-pancreato-biliary practice, however, no standardization exists for its safe adoption. Novel strategies are presented for dissemination of safe MIPR. METHODS: An international State-of-the-Art conference evaluating multiple aspects of MIPR was conducted by a panel of pancreas experts in Sao Paulo, Brazil on April 20, 2016. Training and education issues were discussed regarding the introduction of novel strategies for safe dissemination of MIPR. RESULTS: The low volume of pancreatic resections per institution poses a challenge for surgeons to overcome their MIPR learning curve without deliberate training. A mastery-based simulation and biotissue curriculum can improve technical proficiency and allow for training of surgeons before the operating room. Video-based platforms allow for performance reporting and feedback necessary for coaching and surgical quality improvement. Centers of excellence with training involving a standardized approach and proctorship are important concepts that can be utilized in various formats internationally. DISCUSSION: Surgical volume is not sufficient to ensure quality and patient safety in MIPR. Safe adoption of these complex procedures should consider innovative mastery-based training outside of the operating room, novel video based coaching techniques and prospective reporting of patient data and outcomes using standardized definitions.

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: impact on reflux and weight loss.

BACKGROUND: Sleeve gastrectomy (SG) is the most commonly performed weight loss operation, and its 2 most common complications are postoperative reflux and weight recurrence. There is limited evidence to guide decision-making in treating these conditions. OBJECTIVES: To determine the efficacy of conversion of SG to Roux-en-Y gastric bypass (RYGB) for GERD management and weight loss. SETTING: Forty-one hospitals in Michigan. METHODS: We conducted a retrospective cohort study examining patients who underwent conversion of SG to RYGB from 2014 to 2022. The primary outcomes were changes in GERD-HRQL scores, anti-reflux medication use, and weight from baseline to 1 year after conversion. Secondary outcomes included 30-day postoperative complications and resource utilization. RESULTS: Among 2133 patients undergoing conversion, 279 (13%) patients had baseline and 1-year GERD-HRQL survey data and anti-reflux medication data. GERD-HRQL scores decreased significantly from 24.6 to 6.6 (P < .01). Among these, 207 patients (74%) required anti-reflux medication at baseline, with only 76 patients (27%) requiring anti-reflux medication at 1 year postoperatively (P < .01). Of the 380 patients (18%) with weight loss data, mean weight decreased by 68.4lbs, with a 24.3% decline in total body weight and 51.5% decline in excess body weight. In terms of 30-day complications, 308 (14%) patients experienced any complication and 89 (4%) experienced a serious complication, but there were no leaks, perforations, or deaths. Three-hundred and fifty-five (17%) patients presented to the emergency department and 64 (3%) patients underwent reoperation. CONCLUSIONS: This study represents the largest reported experience with conversion from SG to RYGB. We found that conversion to RYGB is associated with significant improvement in GERD symptoms, reduction in anti-reflux medication use, and significant weight loss and is therefore an effective treatment for GERD and weight regain after SG. However, the risks and benefits of conversion surgery should be carefully considered, especially in patients with significant comorbidity burden.