Epiregulin as an Alternative Ligand for Leptin Receptor Alleviates Glucose Intolerance without Change in Obesity.

The leptin receptor (LepR) acts as a signaling nexus for the regulation of glucose uptake and obesity, among other metabolic responses. The functional role of LepR under leptin-deficient conditions remains unclear. This study reports that epiregulin (EREG) governed glucose uptake in vitro and in vivo in Lepob mice by activating LepR under leptin-deficient conditions. Single and long-term treatment with EREG effectively rescued glucose intolerance in comparative insulin and EREG tolerance tests in Lepob mice. The immunoprecipitation study revealed binding between EREG and LepR in adipose tissue of Lepob mice. EREG/LepR regulated glucose uptake without changes in obesity in Lepob mice via mechanisms, including ERK activation and translocation of GLUT4 to the cell surface. EREG-dependent glucose uptake was abolished in Leprdb mice which supports a key role of LepR in this process. In contrast, inhibition of the canonical epidermal growth factor receptor (EGFR) pathway implicated in other EREG responses, increased glucose uptake. Our data provide a basis for understanding glycemic responses of EREG that are dependent on LepR unlike functions mediated by EGFR, including leptin secretion, thermogenesis, pain, growth, and other responses. The computational analysis identified a conserved amino acid sequence, supporting an evolutionary role of EREG as an alternative LepR ligand.

Endoscopic treatments for GERD.

Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.

Predictors of Robotic Versus Laparoscopic Inguinal Hernia Repair.

BACKGROUND: The advent of robotic-assisted surgery has added an additional decision point in the treatment of inguinal hernias. The goal of this study was to identify the patient, surgeon, and hospital demographic predictors of robotic inguinal hernia repair (IHR). METHODS: We conducted a retrospective analysis of 102,241 IHRs (1096 robotic and 101,145 laparoscopic) from 2010 through 2015 with data collected in the Premier Hospital Database. The adjusted odds ratio (OR) of receiving a robotic IHR was calculated for each of several demographic factors using multivariable logistic regression. RESULTS: The rate of robotic IHR increased from 2010 through 2015. Age <65 y and Charlson comorbidity index were not predictors of a robotic IHR. Females were more likely to receive a robotic IHR (OR 1.69, confidence interval [CI] 1.40-2.05, P < 0.0001). Compared with white patients, black patients were more likely (OR 1.33, CI 1.06-1.68, P = 0.0138), and other race patients were less likely (OR 0.47, CI 0.38-0.58, P < 0.0001) to receive a robotic IHR. Compared with Medicare insurance, patients with all other types of insurance were more likely to receive a robotic IHR (OR > 1.00, lower limit of CI > 1.00, P < 0.05). Higher volume surgeons were less likely to perform robotic IHR (OR < 1.00, upper limit of CI < 1.00, P < 0.05). Nonteaching (OR 1.81, CI 1.53-2.13, P < 0.0001), larger (OR > 1.00, lower limit of CI > 1.00, P < 0.05), and rural (OR 1.27, CI 1.03-1.57, P = 0.025) hospitals were more likely to perform robotic IHR. Significant regional variation in the rate of robotic IHR was identified (OR > 1.00, lower limit of CI > 1.00, P < 0.05). CONCLUSIONS: The rate of robotic IHR is increasing exponentially. This study found that female gender, black race, insurance other than Medicare, lower surgeon annual volume, larger hospital size, nonteaching hospital status, rural hospital location, and hospital region were predictors of robotic IHR.

Predictors of laparoscopic versus open inguinal hernia repair.

BACKGROUND: Inguinal hernia repair (IHR) is among the most common general surgery procedures. Multiple studies have examined costs and benefits of laparoscopic approach versus open repair. This study aimed to identify patient, surgeon, and hospital demographic predictors of laparoscopic versus open IHR. METHODS: We conducted a retrospective analysis of 342,814 IHRs (241,669 open; 101,145 laparoscopic) performed in adults (age ≥ 18) from 2010 to 2015 using the Premier Hospital Database. Multivariate logistic regression was used to estimate the adjusted odds ratio of an IHR being laparoscopic versus open with respect to several demographic variables. RESULTS: The odds of an IHR being laparoscopic increased from 2010 to 2015. A laparoscopic procedure was more likely in patients who were < age 65 (OR 1.29, CI 1.24-1.31, p < 0.0001), male (OR 1.31, CI 1.27-1.34, p < 0.0001), privately insured (OR 1.36, CI 1.33-1.40, p < 0.0001), and neither white, black, nor Hispanic (OR 1.11, CI 1.09-1.14, p < 0.0001). The likelihood of a procedure being laparoscopic decreased 13% with each one-unit increase in Charlson comorbidity index value (OR 0.88, CI 0.87-0.89, p < 0.0001). Surgeons were more likely to perform a laparoscopic procedure if they had larger annual IHR caseloads (≥ 45/year; OR 1.57, CI 1.53-1.60, p < 0.0001), and operated at large hospitals (> 500 beds; OR 1.36, CI 1.33-1.39, p < 0.0001) in New England (OR 2.38, CI 2.29-2.47, p < 0.0001). Non-predictors of a laparoscopic procedure included urban/rural hospital location (OR 1.02, CI 0.10-1.05, p = 0.06) and hospital teaching status (OR 1.01, CI 0.99-1.03, p = 0.2084). CONCLUSIONS: Use of laparoscopic IHR is increasing. Patient age, gender, race, and insurance type, as well as surgeon annual volume, hospital size, and hospital region were predictors of a laparoscopic procedure. Further studies are needed to explain and remedy underlying differences impacting these predictors.

Endoscopic stent placement for treatment of sleeve gastrectomy leak: a single institution experience with fully covered stents.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has risen in prevalence as a standalone surgical option for treating obesity over the last 15 years. One of the most worrisome complications is development of a leak at the gastrectomy staple line. OBJECTIVE: The objective of this report is to describe our single-institution experience in managing SG staple-line leaks with fully covered endoscopic stents. SETTING: Academic medical center, United States. METHODS: Data for all patients who underwent endoscopic stent placement for an SG leak between 2010 and 2016 at a single academic institution were retrospectively reviewed. Patient medical history, perioperative information, stent placement details, outcomes, and subsequent interventions were recorded. RESULTS: Twenty-four patients with SG staple-line leaks treated with fully covered endoscopic stents were identified. Leaks were identified at a median of 31.5 days postoperatively (range, 1-1615 d). The majority of patients underwent other treatment(s) for their leak before stent placement at our institution. Stents remained in place for an average of 28.8 ± 16.8 days. Migration occurred in 22% of all stent placements. Three patients were lost to follow-up, and 14 of the remaining 21 patients (66.7%) healed after stent placement. Five patients (23.8%) ultimately required operative revision with partial gastrectomy and Roux-en-Y esophagojejunostomy for management of persistent leaks. CONCLUSION: Endoscopic management using fully covered stents for staple-line leaks after SG is effective in the majority of patients. However, algorithms are needed for the management of chronic staple-line leaks, which are less likely to heal with stent placement.

Impact of minimally invasive surgery on healthcare utilization, cost, and workplace absenteeism in patients with Incisional/Ventral Hernia (IVH).

BACKGROUND: Incisional hernia repair is one of the most common general surgery operations being performed today. With the advancement of laparoscopy since the 1990s, we have seen vast improvements in faster return to normal activity, shorter hospital stays and less post-operative narcotic use, to name a few. OBJECTIVE: The key aims of this review were to measure the impact of minimally invasive surgery versus open surgery on health care utilization, cost, and work place absenteeism in the patients undergoing inpatient incisional/ventral hernia (IVH) repair. METHODS: We analyzed data from the Truven Health Analytics MarketScan® Commercial Claims and Encounters Database. Total of 2557 patients were included in the analysis. RESULTS: Of the patient that underwent IVH surgery, 24.5% (n = 626) were done utilizing minimally invasive surgical (MIS) techniques and 75.5% (n = 1931) were done open. Ninety-day post-surgery outcomes were significantly lower in the MIS group compared to the open group for total payment ($19,288.97 vs. $21,708.12), inpatient length of stay (3.12 vs. 4.24 days), number of outpatient visit (5.48 vs. 7.35), and estimated days off (11.3 vs. 14.64), respectively. At 365 days post-surgery, the total payment ($27,497.96 vs. $30,157.29), inpatient length of stay (3.70 vs. 5.04 days), outpatient visits (19.75 vs. 23.42), and estimated days off (35.71 vs. 41.58) were significantly lower for MIS group versus the open group, respectively. CONCLUSION: When surgical repair of IVH is performed, there is a clear advantage in the MIS approach versus the open approach in regard to cost, length of stay, number of outpatient visits, and estimated days off.

Stray energy transfer during endoscopy.

INTRODUCTION: Endoscopy is the standard tool for the evaluation and treatment of gastrointestinal disorders. While the risk of complication is low, the use of energy devices can increase complications by 100-fold. The mechanism of increased injury and presence of stray energy is unknown. The purpose of the study was to determine if stray energy transfer occurs during endoscopy and if so, to define strategies to minimize the risk of energy complications. METHODS AND PROCEDURES: A gastroscope was introduced into the stomach of an anesthetized pig. A monopolar generator delivered energy for 5 s to a snare without contacting tissue or the endoscope itself. The endoscope tip orientation, energy device type, power level, energy mode, and generator type were varied to mimic in vivo use. The primary outcome (stray current) was quantified as the change in tissue temperature (°C) from baseline at the tissue closest to the tip of the endoscope. Data were reported as mean ± standard deviation. RESULTS: Using the 60 W coag mode while changing the orientation of the endoscope tip, tissue temperature increased by 12.1 ± 3.5 °C nearest the camera lens (p < 0.001 vs. all others), 2.1 ± 0.8 °C nearest the light lens, and 1.7 ± 0.4 °C nearest the working channel. Measuring temperature at the camera lens, reducing power to 30 W (9.5 ± 0.8 °C) and 15 W (8.0 ± 0.8 °C) decreased stray energy transfer (p = 0.04 and p = 0.002, respectively) as did utilizing the low-voltage cut mode (6.6 ± 0.5 °C, p < 0.001). An impedance-monitoring generator significantly decreased the energy transfer compared to a standard generator (1.5 ± 3.5 °C vs. 9.5 ± 0.8 °C, p < 0.001). CONCLUSION: Stray energy is transferred within the endoscope during the activation of common energy devices. This could result in post-polypectomy syndrome, bleeding, or perforation outside of the endoscopist's view. Decreasing the power, utilizing low-voltage modes and/or an impedance-monitoring generator can decrease the risk of complication.

Preoperative chemical component relaxation using Botulinum toxin A: enabling laparoscopic repair of complex ventral hernia.

BACKGROUND: Repair of complex ventral hernia can be very challenging for surgeons. Closure of large defects can have serious pathophysiological consequences. Botulinum toxin A (BTA) has recently been described to provide flaccid paralysis to abdominal muscles prior to surgery, facilitating closure and repair. METHODS: This was a prospective observational study of 32 patients who underwent ultrasound-guided injections of BTA to the lateral abdominal wall muscles prior to elective repair of complex ventral hernia between January 2013 and December 2015. Serial non-contrast abdominal CT imaging was performed to measure changes in fascial defect size, abdominal wall muscle length and thickness. All hernias were repaired laparoscopically or laparoscopic-assisted with placement of intra-peritoneal mesh. RESULTS: Thirty-two patients received BTA injections which were well tolerated with no complications. A comparison of baseline (preBTA) CT imaging with postBTA imaging demonstrated an increase in mean baseline abdominal wall length from 16.4 to 20.4 cm per side (p < 0.0001), which translates to a gain in mean transverse length of the unstretched anterolateral abdominal wall muscles of 4.0 cm/side (range 0-11.7 cm/side). Fascial closure was achieved in all cases, with no instances of raised intra-abdominal pressures or its sequelae, and there have been no hernia recurrences to date. CONCLUSIONS: Preoperative BTA injection to the muscles of the anterolateral abdominal wall is a safe and effective technique for the preoperative preparation of patients prior to laparoscopic mesh repair of complex ventral hernia. This technique elongates and thins the contracted and retracted musculature, enabling closure of large defects.

Pharmacotherapy in Conjunction with a Diet and Exercise Program for the Treatment of Weight Recidivism or Weight Loss Plateau Post-bariatric Surgery: a Retrospective Review.

BACKGROUND: Bariatric surgery is an effective therapeutic option for management of obesity. However, weight recidivism (WR) and weight loss plateau (WLP) are common problems. We present our experience with the use of two pharmacotherapies in conjunction with our standard diet and exercise program in those patients who experienced WR or WLP. METHODS: From June 2010 to April 2014, bariatric surgery patients who experienced WR or WLP after undergoing Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB), and who were treated with phentermine (Ph) or phentermine-topiramate (PhT), were reviewed retrospectively. Generalized estimating equations were used to compare patient weights through 90 days between initial surgery type and medication type. Patient weights, medication side effect, and co-morbidities were collected during the first 90 days of therapy. RESULTS: Fifty-two patients received Ph while 13 patients received PhT. Overall, patients in both groups lost weight. Among those whose weights were recorded at 90 days, patients on Ph lost 6.35 kg (12.8% excess weight loss (EWL); 95% confidence interval (CI) 4.25, 8.44) and those prescribed PhT lost 3.81 kg (12.9% EWL; CI 1.08, 6.54). Adjusting for baseline weight, time since surgery, and visit through 90 days, patients treated with Ph weighed significantly less than those on PhT throughout the course of this study (1.35 kg lighter; 95% CI 0.17, 2.53; p = 0.025). There were no serious side effects reported. CONCLUSIONS: Phentermine and phentermine-topirimate in addition to diet and exercise appear to be viable options for weight loss in post-RYGB and LAGB patients who experience WR or WLP.

Effectiveness of laparoscopic Roux-en-Y gastric bypass on obese class I type 2 diabetes mellitus patients.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) can dramatically improve type 2 diabetes mellitus (T2D) in obese class II and III patients. There is increasing evidence that shows bariatric surgery can also ameliorate T2D in patients with BMI between 30 kg/m(2) and 35 kg/m(2) (obese class I). OBJECTIVE: To compare the effectiveness of LRYGB on T2D in obese class I patients with that of obese class II and III T2D patients. SETTING: University Hospital, China METHODS: A prospective study was performed in the authors' center from March 2010 to July 2011. Forty-two consecutive obese patients were included in the study. Anthropometric and metabolism parameters were compared between obese class II and III patients and obese class I patients before and after LRYGB. RESULTS: No patients were lost to follow up. After 36 months, metabolic parameters significantly improved in both groups. Partial remission rates between the 2 groups at each time point (12 months, 24 months, and 36 months) were comparable. Obese class II and III patients had higher complete remission rates at 12 months and 24 months, but no difference was observed at 36 months. CONCLUSION: Both obese class II and III patients and obese class I T2D patients showed significant improvement in multiple parameters after LRYGB. Obese class II and III patients had a higher complete remission rate than obese class I patients. Standardized remission criteria are needed to make outcomes form different centers comparable. Large prospective studies are needed and long-term outcomes have to be observed to better evaluate effectiveness of LRYGB on obese class I T2D patients.

Physiology and pathogenesis of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is one of the most common problems treated by primary care physicians. Almost 20% of the population in the United States experiences occasional regurgitation, heartburn, or retrosternal pain because of GERD. Reflux disease is complex, and the physiology and pathogenesis are still incompletely understood. However, abnormalities of any one or a combination of the three physiologic processes, namely, esophageal motility, lower esophageal sphincter function, and gastric motility or emptying, can lead to GERD. There are many diagnostic and therapeutic approaches to GERD today, but more studies are needed to better understand this complex disease process.

ß-Nicotinamide adenine dinucleotide acts at prejunctional adenosine A1 receptors to suppress inhibitory musculomotor neurotransmission in guinea pig colon and human jejunum.

Intracellular microelectrodes were used to record neurogenic inhibitory junction potentials in the intestinal circular muscle coat. Electrical field stimulation was used to stimulate intramural neurons and evoke contraction of the smooth musculature. Exposure to ß-nicotinamide adenine dinucleotide (ß-NAD) did not alter smooth muscle membrane potential in guinea pig colon or human jejunum. ATP, ADP, ß-NAD, and adenosine, as well as the purinergic P2Y1 receptor antagonists MRS 2179 and MRS 2500 and the adenosine A1 receptor agonist 2-chloro-N6-cyclopentyladenosine, each suppressed inhibitory junction potentials in guinea pig and human preparations. ß-NAD suppressed contractile force of twitch-like contractions evoked by electrical field stimulation in guinea pig and human preparations. P2Y1 receptor antagonists did not reverse this action. Stimulation of adenosine A1 receptors with 2-chloro-N6-cyclopentyladenosine suppressed the force of twitch contractions evoked by electrical field stimulation in like manner to the action of ß-NAD. Blockade of adenosine A1 receptors with 8-cyclopentyl-1,3-dipropylxanthine suppressed the inhibitory action of ß-NAD on the force of electrically evoked contractions. The results do not support an inhibitory neurotransmitter role for ß-NAD at intestinal neuromuscular junctions. The data suggest that ß-NAD is a ligand for the adenosine A1 receptor subtype expressed by neurons in the enteric nervous system. The influence of ß-NAD on intestinal motility emerges from adenosine A1 receptor-mediated suppression of neurotransmitter release at inhibitory neuromuscular junctions.

Laparoscopic adjustable gastric banded plication: case-matched study from a single U.S. center.

BACKGROUND: Laparoscopic adjustable gastric banded plication (LAGBP) is a novel technique for weight loss surgery. This study evaluates the safety and short-term efficacy of LAGBP in a U.S. population. The setting was an academic medical center in the United States. METHODS: Patients who underwent LAGBP between 2012 and 2013 were reviewed retrospectively. Demographic characteristics, pre and perioperative details, body mass index (BMI), and percent excess weight loss (%EWL) were analyzed and compared to case-matched cohorts that had laparoscopic adjustable gastric banding (LAGB) or laparoscopic sleeve gastrectomy (LSG) during the same time period. RESULTS: Seventeen patients (14 females) underwent LAGBP during the study period and were case-matched based on age, sex, race, and preoperative BMI with patients having LAGB and LSG. Mean age and preoperative BMI for LAGBP cohort were 42.5±11.6 years and 47.7±6.5 kg/m2, respectively. Mean operative time and estimated blood loss were 72±16 minutes and 23±23 mL, respectively, compared to 49±16 minutes (P=.002) and 15±23 mL for LAGB, and 66±18 minutes and 36±22 mL for LSG. There were no perioperative deaths. Hospital length of stay was 1.1±.3 days for LAGBP, versus .7±.3 days (P=.004) for LAGB, and 2.7±1.4 days (P<.001) for LSG. At 12-month follow-up, patients in the LAGBP and LAGB groups had undergone similar number of band adjustments (4.7 versus 5.1; P=.68). The %EWL was 46.1±14.8% for the LAGBP cohort, compared to 38.9±20.6% for LAGB, and 57.7±16% for LSG. CONCLUSION: LAGBP is technically feasible and safe, and offers weight loss results positioned between LAGB and LSG at 1 year. To date, this is the largest U.S. series to compare this novel technique to more traditional weight loss procedures.

Bioabsorbable hernia plugs in laparoscopic inguinal herniorraphy: short-term and long-term results.

PURPOSE: To report our short-term and long-term experience with laparoscopic inguinal hernia repair (LIHR) using a bioabsorbable plug. METHODS: Patients who underwent LIHR from 2009 to 2011 using a bioabsorbable plug and synthetic mesh patch were reviewed retrospectively. Short-term follow-up information was obtained within 30 days of surgery, whereas long-term follow-up was obtained in 2014. Quality of life was assessed using the Carolinas Comfort Scale. RESULTS: Forty-four patients (43 male), including 6 (13.6%) with recurrent disease, underwent 52 LIHR with a bioabsorbable plug. Mean age and body mass index were 60.9 ± 10.5 years and 27.9 ± 4.7 kg/m, respectively. Among 39 (88.6%) patients available for short-term follow-up, early postoperative complications were seen in 10 (25.6%) patients, all of which resolved spontaneously. Mean long-term follow-up duration was 41.6 ± 4.1 months, among 30 (68.2%) patients (40 hernia repairs). There were 2 (5%) hernia recurrences, with 1 requiring a reoperation 12 months after initial repair. Only 2 (6.7%) patients reported moderate or bothersome chronic pain. CONCLUSIONS: Bioabsorbable plug combined with a synthetic mesh is safe and effective for use during LIHR. The technique offers an acceptable incidence of chronic pain and recurrence.

Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy.

BACKGROUND: Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC. METHODS: Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot's triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected. RESULTS: Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6 ± 13.7 years and 31.5 ± 8.2 kg/m(2), respectively. ICG was administered 73.8 ± 26.4 min prior to incision. NIRF-C was significantly faster than IOC (1.9 ± 1.7 vs. 11.8 ± 5.3 min, p < 0.001). IOC was unobtainable in 20 (24.4 %) patients while NIRF-C did not visualize biliary structures in 4 (4.9 %) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5 %, respectively, compared to 72.0, 75.6, and 74.3 % for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80 % of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C. CONCLUSIONS: NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.

Laparoscopic Roux-en-Y gastric bypass for treatment of symptomatic paraesophageal hernia in the morbidly obese: medium-term results.

BACKGROUND: The ideal surgical approach for treatment of symptomatic paraesophageal hernias (PEH) in obese patients remains elusive. The objective of this study was to assess the safety, feasibility, and effectiveness of combined laparoscopic PEH repair and Roux-en-Y gastric bypass (RYGB) for the management of symptomatic PEH in morbidly obese patients. METHODS: Fourteen patients with symptomatic PEH and morbid obesity (body mass index [BMI]>35 kg/m(2)) underwent laparoscopic PEH repair with RYGB between 2008 and 2011. Demographic characteristics and preoperative and perioperative details were analyzed. Patients were contacted in October 2013 for follow-up. BMI, reflux symptoms, and disease-specific quality of life (QoL) data were obtained. RESULTS: There were 11 females (79%). Median age and preoperative BMI were 48 years and 42 kg/m(2), respectively. Mean operative time was 180 minutes, with median length-of-stay of 4 days. There were no perioperative deaths, and 5 patients experienced postoperative complications including 1 gastrojejunostomy leak. Complete follow-up with a median follow-up interval of 35 months was available in 9 (64%) patients. The median % excess weight loss was 67.9%. Thirty-three percent required antisecretory medications for reflux control, compared to 89% preoperatively. Seventy-eight percent of patients reported good to excellent QoL outcomes assessed by the Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire. Overall, 89% of patients were satisfied with their operation and would undergo the procedure again. CONCLUSION: Combined laparoscopic PEH repair and RYGB is a safe, feasible, and effective treatment option for morbidly obese patients with symptomatic PEH, and offers good to excellent disease-specific quality-of-life outcomes at medium-term follow-up. To date, this is the largest series with the longest follow-up in this unique patient population.

Two-year outcomes for medicaid patients undergoing laparoscopic Roux-en-Y gastric bypass: a case-control study.

BACKGROUND: Millions of patients will be added to Medicaid programs throughout the country due to expansion driven by the Affordable Care Act. Since 90 % of state Medicaid programs cover bariatric surgery, the outcomes of Medicaid patients will be important to study. We performed a retrospective analysis to compare outcomes between Medicaid and non-Medicaid bariatric surgery patients over a two-year period. METHODS: All patients who underwent a laparoscopic Roux-en-Y gastric bypass at The Ohio State University Medical Center from January 2008-April 2011 were identified. Of these 609 patients, 30 Medicaid patients were identified and compared to 90 randomly selected non-Medicaid patients (1:3 case-control). Preoperative data and postoperative outcome data (weight loss, comorbidity resolution, complications, and mortality) were obtained from electronic medical records. Descriptive statistical analyses were performed to compare categorical and continuous variables. RESULTS: Medicaid patients had a significantly higher average BMI (58.4 vs. 49.5; p < 0.001) and higher rates of comorbidities. Over a 90-day postoperative period, Medicaid patients experienced a higher wound complication rate (20.0 vs. 5.6 %; p = 0.03) and visited the ER more frequently (33.3 vs. 10.0 %; p = 0.007) but had similar rates of medical complications compared to non-Medicaid patients. The Medicaid cohort lost 52.1 % of its excess body weight vs. 64.6 % for the non-Medicaid cohort (p = 0.02) over a two-year period. There were no significant differences in comorbidity resolution, anastomotic complications, or mortality after 2 years of follow-up. CONCLUSION: Despite being a higher risk cohort, Medicaid patients undergoing laparoscopic Roux-en-Y gastric bypass had similar long-term outcomes compared to non-Medicaid patients.