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

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

Examining current patterns of opioid prescribing and use after bariatric surgery.

BACKGROUND: Evidence-based guidelines on the appropriate amount of opioid medications to prescribe following bariatric surgery are lacking. We sought to determine our current opioid-prescribing practices, patient utilization, and satisfaction with pain control following elective bariatric surgery. METHODS: A retrospective chart review and phone survey were conducted on patients who underwent laparoscopic or robotic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from April 2018 to March 2019 at a single academic medical center. Opioid medications were converted to morphine milligram equivalents provided (MMEs). RESULTS: In total, 192 patients met inclusion criteria. The median amount of opioid medication prescribed on discharge was 300 oral MMEs, although there was a significant difference between the MMEs prescribed to patients with and without chronic opioid therapy (median 300 MMEs opioid naïve vs. 375 MMEs chronic opioid therapy, p = 0.01). Significantly fewer SG patients required a refill of their opioid medication compared to RYGB (8.3% vs. 23.9%, p = 0.003). Of the 192 patients, 87 (45.3%) completed the phone survey. Fifty-six patients (64%) reported that they took half or less of the initially prescribed opioids. Of the patients with leftover medication, 36% reported that they did not dispose of the medication. Overall understanding of pain control options after surgery was significantly lower in patients who felt they were prescribed "too little" opioids (p = 0.01), patients requiring refills (p = 0.02), and patients who were not satisfied with their pain control (p = 0.02). CONCLUSION: There is a gap between the amount of opioid medication prescribed and taken by patients following bariatric surgery in our practice. Patients who were least satisfied with their pain control reported knowledge gaps about pain control options that were more significant than patients who were more satisfied. Future initiatives should focus on the reduction of opioids prescribed to bariatric surgery patients post-operatively and on opioid education for patients.

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

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

Primary care providers' attitudes and knowledge of bariatric surgery.

BACKGROUND: Despite the increasing obesity prevalence among American adults, relatively few qualified patients proceed to bariatric surgery. Suggested explanations include referral barriers for weight loss management at primary care provider (PCP) visits. This study aims to assess the referral and practice patterns of PCPs treating patients with obesity. Our goal is to understand treatment barriers in order to implement targeted interventions that enhance quality of care. METHODS: A 39-question electronic survey was emailed to PCPs at a single academic institution with community physicians. Questions explored providers' demographics, referral patterns, and knowledge of pathophysiologic obesity mechanisms and bariatric surgery qualifications. Frequency and univariate analyses were performed and compared providers' demographics, positions, and BMIs between referring providers and non-referring providers. RESULTS: Of 121 surveys distributed, we achieved a 33.9% response rate (n = 41). 78.0% stated that > 15% of their patients in the preceding year were classified as obese. PCPs indicated initiating weight loss management conversations < 50% of the time with 48.8% of patients. Provider-identified barriers to discussing weight loss surgery included being unsure if patient's insurance would cover the procedure or if patients would qualify (24.4% vs. 19.5%). In addition, 43.9% of providers felt that the risks of bariatric surgery outweigh the benefits. CONCLUSION: Despite a large percentage of patients cared for by PCPs being classified as obese, few providers initiate discussions on weight loss options with potentially eligible surgical candidates. The barriers identified indicate an opportunity for improved education on patient qualifications, strategies for streamlining conversations and referrals, and reinforcement of the safety of surgical weight loss. Providers' desire for this education demonstrates an opportunity to work toward minimizing the referral gap by increasing patient conversations about these topics.

Linear vs. circular-stapled gastrojejunostomy in Roux-en-Y gastric bypass.

BACKGROUND: Various surgical techniques exist to create the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (LRYGB). Linear-stapled anastomosis (LSA) and circular-stapled anastomosis (CSA) are two commonly employed techniques. We hypothesized that CSA is associated with an increased rate of surgical site infection (SSI) and gastrojejunostomy stenosis when compared to LSA. METHODS: This study is a retrospective review of patients who underwent LRYGB for morbid obesity at a single institution between 2012 and 2016. Three bariatric surgeons contributed patients to this series. Clinical information and perioperative outcomes were collected through 90 days after surgery. RESULTS: 171 patients met the inclusion criteria. Two patients did not complete 90-day follow-up and were excluded from the analysis (88 patients CSA, 81 LSA; 99% 90-day follow-up). Patient demographics did not differ between groups. The LSA technique was associated with a significantly reduced rate of SSI (0 (0%) vs. 6 (6.8%), p = 0.02) and stenosis (2 (2.5%) vs. 17 (19.3%), p < 0.01). The CSA technique demonstrated a greater number of endoscopic dilations per stenotic event (1.5 ± 0.8 vs. 1.0 ± 0, p = 0.03). CONCLUSION: In our experience, a gastrojejunostomy constructed with an LSA technique was associated with a significantly reduced rate of stenosis and SSI compared to the CSA technique. LSA is currently our anastomotic technique of choice in LRYGB.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass.

BACKGROUND: Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB). OBJECTIVE: This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU). METHODS: PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee. RESULTS: Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures. CONCLUSIONS: This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Metabolic Syndrome Is a Significant Predictor of Postoperative Morbidity and Mortality Following Bariatric Surgery.

INTRODUCTION/PURPOSE: Metabolic syndrome is commonly demonstrated in patients with morbid obesity undergoing bariatric surgery. The purpose of this study was to determine the effect of metabolic syndrome on morbidity and mortality following bariatric surgery. MATERIALS AND METHODS: The National Surgical Quality Improvement Program (NSQIP) dataset was queried for patients who underwent bariatric surgical procedures between 2012 and 2014. Patient demographics, comorbid conditions, bariatric procedure type, and postoperative complications were analyzed. Metabolic syndrome was defined as having a body mass index > 30 kg/m2 in the presence of the comorbid conditions of hypertension and diabetes. Regression analysis was used to determine the relationship between metabolic syndrome and postoperative morbidity and mortality. RESULTS: During the study interval, 59,404 patients underwent bariatric surgery (Roux-en-Y gastric bypass = 28,263, sleeve gastrectomy = 30,239, revision = 422, and biliopancreatic diversion = 480). The mean body mass index was 45.9 kg/m2, and the mean age was 45 years. Of the cohort, 30,104 (50.6%) patients had a diagnosis of hypertension, 16,558 (27.8%) had diabetes mellitus, and 12,803 (21.5%) met the criteria for metabolic syndrome. Patients with metabolic syndrome were more likely to have Roux-en-Y gastric bypass procedure, a history of congestive heart failure, severe COPD, renal failure, and diminished functional status (p < 0.0001). Morbidity was greater for patients with metabolic syndrome (7.5% vs. 5%; p < 0.0001), and patients in this subset also had a 3.2-fold increased risk of mortality (p < 0.0001). DISCUSSION: Metabolic syndrome is prevalent in patients who undergo bariatric surgery. We have demonstrated that patients with the constellation of comorbid conditions defining metabolic syndrome are at an increased risk of morbidity and mortality following bariatric surgery. Patients and surgeons should be informed of the potential increased risk in this patient population.

Preoperative functional health status is a predictor of short-term postoperative morbidity and mortality after bariatric surgery.

BACKGROUND: Functional health status (FHS) is the ability to perform activities of daily living without caregiver assistance. OBJECTIVES: The primary aim of this study was to determine the impact of impaired preoperative FHS on morbidity and mortality within 30 days of bariatric surgery. SETTING: Academic medical center in the United States. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 data set was queried for primary minimally invasive bariatric procedures. The demographic characteristics and perioperative details of patients who were functionally independent were compared with patients with impaired FHS. Multivariable logistic regression analysis was performed to determine the odds of developing a perioperative complication or death for patients with impaired functional health. RESULTS: Of patients, 1515 (1.0%) were reported as having impaired FHS and 147,195 patients (99.0%) were independent before surgery. Patients with impaired FHS experienced significantly longer length of hospital stays (2.4 versus 1.8 d; P < .0001), a higher morbidity (adjusted odds ratio 1.5; P <0.0001), and higher mortality (adjusted odds ratio 2.1; P < .0001). Impaired FHS resulted in significantly increased rate of unplanned admissions to the intensive care unit, interventions, reoperations, and readmissions within 30 days of surgery. CONCLUSIONS: Patients with impaired FHS preoperatively have a significantly increased risk of short-term morbidity and mortality after bariatric surgery. The results of this study highlight the importance of establishing quality initiatives focused on improving short-term outcomes for patients with impaired functional health status.

Mesh Selection in Abdominal Wall Reconstruction.

Selection of mesh for ventral hernia repair and abdominal wall reconstruction can be challenging. Since the adoption of a tension-free mesh repair, the recurrence rates and outcomes after ventral hernia repair have substantially improved. The market for medical prostheses is constantly changing, with new technology in development attempting to create the ideal mesh for each clinical scenario. Permanent mesh is typically used for clean wounds. The various mesh materials, density, and pore sizes are discussed. In addition, the materials commonly used for contaminated wounds (absorbable synthetic and biologic meshes) are described. The latest literature regarding the use of various mesh materials is reviewed and organized to help make an informed decision regarding the appropriate use of reinforcing material.