Bariatric surgery: trends in utilization, complications, conversions and revisions.

BACKGROUND: Sleeve gastrectomy (SG) increased in popularity after 2010 but recent data suggest it has concerning rates of gastroesophageal reflux and need for conversions. This study aims to evaluate recent trends in the utilization of bariatric procedures, associated complications, and conversions using an administrative claims database in the United States. METHODS: We included adults who had bariatric procedures from 2000 to 2020 with continuous enrollment for at least 6 months in the MarketScan Commercial Claims and Encounters database. Index bariatric procedures and subsequent revisions or conversions were identified using CPT codes. Baseline comorbidities and postoperative complications were identified with ICD-9-CM and ICD-10 codes. Cumulative incidences of complications were estimated at 30-days, 6-months, and 1-year and compared with stabilized inverse probability of treatment weighted Kaplan-Meier analysis. RESULTS: We identified 349,411 bariatric procedures and 5521 conversions or revisions. The sampled SG volume appeared to begin declining in 2018 while Roux-en-Y gastric bypass (RYGB) remained steady. Compared to RYGB, SG was associated with lower 1-year incidence [aHR, (95% CIs)] for 30-days readmission [0.65, (0.64-0.68)], dehydration [0.75, (0.73-0.78)], nausea or vomiting [0.70, (0.69-0.72)], dysphagia [0.55, (0.53-0.57)], and gastrointestinal hemorrhage [0.43, (0.40-0.46)]. Compared to RYGB, SG was associated with higher 1-year incidence [aHR, (95% CIs)] of esophagogastroduodenoscopy [1.13, (1.11-1.15)], heartburn [1.38, (1.28-1.49)], gastritis [4.28, (4.14-4.44)], portal vein thrombosis [3.93, (2.82-5.48)], and hernias of all types [1.36, (1.34-1.39)]. There were more conversions from SG to RYGB than re-sleeving procedures. SG had a significantly lower 1-year incidence of other non-revisional surgical interventions when compared to RYGB. CONCLUSIONS: The overall volume of bariatric procedures within the claims database appeared to be declining over the last 10 years. The decreasing proportion of SG and the increasing proportion of RYGB suggest the specific complications of SG may be driving this trend. Clearly, RYGB should remain an important tool in the bariatric surgeon's armamentarium.

Updates in Bariatric Surgery.

Bariatric surgery is currently the most effective long-term treatment for morbid obesity as well as type-2 diabetes mellitus. The field of metabolic and bariatric surgery has seen tremendous growth over the past decade with dramatically reduced risks. This article aims to provide an update on bariatric surgery, highlighting the latest outcomes, improvements, and challenges in the field. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) released a major update to the indications for bariatric surgery at BMI ≥35 kg/m2 regardless of co-morbidities and 30-34.9 kg/m2 with obesity-related comorbidities. Sleeve gastrectomy has emerged as the most popular bariatric procedure in the last 10 years with its remarkable efficacy and safety profile. The implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and Enhanced Recovery After Surgery (ERAS) protocols have significantly improved the quality of care for all bariatric patients. The recent introduction and FDA approval of Glucagon-Like Peptide-1 (GLP-1) agonists for chronic obesity has garnered significant media coverage and popularity, but no guidelines exist regarding its use in relation to bariatric surgery. This update underscores the need for tailored approaches, ongoing research, and the integration of evidence-based medicine and innovations to enhance patient care.

Predicting readmission after bariatric surgery using machine learning.

BACKGROUND: While bariatric surgery is an effective method for achieving long-term weight loss, postoperative readmissions are associated with negative clinical outcomes and significant costs. OBJECTIVES: We aimed to use machine learning (ML) algorithms to predict readmissions and compare results to logistic regression. SETTING: Hospitals participating in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, United States. METHODS: Patients who underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch between 2016 and 2020 were selected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Patient variables reported by the MBSAQIP database were analyzed by ML algorithms random forest (RF), gradient boosting (XGB), and deep neural networks (NN), and the results of the predictive models were compared to logistic regression using area under the receiver operating characteristic curve (AUROC). RESULTS: Our study included 863,348 patients, of which 39,068 (4.52%) were readmitted. AUROC scores were XGB .785 (95% CI .784-.786), RF .785 (95% CI .784-.785), and NN .754 (95% CI .753-.754), compared with .62 (95% CI .62-.621) for logistic regression (LR) (P < .001). The sensitivity and specificity for XGB, the best performing model, were 73.81% and 70%, compared with 52.94% and 70% for logistic regression. The most important variables were intervention or reoperation prior to discharge, unplanned ICU admission, initial procedure, and the intraoperative transfusion. CONCLUSIONS: ML demonstrates significant advantages over logistic regression when predicting 30-day readmission following bariatric surgery. With external validation, models could identify the best candidates for early discharge or targeted postdischarge resources.

Application of machine learning to predict postoperative gastrointestinal bleed in bariatric surgery.

BACKGROUND: Postoperative gastrointestinal bleeding (GIB) is a rare but serious complication of bariatric surgery. The recent rise in extended venous thromboembolism regimens as well as outpatient bariatric surgery may increase the risk of postoperative GIB or lead to delay in diagnosis. This study seeks to use machine learning (ML) to create a model that predicts postoperative GIB to aid surgeon decision-making and improve patient counseling for postoperative bleeds. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was used to train and validate three types of ML methods: random forest (RF), gradient boosting (XGB), and deep neural networks (NN), and compare them with logistic regression (LR) regarding postoperative GIB. The dataset was split using fivefold cross-validation into training and validation sets, in an 80/20 ratio. The performance of the models was assessed using area under the receiver operating characteristic curve (AUROC) and compared with the DeLong test. Variables with the strongest effect were identified using Shapley additive explanations (SHAP). RESULTS: The study included 159,959 patients. Postoperative GIB was identified in 632 (0.4%) patients. The three ML methods, RF (AUROC 0.764), XGB (AUROC 0.746), and NN (AUROC 0.741) all outperformed LR (AUROC 0.709). The best ML method, RF, was able to predict postoperative GIB with a specificity and sensitivity of 70.0% and 75.4%, respectively. Using DeLong testing, the difference between RF and LR was determined to be significant with p < 0.01. Type of bariatric surgery, pre-op hematocrit, age, duration of procedure, and pre-op creatinine were the 5 most important features identified by ML retrospectively. CONCLUSIONS: We have developed a ML model that outperformed LR in predicting postoperative GIB. Using ML models for risk prediction can be a helpful tool for both surgeons and patients undergoing bariatric procedures but more interpretable models are needed.

Preferred Feedback Styles Among Different Groups in an Academic Medical Center.

INTRODUCTION: Feedback is an essential component in complex work environments. Different generations have been shown to have different sets of values, derived from societal and cultural changes. We hypothesize that generational differences may be associated with preferred feedback patterns among medical trainees and faculty in a large academic institution. METHODS: A survey was distributed to all students, residents/fellows, and faculty at a large academic medical institution from April 2020 through June 2020. Survey questions evaluated feedback methods for six domains: preparedness, performance, attitude, technical procedures, inpatient, and outpatient care. Participants selected a preferred feedback method for each category. Patient demographics and survey responses were described using frequency statistics. We compared differences in feedback preferences based on generation and field of practice. RESULTS: A total of 871 participants completed the survey. Preferred feedback patterns in the medical field do not seem to align with sociologic theories of generational gaps. Most participants preferred to receive direct feedback after an activity away from their team, irrespective of their age or medical specialty. Individuals preferred direct feedback during an activity in front of their team only for technical procedures. Compared to nonsurgeons, surgeons were more likely to prefer direct feedback in front of team members for preparedness, performance, and attitude. CONCLUSIONS: Generational membership is not significantly associated with preferred feedback patterns in this complex medical academic environment. Variations in feedback preferences are associated with field of practice that may be due to specialty-specific differences in culture and personality traits present within certain medical specialties, particularly surgery.

Evaluating the Ergonomics of Surgical Residents During Laparoscopic Simulation: A Novel Computerized Approach.

BACKGROUND: Assessment of residents' body positioning during laparoscopy has not been adequately investigated. This study presents a novel computer vision technique to automate ergonomic evaluation and demonstrates this approach through simulated laparoscopy. METHODS: Surgical residents at a single academic institution were video recorded performing tasks from the Fundamentals of Laparoscopic Surgery (FLS). Ergonomics were assessed by 2 raters using the Rapid Upper Limb Assessment (RULA) tool. Additionally, a novel computer software program was used to measure ergonomics from the video recordings. All participants completed a survey on musculoskeletal complaints, which was graded by severity. RESULTS: Ten residents participated; all performed FLS in postures that exceeded acceptable ergonomic risks as determined by both the human and computerized RULA scores (P < .001). Lower-level residents scored worse than upper-level residents on the human-graded RULA assessment (P = .04). There was no difference in computer-graded RULA scores by resident level (P = .39) and computer-graded scores did not correlate with human scores (P = .75). Shoulder and wrist position were the greatest contributors to higher computer-graded scores (P < .001). Self-reported musculoskeletal complaints did not differ at resident level (P = .74); however, all residents reported having at least 1 form of musculoskeletal complaint occurring "often." CONCLUSIONS: Surgery residents demonstrated suboptimal ergonomics while performing simulated laparoscopic tasks. A novel computer program to measure ergonomics did not agree with the scores generated by the human raters, although it concluded that resident ergonomics remain a concern, especially regarding shoulder and wrist positioning.

Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: A Single-Institution Report.

Laparoscopic sleeve gastrectomy (LSG) is an effective weight-loss operation. Portomesenteric vein thrombosis (PMVT) is an important complication of LSG. We identified four cases of PMVT after LSG at our institution in women aged 36-47 with BMIs ranging from 44-48 kg/m2. All presented 8-19 days postoperatively. Common symptoms were nausea, vomiting, and abdominal pain. Thrombotic risk factors were previous deep vein thrombosis and oral contraceptive use. Management included therapeutic anti-coagulation, directed thrombolysis, and surgery. Complications were readmission, bowel resection, and bleeding. Discharge recommendations ranged from 3-6 months of anticoagulation using various anticoagulants. No consensus was reached on post-treatment hypercoagulable work up or imaging. All cases required multi-disciplinary approach with Surgery, Interventional Radiology, and Hematology. As PMVT is a rare but potentially morbid complication of LSG, further development of tools that quantify preoperative thrombotic risk and clear guidance regarding use of anticoagulants are needed for prevention and treatment of PMVT following LSG.

Comparison of robot-assisted sleeve gastrectomy outcomes in multiple staple line treatment modalities from 2015 to 2019: a 5-year propensity score-adjusted MBSAQIP® analysis.

BACKGROUND: Robot-assisted sleeve gastrectomy (RSG) is an increasingly common approach to sleeve gastrectomy (SG). Staple line reinforcement (SLR) is well-discussed in laparoscopic SG literature, but not RSG- likely due to the absence of dedicated robotic SLR devices. However, most RSG cases report SLR. This retrospective analysis compares outcomes in RSG cases reporting (1) any staple line treatment (SLT) vs none and (2) SLR vs oversewing. METHODS: MBSAQIP was queried for adults who underwent RSG from 2015 to 2019. Open procedures, Natural Orifice Transluminal Endoscopic Surgery, hand-assisted, single-incision, concurrent procedures, and illogical BMIs were excluded (n = 3444). Final sample included 52,354 patients. Two comparisons were made: SLT (n = 34,886) vs none (n = 17,468) and SLR (n = 22,217) vs oversew (n = 5620). We fitted multivariable regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) and performed propensity score analysis with inverse probability of treatment weight based on patient factors. RESULTS: Most RSG cases utilized SLT (66.6%). Cases with SLT had a reduced risk of organ space SSI (RR 0.68 [0.49, 0.94]), 30-day reoperation (RR 0.77 [0.64, 0.93]), 30-day re-intervention (RR 0.80 [0.67, 0.96]), sepsis (RR 0.58 [0.35, 0.96]), unplanned intubation (RR 0.59 [0.37, 0.93]), extended ventilator use (RR 0.46 [0.23, 0.91]), and renal failure (RR 0.40 [0.19, 0.82]) compared to no-treatment cases. In single-treatment cases (n = 27,837), most utilized SLR (79.8%). Cases with oversew had a higher risk of any SSI (RR 1.70 [1.19, 2.42]), superficial incisional SSI (RR 1.71 [1.06, 2.76]), septic shock (RR 6.47 [2.11, 19.87]), unplanned intubation (RR 2.18 [1.06, 4.47]), and extended ventilator use (> 48 h) (RR 4.55 [1.63, 12.71]) than SLR. CONCLUSIONS: Our data suggest SLT in RSG is associated with reduced risk of some adverse outcomes vs no-treatment. Among SLT, SLR demonstrated lower risk than oversewing. However, risk of all-cause mortality, cardiac arrest, and unplanned ICU admission were not significant.

Comparison of post-operative outcomes of large direct inguinal hernia repairs based on operative approach (open vs. laparoscopic vs. robotic) using the ACHQC (Abdominal Core Health Quality Collaborative) database.

PURPOSE: To compare clinical outcomes for open, laparoscopic, and robotic hernia repairs for direct, unilateral inguinal hernia repairs, with particular focus on 30-day morbidity surgical site infection (SSI); surgical site occurrence (SSO); SSI/SSO requiring procedural interventions (SSOPI), reoperation, and recurrence. METHODS: The Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective, primary, > 3 cm medial, unilateral inguinal hernia repairs with an open (Lichtenstein), laparoscopic, or robotic operative approach. Preoperative demographics and patient characteristics, operative techniques, and outcomes were studied. A 1-to-1 propensity score matching algorithm was used for each operative approach pair to reduce selection bias. RESULTS: There were 848 operations included: 297 were open, 285 laparoscopic, and 266 robotic hernia repairs. There was no evidence of a difference in primary endpoints at 30 days including SSI, SSO, SSI/SSO requiring procedural interventions (SSOPI), reoperation, readmission, or recurrence for any of the operative approach pairs (open vs. robotic, open vs. laparoscopic, robotic vs. laparoscopic). For the open vs. laparoscopic groups, QoL score at 30 day was lower (better) for laparoscopic surgery compared to open surgery (OR 0.53 [0.31, 0.92], p = 0.03), but this difference did not hold at the 1-year survey (OR 1.37 [0.48, 3.92], p = 0.55). Similarly, patients who underwent robotic repair were more likely to have a higher (worse) 30-day QoL score (OR 2.01 [1.18, 3.42], p = 0.01), but no evidence of a difference at 1 year (OR 0.83 [0.3, 2.26] p = 0.71). CONCLUSIONS: Our study did not reveal significant post-operative outcomes between open, laparoscopic, and robotic approaches for large medial inguinal hernias. Surgeons should continue to tailor operative approach based on patient needs and their own surgical expertise.

Gastric Bypass Versus Sleeve Gastrectomy: Comparison of Patient Outcomes, Satisfaction, and Quality of Life in a Single-Center Experience.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most common primary bariatric operation performed in the United States. Its relative technical ease, combined with a decreased risk for anatomic and malabsorptive complications make LSG an attractive option compared to laparoscopic gastric bypass (LGB) for many patients and surgeons. However, emerging evidence for progressive gastroesophageal reflux disease (GERD) after LSG, and the inferior weight loss in many studies, suggests that the enthusiasm for LSG requires reassessment. We hypothesized that patient satisfaction and quality of life (QoL) may be lower after LSG compared to LGB because of these differences. Methods: We distributed a survey querying weight-loss outcomes, complications, foregut symptoms, QoL, and overall satisfaction to patients who underwent bariatric operations at our institution between 2000 and 2020 and who had electronic mail contact information available. Mean follow-up was 2.75 ± 2.41 years for LGB patients and 3.37 ± 2.18 (P = .021) years for LSG patients. We compared these groups for weight-loss outcomes, changes in foregut symptoms, gastrointestinal QoL, postbariatric QoL, and overall satisfaction using appropriate statistical tests. Results: Among 323 respondents, 126 underwent LGB and 197 underwent LSG. LGB patients had larger body mass index (BMI) reduction than LSG patients (-17.16 ± 9.07 kg/m2 versus -14.87 ± 7.4 kg/m2, P = .023). LGB patients reported less reflux (P = .003), with decreased heartburn (P < .0001) and regurgitation (P = .0027). However, a greater proportion of LGB patients reported at least one complication (P = .025). Despite this, more LGB patients reported satisfaction (92.86%) than LSG patients (73.6%). Conclusion: LGB patients are significantly more likely to be satisfied than LSG patients. Factors contributing to the higher level of satisfaction include less GERD and better BMI decrease.

Inflammation and Metabolism of Influenza-Stimulated Peripheral Blood Mononuclear Cells From Adults With Obesity Following Bariatric Surgery.

BACKGROUND: Obesity dysregulates immunity to influenza infection. Therefore, there is a critical need to investigate how obesity impairs immunity and to establish therapeutic approaches that mitigate the impact of increased adiposity. One mechanism by which obesity may alter immune responses is through changes in cellular metabolism. METHODS: We studied inflammation and cellular metabolism of peripheral blood mononuclear cells (PBMCs) isolated from individuals with obesity relative to lean controls. We also investigated if impairments to PBMC metabolism were reversible upon short-term weight loss following bariatric surgery. RESULTS: Obesity was associated with systemic inflammation and poor inflammation resolution. Unstimulated PBMCs from participants with obesity had lower oxidative metabolism and adenosine triphosphate (ATP) production compared to PBMCs from lean controls. PBMC secretome analyses showed that ex vivo stimulation with A/Cal/7/2009 H1N1 influenza led to a notable increase in IL-6 with obesity. Short-term weight loss via bariatric surgery improved biomarkers of systemic metabolism but did not improve markers of inflammation resolution, PBMC metabolism, or the PBMC secretome. CONCLUSIONS: These results show that obesity drives a signature of impaired PBMC metabolism, which may be due to persistent inflammation. PBMC metabolism was not reversed after short-term weight loss despite improvements in measures of systemic metabolism.

Association of Preoperative Glycosylated Hemoglobin Level with 30-Day Outcomes Following Laparoscopic Roux-en-Y Gastric Bypass: an Analysis of the ACS-MBSAQIP Database.

PURPOSE: Elevated glycosylated hemoglobin (HbA1c) levels have been associated with increased morbidity and mortality following several cardiac, colorectal, orthopedic, and vascular surgery operations. The purpose of this study was to determine if there is a HgA1c cut-point that can be used in patients undergoing laparoscopic Roux-en-Y gastric bypass to decrease the risk of 30-day wound events and additional 30-day morbidity and mortality. MATERIALS AND METHODS: All patients undergoing first-time, elective Roux-en-Y gastric bypass in 2017 and 2018 with a diagnosis of diabetes mellitus (DM) and a preoperative HbA1c level were identified within the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative HbA1c levels with 30-day morbidity and mortality was investigated. RESULTS: A total of 13,806 patients met inclusion criteria. Two natural HbA1c inflection points for composite wound events, including superficial, deep, and organ space surgical site infections (SSI) and wound dehiscence, were found. A HbA1c level of ≤ 6.5% was associated with a decreased odds of experiencing the composite 30-day wound event outcome while a HbA1c level of > 8.6% was associated with an increased odds of experiencing the composite 30-day wound event outcome. The differences in the incidence of the 30-day composite wound event outcomes were driven primarily by superficial and organ space SSI, including anastomotic leaks. CONCLUSION: Patients with DM being evaluated for RYGB surgery with a HbA1c level > 8.6% are at an increased risk for 30-day wound events, including superficial and organ space SSI.

Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database.

BACKGROUND: It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use. METHODS: Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression. RESULTS: A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively. CONCLUSIONS: Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.

Autoimmune and viral risk factors are associated with achalasia: A case-control study.

BACKGROUND: Achalasia is a rare esophageal motility disorder of uncertain etiology. While past studies have indicated that autoimmune conditions and viral infections may be associated with development of achalasia, these associations are yet to be examined in large, population-based studies. METHODS: A matched case-control study was performed using administrative claim data from the IBM MarketScan Commercial Claims and Encounters Database between 2000 and 2019. A history of selected autoimmune conditions and viral infections was assessed using past medical claims. Multivariable conditional logistic regression was used to account for the matched nature of the study design and further control for confounding by demographic and clinical characteristics when reporting adjusted odds ratios (aORs). KEY RESULTS: Among 6769 cases and 27,076 controls, presence of any of the autoimmune conditions studied was associated with increased odds of achalasia (aOR = 1.26, 95% CI: 1.11, 1.42). Scleroderma or systemic sclerosis (aOR = 8.13, 95% CI: 3.34, 19.80) and Addison's disease (aOR = 3.83, 95% CI: 1.83, 8.04) had the strongest associations with achalasia. Presence of any of the viral infections studied was also associated with an increased risk of achalasia (aOR = 1.58, 95% CI: 1.23, 2.01). Varicella zoster virus (aOR = 3.84, 95% CI: 1.94, 7.62) and human papillomavirus (aOR = 1.77, 95% CI: 1.15, 2.73) both had strong relationships with achalasia. CONCLUSIONS AND INFERENCES: These findings suggest that achalasia may have autoimmune and viral components contributing to its etiology. Future mechanistic studies could target specific diseases and agents highlighted by this research.

Minimally invasive Heller myotomy with partial posterior fundoplication for the treatment of achalasia: long-term results from a tertiary referral center.

INTRODUCTION: Few studies have reported the long-term results of minimally invasive Heller myotomy (HM) for the treatment of achalasia. Herein, we detail our 17-year experience with HM for the treatment of achalasia from a tertiary referral center. METHODS: All patients undergoing elective HM at our institution from 2000 to 2017 were identified within a prospective institutional database. These patients were sent mail and electronic surveys to capture their symptoms of dysphagia, chest pain, and regurgitation pre- and postoperatively and were asked to evaluate their postoperative gastrointestinal quality of life. Responses from adult patients who underwent minimally invasive Heller myotomy with partial posterior (i.e., Toupet) fundoplication (HM-TF) were analyzed. RESULTS: 294 patients were eligible for study inclusion; 139 (47%) completed our survey. Median time from HM-TF to survey response was 5.6 years. A majority of patients reported improvement in their dysphagia (91%), chest pain (70%), and regurgitation (87%) symptoms. Patients who underwent HM-TF more than 5 years ago were most likely to report heartburn symptoms. One (1%) patient went on to require esophagectomy for ongoing dysphagia and one (1%) patient required revisional fundoplication for their heartburn symptoms. CONCLUSIONS: Minimally invasive Heller myotomy and posterior partial fundoplication is a durable treatment for achalasia over the long term. Additional prospective and multi-institutional studies are needed to validate our results.

Roux-en-Y Gastric Bypass Is Associated With Increased Hazard for De Novo Alcohol-related Complications and Liver Disease.

GOAL: The goal of this study was to determine if bariatric surgeries are associated with de novo alcohol-related complications. BACKGROUND: Bariatric surgery is associated with an increased risk of alcohol use disorders. The effect of bariatric surgeries on other alcohol-related outcomes, including liver disease, is understudied. MATERIALS AND METHODS: Using the IMS PharMetrics database, we performed a cohort study of adults undergoing bariatric surgery or cholecystectomy, excluding patients with an alcohol-related diagnosis within 1 year before surgery. The primary outcome was any alcohol-related diagnosis after surgery. We fit a multivariable Cox proportional hazards model to determine independent associations between bariatric surgeries [Roux-en-Y gastric bypass (RYGB); adjustable gastric band; sleeve gastrectomy] versus cholecystectomy and the development of de novo alcohol-related outcomes. We further fit complication-specific models for each alcohol-related diagnosis. RESULTS: RYGB was significantly associated with an increased hazard of any de novo alcohol-related diagnosis [adjusted hazard ratio (AHR)=1.51, 95% confidence interval (CI): 1.40-1.62], while adjustable gastric band (AHR=0.55, 95% CI: 0.48-0.63) and sleeve gastrectomy (AHR=0.77, 95% CI: 0.64-0.91) had decreased hazards. RYGB was associated with a 2- to 3-fold higher hazard for alcoholic hepatitis (AHR=1.98, 95% CI: 1.17-3.33), abuse (AHR=2.05, 95% CI: 1.88-2.24), and poisoning (3.14, 95% CI: 1.80-5.49). CONCLUSIONS: RYGB was associated with higher hazards of developing de novo alcohol-related hepatitis, abuse, and poisoning compared with a control group. Patients without a history of alcohol use disorder should still be counseled on the increased risk of alcohol use and alcohol-related complications, including alcohol-related liver disease, following RYGB, and should be monitored long term for the development of alcohol-related complications.

The Endoscopic Management of Achalasia: Less May Lead to More.

Achalasia is a rare motor disorder of the lower esophageal sphincter. Currently, both endoscopic and surgical techniques are used to treat achalasia. Herein, we detail our institutional experience of surgical re-intervention following the endoscopic management of achalasia.

Preparation for Challenging Cases: What Differentiates Expert From Novice Surgeons?

OBJECTIVE: The study of expert performance provides a rich field for exploration in the surgical literature. This study aimed to examine the difference between expert and novice surgeons in their preparation for challenging cases. DESIGN: Expert (attending) and novice (postgraduate-year 2) surgeons were presented two cases of complicated cholecystitis and were asked how they would prepare, what they would expect to encounter intraoperatively, and how they would deal with these challenges. Their responses were recorded, transcribed verbatim and analyzed using thematic analysis. SETTING: Academic teaching hospitals. PARTICIPANTS: Two group of expert and novice surgeons. RESULTS: Nine experts and eleven novices from two academic centers participated. The majority of novices focused on patient history, work-up, preoperative optimization, anatomy, and anticipation of intraoperative challenges. In addition to the patient's presentation and preoperative optimization, most experts' thoughts were directed toward preparation for surgery (level of urgency, required skills in surgical team, case difficulty, and risk of conversion to open). Experts would involve the patient in the decision-making and were more likely to communicate with the operating room team. While novices attempted to predict challenges depending on gallbladder condition and intra-abdominal adhesions, the experts highlighted the importance of various elements of the operative field, the detail of the technique and possible challenges, and their troubleshooting plans. Regarding operative planning to address anticipated challenges, novices would tailor their plan to patient characteristics and verbalized an analytical "if-then" approach for all possibilities they might encounter. Experts would start with their standard technique regardless of case complexity and would deal with contingencies as they arise. Safety was a critical part of expert surgeons' plans. CONCLUSIONS: Novices mostly conveyed descriptive knowledge based on presented facts while experts demonstrated an ability to paint a richer mental image of possible future events by creating comprehensive anticipation of the operative field. Further studies are needed to validate the results of this study.

Pilot Study Using Neurofeedback as a Tool to Reduce Surgical Resident Burnout.

BACKGROUND: Burnout is prevalent among surgical residents. Neurofeedback is a technique to train the brain in self-regulation skills. We aimed to assess the impact of neurofeedback on the cognitive workload and personal growth areas of surgery residents with burnout and depression. STUDY DESIGN: Fifteen surgical residents with burnout (Maslach Burnout Inventory [MBI] score > 27) and depression (Patient Health Questionnaire-9 Depression Screen [PHQ-9] score >10), from 1 academic institution, were enrolled and participated in this institutional review board-approved prospective study. Ten residents with more severe burnout and depression scores were assigned to receive 8 weeks of neurofeedback treatments, and 5 others with less severe symptoms were treated as controls. Each participant's cognitive workload (or mental effort) was assessed initially, and again after treatment via electroencephalogram (EEG) while the subjects performed n-back working memory tasks. Analysis of variance (ANOVA) tested for significance between the degree of change in the treatment and control groups. Each subject was also asked to rate changes in growth areas, such as sleep and stress. RESULTS: Both groups showed high cognitive workload in the pre-assessment. After the neurofeedback intervention, the treatment group showed a significant (p < 0.01) improvement in cognitive workload via EEG during the working memory task. These differences were not noted in the control group. There was significant correlation between time (NFB sessions) and average improvement in all growth areas (r = 0.98) CONCLUSIONS: Residents demonstrated high levels of burnout, correlating with EEG patterns indicative of post-traumatic stress disorder. There was a notable change in cognitive workload after the neurofeedback treatment, suggesting a return to a more efficient neural network.

Appropriate patient selection facilitates safe discharge from the PACU after laparoscopic ventral hernia repair: an analysis of the AHSQC database.

BACKGROUND: The postoperative management of patients undergoing laparoscopic ventral hernia repair (VHR) remains relatively unknown. The purpose of our study was to determine if patient and hernia-specific factors could be used to predict the likelihood of hospital admission following laparoscopic VHR using the Americas Hernia Society Quality Collaborative (AHSQC) database. METHODS: All patients who underwent elective, laparoscopic VHR with mesh placement from October 2015 through April 2019 were identified within the AHSQC database. Patients without clean wounds, those with chronic liver disease, and those without 30-day follow-up data were excluded from our analysis. Patient and hernia-specific variables were compared between patients who were discharged from the post-anesthesia care unit (PACU) and patients who required hospital admission. Comparisons were also made between the two groups with respect to 30-day morbidity and mortality events. RESULTS: A total of 1609 patients met inclusion criteria; 901 (56%) patients were discharged from the PACU. The proportion of patients discharged from the PACU increased with each subsequent year. Several patient comorbidities and hernia-specific factors were found to be associated with postoperative hospital admission, including older age, repair of a recurrent hernia, a larger hernia width, longer operative time, drain placement, and use of mechanical bowel preparation. Patients who required hospital admission were more likely than those discharged from the PACU to be readmitted to the hospital within 30 days (4% vs. 2%, respectively) and to experience a 30-day morbidity event (18% vs. 8%, respectively). CONCLUSIONS: Patient- and hernia-specific factors can be used to identify patients who can be safely discharged from the PACU following laparoscopic VHR. Additional studies are needed to determine if appropriate patient selection for discharge from the PACU leads to decreased healthcare costs for laparoscopic VHR over the long-term.