Characteristics and outcomes for patients undergoing revisional bariatric surgery due to persistent obesity: a retrospective cohort study of 10,589 patients.

BACKGROUND: Revisional bariatric surgery in an option for patients who experience weight regain or inadequate weight loss after primary elective bariatric procedures. However, there is conflicting data on safety outcomes of revisional procedures. We aim to characterize patient demographics, procedure type, and safety outcomes for those undergoing revisional compared to initial bariatric interventions to guide management of these patients. METHODS: The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) registry was analyzed, comparing primary elective to revisional bariatric procedures for inadequate weight loss. Bivariate analysis was performed to determine between group differences. Multivariable logistic regression determined factors associated with serious complications or mortality. RESULTS: We evaluated 158,424 patients, including 10,589 (6.7%) revisional procedures. Patients undergoing revisional procedures were more like to be female (85.5% revisional vs. 81.0% initial; p < 0.001), had lower body mass index (43.6 ± 7.8 kg/m2 revisional vs. 45.2 ± 7.8 kg/m2 initial; p < 0.001), and less metabolic comorbidities than patients undergoing primary bariatric surgery. The most common revisional procedures were Roux-en-Y gastric bypass (48.4%) and sleeve gastrectomy (32.5%). Revisional procedures had longer operative duration compared to primary procedures. Patients undergoing revisional procedures were more likely to experience readmission to hospital (4.8% revisional vs. 2.9% initial; p < 0.001) and require reoperation (2.4% revisional vs. 1.0% initial; p < 0.001) within 30 days of the procedure. Revisional procedures were independently associated with increased serious complications (OR 1.49, CI 1.36-1.64, p < 0.001) but were not a significant predictor of 30-day mortality (OR 0.74, CI 0.36-1.50, p = 0.409). CONCLUSIONS: In comparison to primary bariatric surgery, patients undergoing revisional procedures have less metabolic comorbidities. Revisional procedures have worse perioperative outcomes and are independently associated with serious complications. These data help to contextualize outcomes for patients undergoing revisional bariatric procedures and to inform decision making in these patients.

Substance abuse screening prior to bariatric surgery: an MBSAQIP cohort study evaluating frequency and factors associated with screening.

INTRODUCTION: Patients undergoing bariatric surgery experience substantial risk of pre- and postoperative substance use. Identifying patients at risk for substance use using validated screening tools remains crucial to risk mitigation and operative planning. We aimed to evaluate proportion of bariatric surgery patients undergoing specific substance abuse screening, factors associated with screening and the relationship between screening and postoperative complications. METHODS: The 2021 MBSAQIP database was analyzed. Bivariate analysis was performed to compare factors between groups who were screened for substance abuse versus non-screened, and to compare frequency of outcomes. Multivariate logistic regression analysis was performed to assess the independent effect of substance screening on serious complications and mortality, and to assess factors associated with substance abuse screening. RESULTS: A total of 210, 804 patients were included, with 133,313 (63.2%) undergoing screening and 77,491 (36.8%) who did not. Those who underwent screening were more likely to be white, non-smoker, and have more comorbidities. The frequency of complications was not significant (e.g., reintervention, reoperation, leak) or similar (readmission rates 3.3% vs. 3.5%) between screened and not screened groups. On multivariate analysis, lower substance abuse screening was not associated with 30-day death or 30-day serious complication. Factors that significantly affected likelihood of being screened for substance abuse included being black (aOR 0.87, p < 0.001) or other race (aOR 0.82, p < 0.001) compared to white, being a smoker (aOR 0.93, p < 0.001), having a conversion or revision procedure (aOR 0.78, p < 0.001; aOR 0.64, p < 0.001, respectively), having more comorbidities and undergoing Roux-en-y gastric bypass (aOR 1.13, p < 0.001). CONCLUSION: There remains significant inequities in substance abuse screening in bariatric surgery patients regarding demographic, clinical, and operative factors. These factors include race, smoking status, presence of preoperative comorbidities, and procedure type. Further awareness and initiatives highlighting the importance of identifying at risk patients is critical for ongoing outcome improvement.

Asian race is not associated with increased 30-day serious complications or mortality: a MBSAQIP analysis of 594,837 patients.

INTRODUCTION: With expansion of bariatric surgery indications to include Asian patients with diabetes and body mass index (BMI) ≥ 27.5, or BMI ≥ 32.5, it is important to characterize Asian patient population undergoing bariatric surgery and assess their postoperative outcomes. METHODS: This retrospective study analyzed the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All patients undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) who self-reported as Asian or White race were included. The primary outcomes were to characterize the Asian race population in North American and to identify if Asian race was associated with serious complications or mortality at 30 days. RESULTS: Overall, 594,837 patients met inclusion, with 4229 self-reporting Asian racial status. Patients of Asian race were younger (41.8 vs 45.5 years, p < 0.001) and had a lower BMI (42.8 vs 44.7 kg/m2 p < 0.001) than White patients. They were also more likely to have insulin dependent diabetes (10.9% vs 8.2%, p < 0.001), have received prior cardiac surgery (10.0% vs 1.2% p < 0.001), and suffer from renal insufficiency (1.0% vs 0.5%, p < 0.001). There were no significant differences between rates of RYGB (28.3% vs 28.9%, p = 0.4) and mean operative duration (87.7 vs 87.5 min, p = 0.7). Additionally, there were no differences in 30 day outcomes including leak (0.5% vs 0.5%, p = 0.625), bleeding (1.2% vs 1.0%, p = 0.1), serious complications (3.4% vs 3.5%, p = 0.6), or mortality (0.1% vs 0.1%, p = 0.7) and after confounder control, Asian race was not independently associated with serious complications (OR 1.0, CI 0.9-1.2, p = 0.7), or mortality (OR 1.1, CI 0.3-3.3, p = 0.1). CONCLUSIONS: Despite the increased metabolic burden of Asian patients, no differences in 30-day outcomes compared to White patients occurs. This data supports evidence suggesting these patients may safely undergo bariatric surgery independent of their increased metabolic burden.

A 5-year characterization of trends and outcomes in elderly patients undergoing elective bariatric surgery.

BACKGROUND: The North American population with severe obesity is aging and with that so will the number of elderly patients (≥ 65 years) meeting indications for metabolic surgery. Trends in bariatric delivery in this population are poorly characterized and outcomes remain conflicting, limiting potential uptake and delivery. METHODS: The MBSAQIP database was used to identify elderly patients (≥ 65 years) undergoing elective bariatric surgery from 2015 to 2019. Our objectives were to analyze their unique characteristics, surgical operative trends, and outcomes by comparing to a non-elderly cohort. Multivariable logistic regression identified independent predictors of serious complications and 30-day mortality. RESULTS: There was a total of 751,607 patients, 5.3% (n = 39,854) were elderly. Mean ages were 43 ± 11 years (non-elderly) versus 68 ± 3 years (elderly). Elderly patients were less likely to be female (70.7% elderly; 80.1% non-elderly) and had lower BMI (43.17 ± 6.64 kg/m2 elderly; 45.42 ± 7.87 kg/m2 non-elderly). They had higher American Society of Anesthesiologists classification, lower functional status, more insulin dependent diabetes, and hypertension, among other comorbidities. There were no clinically significant differences between the most frequently performed bariatric surgery. Sleeve gastrectomy remained the most common (73.7% non-elderly; 72.3% elderly); however, operative time was longer among the elderly. Functional status was most predictive for both serious complications (OR 1.72; CI 1.53-1.94) and mortality (OR 2.92; CI 1.98-4.31). Surgery among elderly patients was associated with poorer 30-day postoperative outcomes across all categories and was independently associated with serious complications (OR 1.23; CI 1.17-1.30, p < 0.001; AR 4.64%) and 30-day mortality (OR 2.49; CI 2.00-3.11, p < 0.001; AR 0.27%), after adjusting for comorbidities. CONCLUSIONS: After adjusting for comorbidities, functional status remains the most predictive factor for poor outcomes; however, elderly patients have increased 30-day odds of serious complications and 30-day mortality, suggesting a need to tailor our approach to these individuals that carry a unique operative risk.

Does ASA classification effectively risk stratify patients undergoing bariatric surgery: a MBSAQIP retrospective cohort of 138,612 of patients.

INTRODUCTION: It is important to appropriately risk stratify bariatric surgery patients, as these patients often have obesity-related comorbidities which can increase postoperative complication risk but also benefit the most from bariatric surgery. We aimed to evaluate the utility of risk stratification using ASA class for bariatric surgery patients and assessed predictive factors of postoperative complications. METHODS: The 2020 MBSAQIP database was analyzed, and an ASA-deemed high-risk cohort (class IV) and normal-risk (ASA class II and III) cohort were compared. Univariate analysis was performed to characterize differences between cohorts and to compare complication rates. Multivariate logistic regression analysis was performed to determine factors associated with increased odds of postoperative complications. RESULTS: We evaluated 138 612 patients with 5380 (3.9%) considered high-risk and 133 232 (96.1%) normal-risk. High-risk patients were more likely to be older (46.2 ± 12.0vs.43.4 ± 11.9, p < 0.001), male (30.9%vs.18.4%, p < 0.001), have higher BMI (51.4 ± 10.2vs.44.9 ± 7.4, p < 0.001), and have more comorbidities. High-risk patients were more likely to have increased 30-day serious complications (4.5%vs.2.8%, p < 0.001) and death (0.2%vs.0.1%, p = 0.001) but not anastomotic leak (0.2%vs.0.2%, p = 0.983). Multivariate models showed ASA class IV patients were at higher odds for any serious complication by 30 days (aOR 1.36, 95%CI 1.18-1.56, p < 0.001) but not for death (aOR 1.04, 95%CI 0.49-2.21, p = 0.921). The factor independently associated with the highest odds of complication in both models was functional status preoperatively (partially dependent aOR 2.06, 95%CI 1.56-2.72, p < 0.001; fully dependent aOR 3.19, 95%CI 1.10-9.28, p = 0.033 for any serious complication; partially dependent aOR 5.08, 95%CI 2.16-12.00, p < 0.001 for death). CONCLUSIONS: While elevated ASA class correlates with increased serious complications, pre-operative functional status appears to have a much greater contribution to odds of serious complications and mortality. These findings question the utility of using ASA to risk stratify patients peri-operatively and provides evidence for using a simpler and more practical functional status approach.

New persistent opioid use after bariatric surgery: a systematic review and pooled proportion meta-analysis.

INTRODUCTION: Increasing evidence suggests surgical patients are at risk for developing new, persistent opioid use (NPOU) following surgery. This risk may be heightened for patients undergoing bariatric surgery. Few studies have evaluated this important long-term outcome and little is known about the rate of NPOU, or factors associated with NPOU for bariatric surgery patients. METHODS AND PROCEDURE: We conducted a systematic review of MEDLINE, Embase, Scopus, Web of Science, and Cochrane databases in August 2021. Studies were reviewed and data extracted independently by two reviewers following MOOSE guidelines. Studies evaluating bariatric surgery patients reporting NPOU, defined as new opioid use > 90 days after surgery, were included. Abstracts, non-English, animal, n < 5, and pediatric studies were excluded. Primary outcome was NPOU prevalence, and secondary outcomes were patient and surgical factors associated with NPOU. Factors associated with NPOU are reported from findings of individual studies; meta-analysis could not be completed due to heterogeneity of reporting. RESULTS: We retrieved a total of 2113 studies with 8 meeting inclusion criteria. In studies reporting NPOU rates (n = 4 studies), pooled prevalence was 6.0% (95% CI 4.0-7.0%). Patient characteristics reported by studies to be associated with NPOU included prior substance use (tobacco, alcohol, other prescription analgesics), preoperative mental health disorder (anxiety, mood disorders, eating disorders), and public health insurance. Surgical factors associated with NPOU included severe post-operative complications and in-hospital opioid use (peri- or post operatively). CONCLUSIONS: NPOU is an uncommon but important complication following bariatric surgery, with patient factors including prior substance abuse, mental health disorders, and use of public health insurance placing patients at increased risk, and surgical factors being complications and peri-operative opioid use. Studies evaluating techniques to reduce NPOU in these high-risk populations are needed.

Endoscopic plication compared to laparoscopic fundoplication in the treatment of gastroesophageal reflux disease: a systematic review and meta-analysis.

INTRODUCTION: Endoscopic plication offers an alternative to surgical fundoplication for treatment of gastroesophageal reflux disease (GERD). This systematic review and meta-analysis evaluate outcomes following endoscopic plication compared to laparoscopic fundoplication. METHODS AND PROCEDURES: Systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted in September 2022. Study followed PRISMA guidelines. Studies comparing endoscopic plication to laparoscopic fundoplication with n > 5 were included. Primary outcome was PPI cessation, with secondary outcomes including complications, procedure duration, length of stay, change in lower esophageal sphincter (LES) tone, and DeMeester score. RESULTS: We reviewed 1544 studies, with five included comparing 105 (46.1%) patients receiving endoscopic plication (ENDO) to 123 (53.9%) undergoing laparoscopic fundoplication (LAP). Average patient age was 47.6 years, with those undergoing plication being younger (46.4 ENDO vs 48.5 LAP). BMI (26.6 kg/m2 ENDO vs 26.2 kg/m2 LAP), and proportion of females (42.9% ENDO vs 37.4% LAP) were similar. Patients undergoing laparoscopic procedures had worse baseline LES pressure (12.8 mmHg ENDO vs 9.0 mmHg LAP) and lower preoperative DeMeester scores (34.6 ENDO vs. 34.1 LAP). The primary outcome demonstrated that 89.2% of patients undergoing laparoscopic fundoplication discontinued PPI compared to 69.4% for those receiving plication. Meta-analysis revealed that plication had significantly reduced odds of PPI discontinuation (OR 0.27, studies = 3, 95% CI 0.12 to 0.64, P = 0.003, I2 = 0%). Secondary outcomes demonstrated that odds of complications (OR 1.46, studies = 4, 95% CI 0.34 to 6.32, P = 0.62, I2 = 0%), length of stay (MD - 1.37, studies = 3, 95% CI - 3.48 to 0.73, P = 0.20, I2 = 94%), and procedure durations were similar (MD 0.78, studies = 3, 95% CI - 39.70 to 41.26, P = 0.97, I2 = 98%). CONCLUSIONS: This is the first meta-analysis comparing endoscopic plication to laparoscopic fundoplication. Results demonstrate greater likelihood of PPI discontinuation with laparoscopic fundoplication with similar post-procedural risk.

Opioid prescribing practices following bariatric surgery: a systematic review and pooled proportion meta-analysis.

INTRODUCTION: A paucity of literature exists regarding current opioid prescribing and use following bariatric surgery. We aimed to characterize opioid prescribing practices and use following bariatric surgery to inform future studies and optimized prescribing practices. METHODS AND PROCEDURE: We performed a systematic review of Ovid MEDLINE, Ovid Embase, Scopus, Web of Science Core Collection, and Cochrane Library (via WILEY) on August 20, 2021. Two reviewers reviewed and extracted data independently. Studies evaluating adult patients undergoing bariatric surgery that reported opioid prescriptions at discharge were included. Abstracts, non-English studies, and those with n < 5 were excluded. Primary outcomes assessed the amount of morphine milligram equivalents (MMEs) prescribed at discharge. Secondary outcomes evaluated opioids used following discharge, proportion of patients with unused opioid, and if unused opioids were properly discarded. RESULTS: We evaluated 2113 studies, with 18 undergoing full-text review, and 5 meeting inclusion criteria. Overall, 847 patients were included, with 450 (53%) undergoing sleeve gastrectomy and 393 (46%) receiving Roux-en-Y gastric bypass. Most patients were female (n = 484/589, 82.2%), and the average age and BMI were 44.6 (± 11.8) years and 48.1 kg/m2 (± 8.4 kg/m2), respectively. On average, 348.4 MMEs were prescribed to patients undergoing bariatric surgery. Patients used only 84.7 MMEs, with 87.0% (95% CI 66.0-99.0%) having unused opioid, and 41/120 (34.2%) retaining these excess opioids. CONCLUSION: Nearly 90% of all bariatric patients evaluated in our systematic review are prescribed excessive opioids at discharge. Further work characterizing current opioid prescribing practices and use may help guide development of standardized post-bariatric surgery prescription guidelines.

Gastric ischemic conditioning prior to esophagectomy reduces anastomotic leaks and strictures: a systematic review and meta-analysis.

BACKGROUND: Gastric ischemic conditioning (GIC) is a strategy to promote neovascularization of the gastric conduit to reduce the risk of anastomotic complications following esophagectomy. Despite a number of studies and reviews published on the concept of ischemic conditioning, there remains no clear consensus regarding its utility. We performed an updated systematic review and meta-analysis to determine the impact of GIC, particularly on anastomotic leaks, conduit ischemia, and strictures. METHODS: A systematic search of MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library was performed on February 5th, 2020 by a university librarian after selection of key search terms with the research team. Inclusion criteria included human participants undergoing esophagectomy with gastric conduit reconstruction, age ≥ 18, N ≥ 5, and GIC performed prior to esophagectomy. Our primary outcome of interest was anastomotic leaks. Our secondary outcome was gastric conduit ischemia, anastomotic strictures, and overall survival. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel fixed-effects model. RESULTS: A total of 1712 preliminary studies were identified and 23 studies included for final review. GIC was performed in 1178 (53.5%) patients. Meta-analysis revealed reduced odds of anastomotic leaks (OR 0.67; 95% CI 0.46-0.97; I2 = 5%; p = 0.03) and anastomotic strictures (OR 0.48; 95% CI 0.29-0.80; I2 = 65%; p = 0.005). Meta-analysis revealed no difference in odds of conduit ischemia (OR 0.40; 95% CI 0.13-1.23; I2 = 0%; p = 0.11) and no difference in odds of overall survival (OR 0.54; 95% CI 0.29-1.02; I2 = 22%; p = 0.06). CONCLUSION: GIC is associated with reduced odds of anastomotic leaks and anastomotic strictures and may decrease morbidity in patients undergoing esophagectomy. Further prospective randomized trials are needed to better identify the optimal patient population, timing, and techniques used to best achieve GIC.

Management of choledocholithiasis after Roux-en-Y gastric bypass: a systematic review and pooled proportion meta-analysis.

BACKGROUND: Several therapeutic modalities have been proposed for the management of choledocholithiasis (CDL) following Roux-en-Y gastric bypass (RYGB), yet debate exists regarding the optimal management. The purpose of our study was to review the current literature to compare the efficacy of various techniques in the management of CDL post-RYGB. METHODS: A comprehensive search of multiple databases was conducted. Studies reporting on the management of CDL in patients post-RYGB and including at least 5 patients were eligible for inclusion. The primary outcome was successful stone clearance. Secondary outcomes included procedure duration, length of hospital stay, and adverse events. RESULTS: Of 3259 identified studies, 53 studies involving 857 patients were included in the final analysis. The mean age was 54.4 years (SD 7.05), 78.8% were female (SD 13.6%), and the average BMI was 30.8 kg/m2 (SD 6.85). Procedures described included laparoscopy-assisted ERCP (LAERCP), balloon-assisted enteroscopy (BAE), ultrasound-directed transgastric ERCP (EDGE), laparoscopic common bile duct exploration (LCBDE), EUS-guided intra-hepatic puncture with antegrade clearance (EGHAC), percutaneous trans-hepatic biliary drainage (PTHBD), and rendezvous guidewire-associated (RGA) ERCP. High rates of successful stone clearance were observed with LAERCP (1.00; 95% CI 0.99-1.00; p = 0.47), EDGE (0.97; 95% CI 0.9-1.00; p = 0.54), IGS ERCP (1.00; 95% CI 0.87-1.00), PTHBD (1.0; 95% CI 0.96-1.00), and LCBDE (0.99; 95% CI 0.93-1.00, p < 0.001). Lower rates of stone clearance were observed with BAE (61.5%; 95%CI 44.3-76.3, p = 0.188) and EGHAC (74.0%; 95% CI 42.9-91.5, p = 0.124). Relative to EDGE, LAERCP had a longer procedure duration (133.1 vs. 67.4 min) but lower complication rates (12.8% vs. 24.3%). CONCLUSION: LAERCP and EDGE had high rates of success in the management of CDL post-RYGB. LAERCP had fewer complications but was associated with longer procedure times. BAE had lower success rates than both LAERCP and EDGE.

Characterization of Near-Infrared Imaging and Indocyanine-Green Use Amongst General Surgeons: A Survey of 263 General Surgeons.

BACKGROUND: Near-infrared fluorescence imaging (NIRFI) is an increasingly utilized imaging modality, however its use amongst general surgeons and its barriers to adoption have not yet been characterized. METHODS: This survey was sent to Canadian Association of General Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons members. Survey development occurred through consensus of NIRFI experienced surgeons. RESULTS: Survey completion rate for those opening the email was 16.0% (n = 263). Most respondents had used NIRFI (n = 161, 61.2%). Training, higher volumes, and bariatric, thoracic, or foregut subspecialty were associated with use (P < .001).Common reasons for NIRFI included anastomotic assessment (n = 117, 72.7%), cholangiography (n = 106, 65.8%), macroscopic angiography (n = 66, 41.0%), and bowel viability assessment (n = 101, 62.7%). Technical knowledge, training and poor evidence were cited as common barriers to NIRFI adoption. CONCLUSIONS: NIRFI use is common with high case volume, bariatric, foregut, and thoracic surgery practices associated with adoption. Barriers to use appear to be lack of awareness, low confidence in current evidence, and inadequate training. High quality randomized studies evaluating NIRFI are needed to improve confidence in current evidence; if deemed beneficial, training will be imperative for NIRFI adoption.

Surgical management of hiatal hernia vs medical therapy to treat bleeding Cameron lesions: a systematic review and meta-analysis.

INTRODUCTION: Cameron lesions (CL) are an under-recognized cause of gastrointestinal bleeding. Diagnosis is often impaired by technical difficulty, and once diagnosed, management remains unclear. Typically, patients are medically managed with proton pump inhibitors (PPI). Small studies have demonstrated improved therapeutic success with surgical management, hypothesizing that reversing mechanical gastric trauma and ischemia allows CL healing. This systematic review and meta-analysis aim to compare therapeutic success of surgical versus medical management of Cameron lesions (CL). METHODS AND PROCEDURES: A comprehensive search and systematic review selected manuscripts using the following inclusion criteria: (1) Endoscopically diagnosed CL (2) Treated surgically (3) Follow-up for resolution of anemia or CL (4) n ≥ 5 (5) Excluding non-English, animal, and studies with patients < 18 years old Meta-analysis was performed to compare resolution of CLs with medical and surgical therapy. RESULTS: Systematic search retrieved 1664 studies, of these, 14 were included (randomized controlled trial = 1; prospective = 2; retrospective = 11). Patients had a mean age of 61.2 years (range 24-91) and were more often female (59.3%). Follow-up was between 3 and 120 months, and 82.9% of patients had hernias > 5 cm. Surgical management was associated with therapeutic success (OR 5.20, 1.83-14.77, I2 = 42%, p < 0.001) with 92% having resolution, compared to 67.2% for those treated with PPI. Surgical complications occurred in 42/109 (38.5%) of patients (48.1% for Open Hill Repair, 15.4% for laparoscopic fundoplication). 40.0% of patients underwent a laparoscopic Nissen or Collis fundoplication, 21.7% underwent open modified Hill repair, and 38.3% had unspecified operations. Hemoglobin improved from 8.85 g/dL pre-operatively to 13.60 g/dL post-operatively. In six studies, surgical patients previously failed medical management. CONCLUSIONS: This is the first systematic review comparing surgical and medical treatment of CL. Surgical management significantly improved therapeutic success. Our study supports therapeutic benefit of surgery in these patients.

Higher Edmonton Obesity Staging System scores are independently associated with postoperative complications and mortality following bariatric surgery: an analysis of the MBSAQIP.

INTRODUCTION: Bariatric surgery is an evidence-based approach for sustained weight loss in patients with severe obesity. The most common procedures in North America are the laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). The Edmonton Obesity Staging System (EOSS) is a tool that assigns patients a score of 0 to 4 according to their obesity-related comorbidities and functional status. Previous research demonstrates that increasing EOSS score is associated with overall non-operative mortality risk. OBJECTIVE: We sought to assess the association of the EOSS with major 30-day postoperative complications following LSG or LRYGB. METHODS: Primary LSG or LRYGB patients were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Patients were assigned EOSS scores according to their comorbidities and functional limitations extracted from the database. Multivariable logistic regression analysis was conducted to evaluate the relationship between EOSS score, age, sex, BMI, type of procedure, or operative time with 30-day major complications. RESULTS: From 2015 to 2017, 430,238 patients (79.4% female) who underwent primary LSG or LRYGB were identified. The relative frequencies of patients by EOSS score were: 0 and 1 (23.9%), 2 (62.8%), 3 (10.5%), and 4 (2.9%). Mean preoperative BMI was 45.4 (SD 7.9) kg/m2 and mean age was 44.6 (SD 12.0) years. The overall 30-day major complication rate was 3.5%. EOSS 2, 3, and 4 were significantly associated with major complications. The strongest associations with major complications were EOSS 4 (OR 2.30; 95% CI 2.11-2.51, p < 0.001) and LRYGB versus LSG (OR 2.03; 95% CI 1.97-2.11, p < 0.001). EOSS 3 and 4 were most strongly associated with death. CONCLUSION: Higher EOSS scores are independently associated with 30-day major postoperative complications and mortality. The EOSS provides utility in staging patients and identifying those at greater risk of postoperative complications.

Impact of psychiatric disorders on patient satisfaction after Nissen Fundoplication.

BACKGROUND: Anxiety and depression have been associated with an increased perception of gastroesophageal reflux symptoms, but there is a paucity of data regarding the outcomes of laparoscopic Nissen Fundoplication (LNF) in this patient population. METHODS: We performed a retrospective cohort study including all patients undergoing LNF between 2011 and 2017. Patients were stratified by baseline usage of serotonin-modulating medication or benzodiazepines as a proxy for depression and anxiety, respectively. Outcome measures included postoperative gastroesophageal health-related quality of life (GERD-HRQL) scores and overall satisfaction rates after surgery. A p value of < 0.05 was considered statistically significant. RESULTS: The population consisted of 271 patients of which 103 patients had depression and 44 patients had anxiety. Patients with depression reported no significant difference in pre- or postoperative GERD-HRQL scores compared to patients without depression and long-term satisfaction rates after surgery were similar in both groups at 76% vs 71%, respectively (p = 0.55). Patients with anxiety reported higher baseline HRQL scores (34 vs. 29, p = 0.05). At long-term follow-up (15 months), patients with anxiety reported slightly worse HRQL scores compared to controls (7 vs. 4, p = 0.11) despite no difference in usage of anti-acid medications or need for endoscopic dilations between the two groups. Patients with anxiety were less likely to report being "satisfied" after surgery (40% vs. 71%, p = 0.01) compared to controls. CONCLUSION: Patients with anxiety have higher subjective reporting of GERD symptoms and are more likely to report being "satisfied" during long-term follow-up after LNF. Patients on medication for depression appear to have similar reporting of GERD symptoms and derive as much benefit from LNF as patients that are not. While LNF does improve the symptom burden in patients with anxiety, satisfaction is rarely achieved in long-term follow-up.

Laparoscopic Nissen fundoplication improves disease-specific quality of life in patients with gastroesophageal reflux disease and functional gastroesophageal outflow obstruction.

INTRODUCTION: The optimal management of functional esophagogastric junction outflow obstruction (EJOO) remains controversial particularly in the setting of concomitant gastroesophageal reflux disease (GERD). There remains a paucity of data regarding the outcomes of laparoscopic Nissen fundoplication (LNF) in this patient population. We hypothesized that GERD patients with manometric findings of EJOO on preoperative manometry do not have increased rates of postoperative dysphagia compared to those with normal or hypotensive LES pressures. MATERIALS AND METHODS: This retrospective cohort study of patients undergoing LNF for GERD compared outcomes in patients with and without functional EJOO (fEJOO). The outcomes of interest included disease-specific quality of life improvement, dysphagia scores, and the need for endoscopic dilation following fundoplication. RESULTS: Two hundred and eleven patients underwent LNF for GERD and 15 (7.1%) were classified as having fEJOO. Baseline GERD-HRQL [30.0 (21.5-37) vs. 31 (21-37), p = 0.57] were similar between fEJOO and control patients, respectively. There was no difference in baseline dysphagia scores [3.5 (2-5) vs. 2.0 (1-4), p = 0.64] between the two groups. Postoperative GERD-HRQL [5.0 (2-13) vs. 4.0 (1-8), p = 0.59] scores did not differ between fEJOO and control patients at 6-week follow-up. One year after surgery, GERD-HRQL [8.0 (3-9) vs. 4.5 (2-13), p = 0.97] did not differ between groups. Dysphagia rates were similar at 6-week (p = 0.78) and 1-year follow-ups (p = 0.96). The need for dilation at 1 year following fundoplication was similar in both cohorts (13%, p = 0.96). CONCLUSION: GERD patients with functional EJOO achieved similar improvements in disease-specific quality of life without increased incidence of dysphagia postoperatively.

Higher Edmonton Obesity Staging System scores are associated with complications following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The Edmonton Obesity Staging System (EOSS) is a staging system describing comorbidities and functional limitations associated with obesity, thus facilitating the prioritization of patients for bariatric surgery. Our objective was to elucidate any associations of EOSS scores with major complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: A retrospective chart review examined patients who received primary LRYGB from 2009 to 2015 at a single center. Collected data included patient comorbidities, preoperative EOSS stage, body mass index (BMI), age, percent excess weight loss, and 1-year major complications. Major complications were defined by a Clavien-Dindo classification ≥ IIIa. RESULTS: 378 patients (81.7% female) receiving primary LRYGB were reviewed with the following EOSS stages: 0 (3.7%), 1 (10.8%), 2 (78.6%), 3 (6.9%), and 4 (0.0%). The mean preoperative BMI was 45.9 (SD 6.3) kg/m2. The overall major complication rate was 9.3%. Major complication rates for EOSS stages 0, 1, 2, and 3 were 7.1%, 4.9%, 8.8%, and 23.1%, respectively. Follow-up rates at 12 months were 76.6% with a mean overall follow-up of 10.9 (2.1) months. Multivariable analysis showed that patients undergoing LRYGB with an EOSS of 3 were more likely to experience major complications (OR 2.94; CI 1.04 to 8.35, p = 0.043). CONCLUSION: Our findings suggest that undergoing LRYGB with EOSS stage 3 has increased odds of major complications. As such, the EOSS demonstrates utility in identifying bariatric surgery candidates at risk of major postoperative morbidity. Further studies are required to assess the applicability of the EOSS for patients undergoing other forms of bariatric surgery.

Idiopathic intracranial hypertension and bariatric surgery: a systematic review

Background: Idiopathic intracranial hypertension (IIH) is a rare condition typically affecting women with obesity who are of child-bearing age. Patients commonly present with headaches, visual disturbances, pulsatile tinnitus and papilledema. The association between IIH and obesity has been well established in the literature, suggesting that weight loss may contribute to improving IIH. For patients with severe obesity for whom conservative management is not successful, bariatric surgery is an effective modality for weight loss. We aimed to systematically review the literature to determine the efficacy of bariatric surgery in the treatment of IIH Methods: We conducted a comprehensive search of MEDLINE, Embase, Scopus, the Cochrane Library and Web of Science (limited to studies in humans published in English between January 1946 and July 2015). Results: Twelve primary studies (n = 39 patients) were included in the systematic review. All patients had a preoperative diagnosis of IIH. Preoperative body mass index (BMI) was 47.4 ± 3.6 kg/m2 ; BMI improved to 33.7 ± 2.1 kg/m2 and 33.9 ± 11.6 kg/m2 at 6 and 12 months postoperatively, respectively. Lumbar puncture opening pressures decreased from 34.4 ± 6.9 cmH2O to 14.0 ± 3.6 cmH2O after surgery. Common symptoms of IIH improved after bariatric surgery: headaches (100% preoperatively v. 10% postoperatively), visual complaints (62% v. 44%), tinnitus (56% v. 3%) and papilledema (62% v. 8%). Conclusion: Bariatric surgery appears to lead to considerable improvement in IIH. Idiopathic intracranial hypertension is not a well-publicized comorbidity of obesity, but its presence may be considered as an indication for bariatric surgery.

Contexte: L'hypertension intracrânienne (HTIC) idiopathique est une affection rare qui touche surtout les femmes atteintes d'obésité en âge de procréer. Les symptômes courants sont des maux de tête, des troubles de la vue, des acouphènes pulsatiles et un oedème papillaire. Le lien entre l'HTIC idiopathique et l'obésité est bien établi dans la littérature, ce qui suggère que la perte de poids pourrait améliorer le tableau clinique de l'HTIC. Pour les patients atteints d'obésité sévère pour lesquels le traitement conservateur ne fonctionne pas, la chirurgie bariatrique est un moyen efficace de perdre du poids. Cette revue systématique de la littérature vise à déterminer l'efficacité de la chirurgie bariatrique dans le traitement de l'HTIC idiopathique. Méthodes: Nous avons interrogé MEDLINE, Embase, Scopus, la Bibliothèque Cochrane et Web of Science (limites : études portant sur les humains publiées en anglais entre janvier 1946 et juillet 2015). Résultats: Douze études primaires (n = 39 patients) ont été incluses dans la revue systématique. Tous les patients avaient un diagnostic préopératoire d'HTIC idiopathique. L'indice de masse corporelle (IMC) préopératoire était de 47,4 ± 3,6 kg/m2 ; l'IMC est passé à 33,7 ± 2,1 kg/m2 6 mois après l'opération, puis à 33,9 ± 11,6 kg/m2 12 mois après l'opération. Les pressions d'ouverture des ponctions lombaires sont passées de 34,4 ± 6,9 cmH2O à 14,0 ± 3,6 cmH2O après l'opération. Les symptômes courants de l'HTIC idiopathique se sont améliorés après la chirurgie bariatrique : maux de tête (100% avant opération c. 10% après), troubles de la vue (62% c. 44%), acouphènes pulsatiles (56% c. 3%) et œdème papillaire (62% c. 8%). Conclusion: La chirurgie bariatrique semble améliorer considérablement les symptômes d'HTIC idiopathique. Cette affection n'est pas une comorbidité bien connue de l'obésité, mais sa présence peut être une indication pour la chirurgie bariatrique comme traitement.

Practice and attitudes regarding double gloving among staff surgeons and surgical trainees.

BACKGROUND: Despite supporting evidence, many staff surgeons and surgical trainees do not routinely double glove. We performed a study to assess rates of and attitudes toward double gloving and the use of eye protection in the operating room. METHODS: We conducted an electronic survey among all staff surgeons and surgical trainees at 2 tertiary care centres in Alberta between September and November 2015.We analyzed the data using log-binomial regression for binary outcomes to account for multiple independent variables and interactions. For 2-group comparisons, we used a 2-group test of proportions. RESULTS: The response rate was 34.3% (361/1051); 205/698 staff surgeons (29.4%) and 156/353 surgical trainees (44.2%) responded. Trainees were more likely than staff surgeons to ever double glove in the operating room (p = 0.01) and to do so routinely (p = 0.01). Staff surgeons were more likely than trainees to never double glove (p = 0.01). A total of 300/353 respondents (85.0%) reported using eye protection routinely in the operating room. Needle-stick injury was common (184 staff surgeons [92.5%], 115 trainees [74.7%]). Reduced tactile feedback, decreased manual dexterity and discomfort/poor fit were perceived barriers to double gloving. CONCLUSION: Rates of double gloving leave room for improvement. Surgical trainees were more likely than staff surgeons to double glove. Barriers remain to routine double gloving among staff surgeons and trainees. Increased education on the benefits of double gloving and early introduction of this practice may increase uptake.

CONTEXTE: Malgré les preuves à l'appui, plusieurs chirurgiens en poste et chirurgiens en formation n'utilisent pas d'emblée le double gantage. Nous avons procédé à une étude pour évaluer le taux d'utilisation du double gantage, les opinions à son endroit et l'utilisation de la protection oculaire au bloc opératoire. MÉTHODES: Nous avons envoyé un sondage électronique à tous les chirurgiens en poste et chirurgiens en formation de 2 centres de soins tertiaires de l'Alberta entre septembre et novembre 2015. Nous avons analysé les données à l'aide d'un modèle de régression logarithmique binomiale pour les résultats binaires afin de tenir compte des variables indépendantes et des interactions. Pour les comparaisons à 2 groupes, nous avons utilisé le test de comparaison de 2 proportions. RÉSULTATS: Le taux de réponse a été de 34,3 % (361/1051); 205 chirurgiens en poste sur 698 (29,4 %) et 156 chirurgiens en formation sur 353 (44,2 %) ont répondu. Au bloc opératoire, les stagiaires étaient plus susceptibles de doubler leurs gants que les chirurgiens en poste (p = 0,01) et de le faire d'emblée (p = 0,01); et les chirurgiens en poste étaient plus susceptibles de ne jamais doubler leurs gants que les stagiaires (p = 0,01). En tout 300 répondeurs sur 353 (85,0 %) ont dit utiliser d'emblée une protection oculaire au bloc opératoire. Les piqûres d'aiguille accidentelles ont été fréquentes (184 chez les chirurgiens en poste [92,5 %], 115 chez les stagiaires [74,7 %]). Une réduction de la sensibilité tactile et de la dextérité manuelle et l'inconfort ou le piètre ajustement ont été les obstacles perçus au double gantage. CONCLUSION: Les taux de double gantage laissent à désirer. Les chirurgiens en formation sont plus susceptibles d'adopter le double gantage que les chirurgiens en poste. Des obstacles continuent de nuire à l'utilisation du double gantage d'emblée, tant chez les chirurgiens en poste que chez les chirurgiens en formation. Une meilleure sensibilisation aux avantages du double gantage et l'introduction de cette pratique dès le début de la formation pourrait faciliter son adoption.

LINX® magnetic esophageal sphincter augmentation versus Nissen fundoplication for gastroesophageal reflux disease: a systematic review and meta-analysis.

BACKGROUND: The LINX® magnetic sphincter augmentation system (MSA) is a surgical technique with short-term evidence demonstrating efficacy in the treatment of medically refractory or chronic gastroesophageal reflux disease (GERD). Currently, the Nissen fundoplication is the gold-standard surgical treatment for GERD. We are the first to systematically review the literature and perform a meta-analysis comparing MSA to the Nissen fundoplication. METHODS: A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science and the Cochrane Library) using search terms "Gastroesophageal reflux or heartburn" and "LINX or endoluminal or magnetic" and "fundoplication or Nissen" was completed. All randomized controlled trials, non-randomized comparison study and case series with greater than 5 patients were included. Five hundred and forty-seven titles were identified through primary search, and 197 titles or abstracts were screened after removing duplicates. Meta-analysis was performed on postoperative quality of life outcomes, procedural efficacy and patient procedural satisfaction. RESULTS: Three primary studies identified a total of 688 patients, of whom 273 and 415 underwent Nissen fundoplication and MSA, respectively. MSA was statistically superior to LNF in preserving patient's ability to belch (95.2 vs 65.9%, p < 0.00001) and ability to emesis (93.5 vs 49.5%, p < 0.0001). There was no statistically significant difference between MSA and LNF in gas/bloating (26.7 vs 53.4%, p = 0.06), postoperative dysphagia (33.9 vs 47.1%, p = 0.43) and proton pump inhibitor (PPI) elimination (81.4 vs 81.5%, p = 0.68). CONCLUSION: Magnetic sphincter augmentation appears to be an effective treatment for GERD with short-term outcomes comparable to the more technically challenging and time-consuming Nissen fundoplication. Long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation.

Quality of Follow-up: Systematic Review of the Research in Bariatric Surgery.

OBJECTIVE: We aim to systematically review the bariatric surgery literature with regards to adequacy of patient follow-up, meeting the McMaster criteria of ≥80% follow-up. BACKGROUND: Loss to follow-up is a major concern and can potentially bias the outcome and interpretation of a study. The quality of follow-up in bariatric surgery is quite variable with recent systematic reviews criticizing the field for its lack of overall follow-up. METHODS: A complete search of PubMed was performed. Literature was restricted to a range of 5 years (2007-2012), English language, and publications listed in PubMed. The McMaster Evidence-based Criteria for High Quality Studies was used to assess the follow-up data adequacy and a logistic meta-regression was performed to identify factors associated with high quality follow-up studies. RESULTS: Ninety-nine published manuscripts were included. For follow-up at study end, only 40/99 (40.4%) of papers had adequate patient follow-up, 42/99 (42.4%) failed to meet the McMaster criteria and 17/99 (17.2%) failed to report any follow-up results. On average, 31% were lost to follow-up at the study's end. Only shorter study duration, and if the study was performed in the US, were associated with studies meeting the McMaster criteria. CONCLUSIONS: Only 40% of studies in the bariatric surgery literature meet criteria for adequate follow-up. On average, studies have 30% of patients lost to follow-up at the stated end-point. Identified study characteristics associated with high quality follow-up included shorter study duration and studies performed in the US.