Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution.

BACKGROUND: Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. METHODS: A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data were analyzed using univariate analysis. RESULTS: One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7 years, 29.7 ± 5.7 kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6 months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. CONCLUSION: Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.

Revision paraesophageal hernia repair outcomes in patients with typical and atypical reflux.

BACKGROUND: Revision laparoscopic anti-reflux surgery (RLARS) is effective in alleviating the typical symptoms of gastroesophageal reflux disease (GERD). RLARS outcomes in patients with atypical GERD symptoms has not been well established. A composite Reflux Symptom Index (RSI) score greater than 13 indicates extraesophageal manifestation of pathological reflux. In this study, we analyzed the differences in quality-of-life (QOL) and perioperative outcomes between patients with atypical versus typical GERD who underwent RLARS. METHODS: A retrospective review was conducted of a prospectively maintained database of patients with pathologic reflux who underwent RLARS from February 2003 to October 2019. The cohort was divided into two groups, those with typical versus atypical manifestations of GERD, as defined by their RSI score. Patients with a RSI score of  > 13 were assigned to the Atypical group and those ≤ 13 were assigned to the Typical group. Patient QOL outcomes were prospectively followed using the RSI survey. Significance was defined by p-value less than 0.05. RESULTS: A total of 133 patients (Typical 61, Atypical 72) were included in the final analysis. The two groups were similar (p > 0.05) in mean age (58.1 ± 13.3 vs. 55.3 ± 15.5 years), body mass index (29.6 ± 5.0 vs. 30.3 ± 5.4), female sex distribution (60.7% vs. 59.7%) and age adjusted Charlson score (1.76 ± 1.58 vs. 1.98 ± 1.94). The Typical group had a higher frequency of type III hiatal hernia (62.3% vs. 29.2%) and Collis gastroplasty (29.5% vs. 5.6%). The groups had similar rates of partial and complete fundoplication with similar median length of stay (Typical: 3.0 ± 3.4 days vs. Atypical: 2.4 ± 1.7 days). After a mean follow-up of 30.2 ± 33.6 months, both groups reported similar rates of improvement in RSI outcome from baseline (58.1% vs 43.3%, p = .149). However, the RSI outcome at the latest follow-up for the Typical group was significantly better than the Atypical group after RLARS (2.8 ± 5.3 vs. 15.9 ± 11.1, respectively). CONCLUSION: Patients who undergo revision paraesophageal hernia repair with objective findings of GERD and subjective complaints of atypical reflux symptoms may show long-term improvement in QOL outcomes. However, these results are contingent on proper patient selection and a thorough work-up for pathological reflux in this population. Further research is needed to determine universal diagnostic criteria to assist in the early detection and surgical treatment of patients with atypical GERD.

Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia.

BACKGROUND: Previous studies analyzing short-term outcomes for per-oral endoscopic myotomy (POEM) have shown excellent clinical response rates and shorter operative times compared to laparoscopic Heller myotomy (LHM). Despite this, many payors have been slow to recognize POEM as a valid treatment option. Furthermore, comparative studies analyzing long-term outcomes are limited. This study compares perioperative and long-term outcomes, cost-effectiveness, and reimbursement for POEM and LHM at a single institution. METHODS: Adult patients who underwent POEM or LHM between 2014 and 2021 and had complete preoperative data with at least one complete follow up, were retrospectively analyzed. Demographic data, success rate, operative time, myotomy length, length of stay, pre- and postoperative symptom scores, anti-reflux medication use, cost and reimbursement were compared. RESULTS: 58 patients met inclusion with 25 undergoing LHM and 33 undergoing POEM. There were no significant differences in preoperative characteristics. Treatment success (Eckardt ≤ 3) for POEM and LHM was achieved by 88% and 76% of patients, respectively (p = 0.302). POEM patients had a shorter median operative time (106 min. vs. 145 min., p = 0.003) and longer median myotomy length (11 cm vs. 8 cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1 day vs. 51.5% for POEM patients (p < 0.001). Both groups showed improvements in dysphagia, heartburn, regurgitation, Eckardt score, GERD HRQL, RSI, and anti-reflux medication use. The improvement in dysphagia score was greater in patients undergoing POEM (2.30 vs 1.12, p = 0.003). Median hospital reimbursement was dramatically less for POEM ($3,658 vs. $14,152, p = 0.002), despite median hospital costs being significantly lower compared to LHM ($2,420 vs. $3,132, p = 0.029). RESULTS: POEM is associated with a shorter operative time and LOS, longer myotomy length, and greater resolution of dysphagia compared to LHM. POEM costs are significantly less than LHM but is poorly reimbursed.

A comparative evaluation of robotic and laparoscopic Roux-en-Y gastric bypass: a critical evaluation on the impact of postoperative pain and opioid requirements.

INTRODUCTION: The benefits of minimally invasive surgery using laparoscopy on postoperative pain and opioid use are well established. Our goal was to determine whether patients who underwent Roux-en-Y gastric bypass using a robotic approach (RA-RYGB) had lower postoperative pain and required less opioids than those undergoing laparoscopic Roux-en-Y gastric bypass (L-RYGB). Secondary outcomes evaluated included length of stay, operative time, and readmissions. METHODS AND PROCEDURES: This was a retrospective cohort study from a tertiary academic medical center. Patients who underwent L-RYGB or RA-RYGB between 5/1/2018 and 10/31/2019 were included. Cases with concomitant hernia repair, chronic opioid use, and those who did not receive a TAP block or multimodal pain control were excluded. Baseline demographics were compared. Inpatient and outpatient opioid use in Morphine Milligram Equivalents (MME) and pain scores (10-point Likert scale) were compared. RESULTS: There were 573 RY patients included (462 L-RYGB; 111 RA-RYGB). Median and maximum inpatient pain scores were similar for L-RYGB and RA-RYGB (3.0 vs 3.1, p = 0.878; 7.0 vs 7.0, p = 0.688). Median inpatient opioid use and maximum single day use were similar for L-RYGB and RA-RYGB (40.0 MME vs. 42.0 MME, p = 0.671; 30.0 MME vs 30.0 MME, p = 0.648). Both the outpatient prescribing of opioids (50.2% vs. 42.3%, p = 0.136) and outpatient opioid MME at 2 weeks (L-RYGB 30.0 MME vs. 33.8 MME, p = 0.854) were comparable between cohorts. Patient reported pain at 2-week follow-up was significantly higher for RA-RYGB (68.1%) than L-RYGB (55.6%) (p = 0.030). RA-RYGB had a higher rate of 30-day readmission and longer operative times compared to the L-RYGB (6.3% vs 13.5%, p = 0.010; 144.5 vs 200.0 min, p < 0.001). CONCLUSION: This study identified no benefit for postoperative pain or opioid requirements in patients undergoing RA-RYGB compared to L-RYGB. The RA-RYGB group was significantly more likely to report pain at the two-week follow-up.

Prevalence and Risk Factors for Bariatric Surgery Readmissions: Findings From 130,007 Admissions in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

OBJECTIVE: To evaluate readmissions following laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB). BACKGROUND: Few studies have evaluated national readmission rates for primary bariatric surgery with national, bariatric-specific data. METHODS: Patients undergoing primary LAGB, LSG, or LRYGB from January 1, 2014 to December 31, 2014, at 698 centers were identified based upon Current Procedural Terminology codes. The primary outcome was 30-day readmission from date of initial operation. RESULTS: A total of 130,007 patients who underwent primary bariatric surgery were identified: 7378 LAGB (5.7%), 80,646 LSG (62.0%), and 41,983 LRYGB (32.3%). A total of 5663 (4.4%) patients were readmitted within 30 days for all causes. Patients undergoing LAGB had the lowest related readmission rate of 1.4%, followed by LSG (2.8%), and LRYGB (4.9%). Of patients who had a complication, 17.9% (n = 785) were readmitted, whereas those without readmission had a complication 1.9% of the time (P < 0.001). The most common cause of a related readmission was nausea, vomiting, fluid, electrolyte, and nutritional depletion (35.4%), followed by abdominal pain (13.5%), anastomotic leak (6.4%), and bleeding (5.8%), accounting for more than 61% of readmissions. When compared with LAGB, LSG, and LRYGB had significantly higher rates of readmission (LSG: odds ratio 1.89; 95% confidence interval 1.52-2.33; LRYGB: odds ratio 3.06; 95% confidence interval 2.46-3.81). CONCLUSIONS: National bariatric readmissions after primary procedures were closely associated with complications, varied based on the type of procedure, and were most commonly due to nausea, vomiting, electrolyte, and nutritional depletion.

Laparoscopic paraesophageal hernia repair is safe in elderly patients.

BACKGROUND: Paraesophageal hernias (PEHs) occur frequently in the elderly. Patients may not be referred for repair due to age or concern for high operative morbidity and mortality. The aim of this study was to compare outcomes of PEH repair based on age. METHODS: Adult patients undergoing PEH repair between 2003 and 2012 at a tertiary referral center were included. Patients were divided by age (Y < 69, YO 70-79 and VO > 80). Body mass index (BMI), Charlson comorbidity index, operative time, estimated blood loss, length of stay, recurrence, Quality of Life in Reflux and Dyspepsia Questionnaire (QOLRAD) scores, morbidity and mortality were analyzed. RESULTS: Two hundred and sixty-seven patients were included: Group Y N = 140 (median age 58.5); Group YO N = 82 (median age 75.0); and Group VO N = 45 (median age 83.0). Group Y had a significantly lower age-adjusted Charlson score compared to the older groups. Group VO had significantly lower BMIs compared to Groups Y and YO. Both groups had similar operative times, intraoperative blood loss and rates of Collis gastroplasty. Group Y had significantly less acute presentations compared to the elderly groups YO 12.2 %, p = 0.028, and VO 22.2 %, p = <0.001. Group Y had a smaller percentage of intrathoracic stomach (55.7 %) as compared to Groups YO (65.1 %; p = 0.001) and VO (74.3 %; p = < 0.001). There were no significant differences in mortalities between all three groups. The mean length of hospital stay was significantly shorter in Group Y (2.45) than in both Group YO (3.12; p = 0.001) and Group VO (5.13; p = <0.001). Major morbidity was significantly lower in the younger group 3.6 % when compared to Group VO (17.8 %; p = 0.001). All groups demonstrated significant improvement in QOLRAD scores. CONCLUSION: The decision to perform laparoscopic paraesophageal hernia repair (LPEHR) in elderly patients remains challenging. LPEHR can be done safely and effectively in elderly patients at experienced centers.

Preoperative use of incretins is associated with increased diabetes remission after RYGB surgery among patients taking insulin: a retrospective cohort analysis.

OBJECTIVE: The main goal of this study was to determine the effects of incretins on type 2 diabetes (T2D) remission after Roux-en-Y gastric bypass (RYGB) surgery for patients taking insulin. BACKGROUND: Type 2 diabetes is a chronic disease with potentially debilitating consequences. RYGB surgery is one of the few interventions that can remit T2D. Preoperative use of insulin, however, predisposes to significantly lower T2D remission rates. METHODS: A retrospective cohort of 690 T2D patients with at least 12 months follow-up and available electronic medical records was used to identify 37 T2D patients who were actively using a Glucagon-like peptide 1 (GLP-1) agonist in addition to another antidiabetic medication, during the preoperative period. RESULTS: Here, we report that use of insulin, along with other antidiabetic medications, significantly diminished overall T2D remission rates 14 months after RYGB surgery (9%) compared with patients not taking insulin (56%). Addition of the GLP-1 agonist, however, increased significantly T2D early remission rates (22%), compared with patients not taking the GLP-1 agonist (4%). Moreover, the 6-year remission rates were also significantly higher for the former group of patients. The GLP-1 agonist did not improve the remission rates of diabetic patients not taking insulin as part of their pharmacotherapy. CONCLUSIONS: Preoperative use of antidiabetic medication, coupled with an incretin agonist, could significantly improve the odds of T2D remission after RYGB surgery in patients also using insulin.

Risk factors associated with mortality after Roux-en-Y gastric bypass surgery.

OBJECTIVE: We sought to identify the major risk factors associated with mortality in Roux-en-Y gastric bypass (RYGB) surgery. BACKGROUND: Bariatric surgery has become an established treatment for extreme obesity. Bariatric surgery mortality has steadily declined with current rates of less than 0.5%. However, significant variation in the mortality rates has been reported for specific patient cohorts and among bariatric centers. METHODS: Clinical outcome data from 185,315 bariatric surgery patients from the Bariatric Outcome Longitudinal Database were reviewed. Of these, 157,559 patients had either documented 30 or more day follow-up data, including mortality. Multiple demographic, socioeconomic, and clinical factors were analyzed by univariate analysis for their association with 30-day mortality after gastric bypass. Variables found to be significant were entered into a multiple logistic regression model to identify factors independently associated with 30-day mortality. On the basis of these results, a RYGB mortality risk score was developed. RESULTS: The overall 30-day mortality rate for the entire bariatric surgery cohort was 0.1%. Of the 81,751 RYGB patients, the mortality rate was 0.15%. Factors significantly associated with 30-day gastric bypass mortality included increasing body mass index (BMI) (P<0.0001), increasing age (P<0.005), male gender (P<0.001), pulmonary hypertension (P<0.0001), congestive heart failure (P=0.0008), and liver disease (P=0.038). When the RYGB risk score was applied, a significant trend (P<0.0001) between increasing risk score and mortality rate is found. CONCLUSIONS: Increasing BMI, increasing age, male gender, pulmonary hypertension, congestive heart failure, and liver disease are risk factors for 30-day mortality after RYGB. The RYGB risk score can be used to determine patients at greater risk for mortality after RYGB surgery.

Next-generation sequence analysis of genes associated with obesity and nonalcoholic fatty liver disease-related cirrhosis in extreme obesity.

OBJECTIVES: Genome-wide association studies (GWAS) have led to the identification of single nucleotide polymorphisms in or near several loci that are associated with the risk of obesity and nonalcoholic fatty liver disease (NAFLD). We hypothesized that missense variants in GWAS and related candidate genes may underlie cases of extreme obesity and NAFLD-related cirrhosis, an extreme manifestation of NAFLD. METHODS: We performed whole-exome sequencing on 6 Caucasian patients with extreme obesity [mean body mass index (BMI) 84.4] and 4 obese Caucasian patients (mean BMI 57.0) with NAFLD-related cirrhosis. RESULTS: Sequence analysis was performed on 24 replicated GWAS and selected candidate obesity genes and 5 loci associated with NAFLD. No missense variants were identified in 19 of the 29 genes analyzed, although all patients carried at least 2 missense variants in the remaining genes without excess homozygosity. One patient with extreme obesity carried 2 novel damaging mutations in BBS1 and was homozygous for benign and damaging MC3R variants. In addition, 1 patient with NAFLD-related cirrhosis was compound heterozygous for rare damaging mutations in PNPLA3. CONCLUSIONS: These results indicate that analyzing candidate loci previously identified by GWAS analyses using whole-exome sequencing is an effective strategy to identify potentially causative missense variants underlying extreme obesity and NAFLD-related cirrhosis.

Laparoscopic sleeve gastrectomy conversion to gastric bypass: conversion rate over time, predictors of conversion, and weight loss outcomes.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most common Bariatric procedure in the United States; however, the frequency of conversion to Roux-en-Y gastric bypass (RYGB) is unknown. OBJECTIVES: The primary aim was to determine the conversion rate over time from LSG to RYGB. The secondary objectives were to evaluate factors associated with conversion and postconversion weight loss outcomes. SETTING: Single Academic Institution, Center of Bariatric Excellence. METHODS: A retrospective analysis of all LSG from 2011 to 2020 was done. Kaplan-Meier analysis was utilized to estimate the conversion rate over time after LSG. Cox regression was utilized to identify predictors of future conversion. RESULTS: Of 875 LSGs, 46 were converted to RYGB from 2011 to 2020. Median follow-up was 2.6 years, and 7-year follow-up rate was 59.9%. The 1-year conversion rate was 1.4%, increasing to 3.8%, 9.0%, and 12.6% at 3, 5, and 7 years respectively. Female gender (hazard ratio [HR] = 4.2, P = .05) and age <55 (HR = 3.5, P = .04) were associated with greater chance of conversion. Preoperative asthma (HR = 1.7, P = .14) and gastroesophageal reflux disease (GERD) (HR = 1.5, P = .18) trended toward higher conversion but were not significant. Of those with body mass index (BMI) >35 at time of conversion, the mean total body weight loss (TBWL) was 13.0% at the time of conversion. This subgroup had additional 13.6% of TBWL 1-year after conversion. CONCLUSIONS: Conversion of LSG to RYGB increased with time to 12.6% conversion rate at 7-years. Patients with GERD prior to LSG had a nonsignificant trend toward conversion, while younger patients and females had significantly higher rates of conversion. There may be additional weight loss benefit for patients converted to RYGB.

Urgent laparoscopic repair of acutely symptomatic PEH is safe and effective.

BACKGROUND: Acute incarceration of paraesophageal hernias (PEHs) requiring urgent or emergent surgery is rare. Patients are often elderly with significant comorbidities and have historically been treated with open abdominal or thoracic incisions. Our study was designed to evaluate the feasibility, safety, and efficacy of laparoscopic paraesophageal hernia repair (LPEHR) in patients with PEH and acute gastric volvulus. METHODS: We reviewed our prospectively maintained database and identified 269 patients who underwent an initial LPEHR between January 2003 and January 2012. Patients were divided into group A (acute), group B (age- and comorbidity-matched 1:3), and group C (all elective repairs). Group A included those admitted with acute symptoms related to PEH and underwent urgent repair. Patient age, Charlson score, operative time, length of stay (LOS), morbidity, mortality, and recurrence rates were compared. RESULTS: Patients who underwent urgent LPEHR had a higher perioperative morbidity rate than the elective and matched groups. The overall mortality rate was low and no statistical difference was found between groups A, B, and C. LOS in group A was longer than groups B and C. The need for ICU admission was also higher in group A. There was no statistical difference in recurrence rates. CONCLUSIONS: Historically, patients presenting with acute symptoms related to PEH have required open repair, which is associated with significant morbidity and mortality. The acute group was older and sicker than our elective LPEHR patients and had more adverse events resulting in a longer LOS, even when compared with comorbidity-matched elective patients. However, the LOS remained shorter than that reported for open repair and there was no mortality. The recurrence rates in all groups were low and comparable to elective repairs.

Impact of Urinary Catheterization on Postoperative Outcomes After Roux-En-Y Gastric Bypass Surgery in Propensity-Matched Cohorts.

BACKGROUND: The impact of urinary catheter avoidance in bariatric enhanced recovery after surgery (ERAS) protocols is yet to be established. The purpose of the current study is to determine whether urinary catheter use in patients undergoing Roux-en-Y gastric bypass (RYGB) procedures has an effect on postoperative outcomes. METHODS: An institutional database was utilized to identify adult patients undergoing primary minimally invasive RYGB surgery. Outcomes included incidence of urinary tract infection (UTI) within 30 days postoperatively, 30-day readmission rates, proportion of patients discharged after postoperative day 1 (delayed discharge), length of stay (LOS), and operating room time. These were compared between propensity-matched groups with and without urinary catheter placement. RESULTS: There were no significant differences in postoperative UTI's (2.2% for both cohorts, P = .593) or 30-day readmission rates for patients with and without urinary catheters (6.6% and 4.4%, respectively, P = .260). Mean LOS (1.7 vs. 1.5 days, P = .001) and the proportion of patients having a delayed discharge (47.3% vs. 33.7%, P = .001) was greater in patients with a catheter. Operating room time was longer in the urinary catheter group (221.8 vs. 207.9 minutes, P = .002). DISCUSSION: Avoidance of indwelling urinary catheters in RYGB surgical patients decreased delayed discharges and LOS without affecting readmission or reoperation rates. Therefore, we recommend that avoidance of urinary catheters in routine RYGB surgery be considered for inclusion into standardized ERAS protocols. Urinary catheters should continue to be utilized in select cases, however, as these were not shown to affect rate of UTIs.

Prior metabolic surgery reduced COVID-19 severity: Systematic analysis from year one of the COVID-19 pandemic.

Background: Obesity is a risk factor for COVID-19 severity. Recent studies suggest that prior metabolic surgery (MS) modifies the risk of COVID-19 severity. Methods: COVID-19 outcomes were compared between patients with MS (n = 287) and a matched cohort of unoperated patients (n = 861). Multiple logistic regression was used to identify predictors of hospitalization. A systematic literature review and pooled analysis was conducted to provide overall evidence of the influence of prior metabolic surgery on COVID-19 outcomes. Results: COVID-19 patients with MS had less hospitalization (9.8% versus 14.3%, p = 0.049). Age 70+, higher BMI, and low weight regain after MS were associated with more hospitalization after COVID-19. A systematic review of 7 studies confirmed that MS reduced the risk of post-COVID-19 hospitalization (OR = 0.71, 95%CI = [0.61-0.83], p < 0.0001) and death (OR = 0.44, 95%CI = [0.30-0.65], p < 0.0001). Conclusion: MS favorably modifies the risks of severe COVID-19 infection. Older age and higher BMI are major risk factors for severity of COVID-19 infection.

Outcomes of Bariatric Surgery in Patients on Chronic Opioids: Can Bariatric Surgery Assist with Decreasing Long-term Opioid Utilization?

PURPOSE: The aim of our study was to assess long-term opioid use following bariatric surgery in patients on preoperative narcotics. METHODS: We evaluated patients utilizing preoperative opioids (OP) who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2020. Patients were propensity-matched to those without preoperative opioid use (NOP) by demographics and comorbidities. Our objectives were to compare opioid use at 1 and 3 years after surgery and evaluate perioperative outcomes. RESULTS: A total of 806 patients, matched 1:1 were evaluated, with 82.7% being females. Mean age was 46.5 years in the OP and 45.6 years in the NOP (p = 0.0018), preoperative BMI was 45.8 in the OP and 46.1 in the NOP (p = 0.695). All patients were followed up for 1 year. In the OP, 156 (38.7%) patients were taking opioids 1 year after surgery as opposed to 27 (6.7%) in the NOP (p < 0.0001). Three years after surgery, 74 (37.5%) patients in the OP and 27 (14.4%) in the NOP were taking outpatient opioids (p < 0.0001). There was no statistically significant difference between OP and NOP groups in terms of readmissions (9.4% vs. 5.7% p = 0.06), reinterventions (3.7 vs. 1.7% p = 0.13), reoperations (3.5% vs. 1.5% p = 0.11), or emergency room visits (8.9% vs. 7.2% p = 0.44). There were no mortalities. CONCLUSION: Most patients requiring preoperative opioids can be weaned off after bariatric surgery. Enhanced recovery pathways are key to obtaining these results. Preoperative opioid use is not associated with increased complications compared to opioid-naïve patients.

Differential DNA methylation and changing cell-type proportions as fibrotic stage progresses in NAFLD.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is characterized by changes in cell composition that occur throughout disease pathogenesis, which includes the development of fibrosis in a subset of patients. DNA methylation (DNAm) is a plausible mechanism underlying these shifts, considering that DNAm profiles differ across tissues and cell types, and DNAm may play a role in cell-type differentiation. Previous work investigating the relationship between DNAm and fibrosis in NAFLD has been limited by sample size and the number of CpG sites interrogated. RESULTS: Here, we performed an epigenome-wide analysis using Infinium MethylationEPIC array data from 325 individuals with NAFLD, including 119 with severe fibrosis and 206 with no histological evidence of fibrosis. After adjustment for latent confounders, we identified 7 CpG sites whose DNAm associated with fibrosis (p < 5.96 × 10-8). Analysis of RNA-seq data collected from a subset of individuals (N = 56) revealed that gene expression at 288 genes associated with DNAm at one or more of the 7 fibrosis-related CpGs. DNAm-based estimates of cell-type proportions showed that estimated proportions of natural killer cells increased, while epithelial cell proportions decreased with disease stage. Finally, we used an elastic net regression model to assess DNAm as a biomarker of fibrotic stage and found that our model predicted fibrosis with a sensitivity of 0.93 and provided information beyond a model based solely on cell-type proportions. CONCLUSION: These findings are consistent with DNAm as a mechanism underpinning or marking fibrosis-related shifts in cell composition and demonstrate the potential of DNAm as a possible biomarker of NAFLD fibrosis.

Assessment and management of gastroesophageal reflux disease following bariatric surgery.

Gastroesophageal reflux disease (GERD) is a common disease in patients with obesity. The incidence of de novo GERD and the effect of bariatric surgery on patients with pre-existing GERD remain controversial. Management of GERD following bariatric surgery is complicated and can range from medical therapy to non-invasive endoscopic options to invasive surgical options. To address these issues, we performed a systematic review of the literature on the incidence of GERD and the various modalities of managing GERD in patients following bariatric surgery. Given the increased number of laparoscopic sleeve gastrectomy (LSG) procedures being performed and the high incidence of GERD following LSG, bariatric surgeons should be familiar with the options available to manage GERD following LSG as well as other bariatric procedures.

Asymptomatic Cholelithiasis and Bariatric Surgery: a Comprehensive Long-Term Analysis of the Risks of Biliary Disease in Patients Undergoing Primary Roux-en-Y Gastric Bypass.

PURPOSE: Currently, there is little consensus on management of the in situ gallbladder of patients undergoing gastric bypass. Our aim was to evaluate outcomes of selective concomitant cholecystectomy (CCY) and long-term biliary outcomes after Roux-en-Y gastric bypass (RYGB). MATERIALS AND METHODS: We performed a retrospective analysis of patients undergoing laparoscopic RYGB (LRYGB) between 2008 and 2018. Chi-square, Fisher's exact, or Wilcoxon rank-sum tests were used to compare outcomes. Concomitant CCY was performed on a selective basis. RESULTS: Three thousand and four patients underwent a RYGB (LRYGB n = 2458, open RYGB n = 546). Fifty-two percent (n = 1670) of patients had undergone CCY at any stage. Thirty-one percent of patients (n = 933) had CCY prior to RYGB, 13% (n = 403) had a concomitant CCY and 13% (n = 214) of the remainder required interval CCY. In the LRYGB subgroup, 29.9% (n = 735) had a prior CCY; 12.9% (n = 202) of those with an in situ gallbladder required interval CCY. Those who underwent concomitant CCY/LRYGB (n = 328) were compared with LRYGB alone (n = 1231). The concomitant CCY group was significantly older and had higher percentage of females, higher preoperative BMI, higher Charlson Comorbidity Index, and a higher medication count. There was no significant difference in BMI nadir, length of stay, complications, or mortality. Interval CCY had a higher incidence of CCY-related complications. CONCLUSION: Our study suggests a higher percentage of bariatric patients with in situ gallbladders will undergo interval CCY than documented in recently published guidelines. Concomitant CCY can be performed without an increase in length of stay or complications. Interval CCY may be associated with a higher complication rate.

The Longitudinal Efficiency of Robotic Surgery: an MBSAQIP Propensity Matched 4-Year Comparison of Robotic and Laparoscopic Bariatric Surgery.

BACKGROUND: The objective of this study was to examine the MBSAQIP database to assess efficiency trends and perioperative outcomes in robotic bariatric surgery. METHODS: Robotic (RA) and laparoscopic (L) sleeve gastrectomy (SG) and gastric bypass (RYGB) were compared using the 2015-2018 MBSAQIP Participant Use Data Files. Patients were propensity matched 1:1 based on sex, body mass index, assistant, and previous obesity or foregut surgery. A total of 93,802 patients were included. RESULTS: Median operative times were significantly longer for both RA-SG (89 vs. 62 min; p < 0.0001) and RA-RYGB (141 vs. 105 min; p < 0.0001) compared with laparoscopic. Over the 4-year period, the difference in operative times (OR delta) between RA-SG and L-SG was unchanged while the difference in operative times between RA-RYGB and L-RYGB increased. Both robotic groups were significantly more likely to be readmitted (RA-SG p = 0.001, RA-RYGB p = 0.006). Robotic SG was more likely to have a reintervention (p = 0.018) and extended length of stay (LOS) (> 4 days) compared with laparoscopic (p = < 0.0002). No significant differences were noted in morbidity and mortality by approach. CONCLUSIONS: Operative times were 30% longer for RA-SG and 25% longer for RA-RYGB when compared with laparoscopic. There was no significant improvement in OR delta for either RA-SG or RA-RYGB over the four years. Readmission rates were higher for both RA-SG and RA-RYGB. Robotic SG had a greater percentage of patients with extended LOS compared with laparoscopic. No evidence of improved efficiency for robotic bariatric surgery as defined by operative time or clinical outcomes was identified.

Comparison of short-term outcomes following Roux-en-Y gastric bypass in male and female patients using the MBSAQIP database.

BACKGROUND: Male sex has long been identified as a risk factor for adverse outcomes, including mortality, after Roux-en-Y gastric bypass (RYGB). OBJECTIVES: The objective of this study was to compare short-term outcomes of patients undergoing laparoscopic RYGB based on biologic sex. SETTING: Geisinger Medical Center, Danville, PA. METHODS: Patients undergoing RYGB in the 2015, 2016, and 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database were propensity matched 1:1 to compare 30-day outcomes between male and female sex. RESULTS: A total 47,906 patients were included (23,953 men/23,953 women). The overall complication rate was higher in female patients (11.5% versus 10.2%; P < .001) with no difference in mortality related to RYGB at 30 days. No significant differences were seen between sexes for organ space surgical site infection or septic shock. Women had significantly more superficial surgical site infections (P = .002), urinary tract infections (P < .001), readmissions (P < .001), and reinterventions (P < .001). Men had significantly more episodes of unplanned intubation (P = .008), extended ventilator use (P = .01), progressive renal insufficiency (P = .01), acute renal failure (P = .008), cardiac arrest (P = .005), intensive care unit admission (P < .001), all-cause 30-day mortality (P = .038), and inpatient mortality rate (P < .001). CONCLUSIONS: Male sex has been identified as a risk factor for adverse events and mortality after RYGB in several risk models. This study demonstrates an overall increased risk of both all-cause mortality and inpatient mortality. The study, however, did not demonstrate a difference in bariatric-related mortality. The prevalence of both major and minor complications was mixed between sexes, while women had a higher overall complication rate after RYGB. The abundance of data available within the MBSAQIP Participant Use Data File facilitates the creation of tools like risk models for bariatric surgery, such as the MBSAQIP Risk calculator.

Differentially expressed mRNAs and lncRNAs shared between activated human hepatic stellate cells and nash fibrosis.

We previously reported dysregulated expression of liver-derived messenger RNA (mRNA) and long noncoding RNA (lncRNA) in patients with advanced fibrosis resulting from nonalcoholic fatty liver disease (NAFLD). Here we sought to identify changes in mRNA and lncRNA levels associated with activation of hepatic stellate cells (HSCs), the predominant source of extracellular matrix production in the liver and key to NAFLD-related fibrogenesis. We performed expression profiling of mRNA and lncRNA from LX-2 cells, an immortalized human HSC cell line, treated to induce phenotypes resembling quiescent and myofibroblastic states. We identified 1964 mRNAs (1377 upregulated and 587 downregulated) and 1460 lncRNAs (665 upregulated and 795 downregulated) showing statistically significant evidence (FDR ≤0.05) for differential expression (fold change ≥|2|) between quiescent and activated states. Pathway analysis of differentially expressed genes showed enrichment for hepatic fibrosis (FDR = 1.35E-16), osteoarthritis (FDR = 1.47E-14), and axonal guidance signaling (FDR = 1.09E-09). We observed 127 lncRNAs/nearby mRNA pairs showing differential expression, the majority of which were dysregulated in the same direction. A comparison of differentially expressed transcripts in LX-2 cells with RNA-sequencing results from NAFLD patients with or without liver fibrosis revealed 1047 mRNAs and 91 lncRNAs shared between the two datasets, suggesting that some of the expression changes occurring during HSC activation can be observed in biopsied human tissue. These results identify lncRNA and mRNA expression patterns associated with activated human HSCs that appear to recapitulate human NAFLD fibrosis.