Large language models and bariatric surgery patient education: a comparative readability analysis of GPT-3.5, GPT-4, Bard, and online institutional resources.

BACKGROUND: The readability of online bariatric surgery patient education materials (PEMs) often surpasses the recommended 6th grade level. Large language models (LLMs), like ChatGPT and Bard, have the potential to revolutionize PEM delivery. We aimed to evaluate the readability of PEMs produced by U.S. medical institutions compared to LLMs, as well as the ability of LLMs to simplify their responses. METHODS: Responses to frequently asked questions (FAQs) related to bariatric surgery were gathered from top-ranked health institutions. FAQ responses were also generated from GPT-3.5, GPT-4, and Bard. LLMs were then prompted to improve the readability of their initial responses. The readability of institutional responses, initial LLM responses, and simplified LLM responses were graded using validated readability formulas. Accuracy and comprehensiveness of initial and simplified LLM responses were also compared. RESULTS: Responses to 66 FAQs were included. All institutional and initial LLM responses had poor readability, with average reading levels ranging from 9th grade to college graduate. Simplified responses from LLMs had significantly improved readability, with reading levels ranging from 6th grade to college freshman. When comparing simplified LLM responses, GPT-4 responses demonstrated the highest readability, with reading levels ranging from 6th to 9th grade. Accuracy was similar between initial and simplified responses from all LLMs. Comprehensiveness was similar between initial and simplified responses from GPT-3.5 and GPT-4. However, 34.8% of Bard's simplified responses were graded as less comprehensive compared to initial. CONCLUSION: Our study highlights the efficacy of LLMs in enhancing the readability of bariatric surgery PEMs. GPT-4 outperformed other models, generating simplified PEMs from 6th to 9th grade reading levels. Unlike GPT-3.5 and GPT-4, Bard's simplified responses were graded as less comprehensive. We advocate for future studies examining the potential role of LLMs as dynamic and personalized sources of PEMs for diverse patient populations of all literacy levels.

Patient and the Public's Perceptions of Bariatric Surgery: A Systematic Review.

INTRODUCTION: Bariatric surgery is an effective therapeutic modality for obesity and related comorbidities, yet it remains significantly underutilized. Patient perceptions and expectations may influence the decisions of eligible patients in pursuing surgery. METHODS: PubMed, SCOPUS, and OVID databases were searched in July 2022 to identify published studies discussing patient and the public's perceptions of bariatric surgery. RESULTS: The literature shows participants often reported bariatric surgery to be a life-changing intervention known to induce weight loss, improve obesity-related comorbidities, and improve quality of life. However, a significant proportion of survey respondents perceived bariatric surgery as unsafe or risky. Patients belonging to racial minority groups cited higher concern with mortality risk, lower weight loss expectations, and different motivations to pursue bariatric surgery. Female patients were significantly more likely to have more positive perceptions of, and higher expectations of weight loss from, bariatric surgery. CONCLUSIONS: The literature highlighted discordance between patient perceptions and the demonstrated clinical safety and efficacy profile of bariatric surgery. Overestimations of the risks, unrealistic expectations, and unfamiliarity with bariatric surgery outcomes were common findings. These perceptions of bariatric surgery may contribute to its underutilization among eligible patients. Perceptions and motivations often varied by race, region, sex, and age, which demonstrates the necessity of patient-centered education in the prereferral stage. The literature also demonstrated misconceptions of bariatric surgery among the public. Further research should explore the impact of education on the perceptions of patients and the public.

Factors Associated With Bariatric Surgery Referral Patterns: A Systematic Review.

INTRODUCTION: Bariatric surgery (BS) has been shown to effectively treat morbid obesity and improve obesity-related comorbidities. Nonetheless, BS remains underutilized among qualified patients. MATERIALS AND METHODS: PubMed, SCOPUS, and OVID databases were searched to identify published comparative studies examining BS referral patterns. Data on barriers to BS referrals were examined and summarized. RESULTS: Barriers to referrals stemmed largely from a lack of familiarity with safety, efficacy, and postoperative care amongst providers. Providers with previous referrals were more likely to report higher knowledge, comfort in referring patients, and ability to provide postoperative care. Provider initiated discussion of BS was positively associated with referrals. Female and younger patients were more likely to receive referrals. Furthermore, access to appropriate peri-operative resources, local bariatric programs, and insurance eligibility were associated with referral rates. Encouragingly, providers across specialties report eagerness to gain exposure and training in BS. CONCLUSIONS: Lack of provider familiarity with BS efficacy, safety and postoperative care likely contributes to low utilization rates of BS. Further potential barriers in access to BS are logistic factors such as insurance coverage, limited local perioperative resources, and clinic time constraints for patient counseling. Promotion of BS amongst providers and both surgical and non-surgical trainees will likely have a significant impact on referral rates and access to this life-saving procedure. Future studies should further investigate the barriers to BS and delineate the effect size of each barrier on referral rates to efficiently increase access.

History of abuse and bariatric surgery outcomes: a systematic review.

BACKGROUND: Although there is evidence to support the relationship between abuse history and obesity, the association between abuse history and outcomes after bariatric surgery is not well-established. We aimed to summarize the current literature examining this relationship, as well as provide clinical recommendations to optimize postoperative outcomes. METHODS: PubMed and SCOPUS databases were queried to identify relevant published studies. RESULTS: Overall, 20 studies were included. Rates of the various types of abuse reported in the bariatric surgery population varied widely across studies, as did the methodology used to assess it. The majority of studies found no significant associations between abuse history and postoperative weight loss outcomes. The literature examining the relationship between abuse history and postoperative psychiatric outcomes was less conclusive. CONCLUSIONS: Most current evidence demonstrates that abuse history is not associated with weight loss outcomes after bariatric surgery. Literature on postoperative psychiatric outcomes is mixed, and more robust studies are needed to further investigate the relationship between abuse history and postoperative psychiatric outcomes. Importantly, abuse history should not preclude patients from undergoing bariatric surgery. Of note, patients may benefit from careful monitoring for emotional distress and worsening of psychiatric comorbidities after surgery and psychiatric counseling and treatment when indicated.

Gastric electric stimulator versus gastrectomy for the treatment of medically refractory gastroparesis.

BACKGROUND: Gastric electrical stimulation (GES) and laparoscopic gastrectomy (LG) are known therapeutic options for medically refractory gastroparesis (MRG) although there are limited data comparing their outcomes. We aim to compare clinical outcomes between patients undergoing GES vs upfront LG for the treatment of MRG while examining factors associated with GES failure and conversion to LG. METHODS: We retrospectively analyzed 181 consecutive patients who underwent GES or LG for MRG at our institution from January 2003 to December 2017. Data collection consisted of chart review and follow-up telephone survey. Statistical analysis utilized Chi-squared, ANOVA, and multivariable logistic regression. RESULTS: Overall, 130 (72%) patients underwent GES and 51 (28%) LG as primary intervention. GES patients were more likely to have diabetic gastroparesis (GES 67% vs LG 39%, p < 0.001), while primary LG patients were more likely to have post-surgical gastroparesis (GES 5% vs LG 43%, p < 0.001). Postoperatively, primary LG patients had higher rates of major in-hospital morbidity events (GES 5% vs LG 18%, p = 0.017) and longer hospital stays (GES 3 vs LG 9 days, p < 0.001). However, over a mean 35-month follow-up period, there were no differences in the rates of major morbidity, readmissions, or mortality. Multivariable regression analysis revealed patients undergoing GES as a primary intervention were less likely to report improvement in symptoms on follow-up compared to primary LG patients OR 0.160 (95% CI 0.048-0.532). Additionally, patients who converted to LG from GES were more likely to have post-surgical gastroparesis as the primary etiology. CONCLUSION: GES as a first-line surgical treatment of MRG was associated with worse outcomes compared to LG. Post-surgical etiology was associated with an increased likelihood of GES failure, and in such patients, upfront gastrectomy may be a superior alternative to GES. Further studies are needed to determine patient selection for operative treatment of MRG.

Hernia-to-neck ratio is associated with emergent ventral hernia repair.

BACKGROUND: The ratio of hernia size to fascial defect size, termed the hernia-to-neck ratio (HNR), has been proposed as a novel predictive factor for umbilical hernia complications. HNR ≥ 2.5 has been suggested to warrant surgery due to association with bowel strangulation, incarceration, and necrosis. The aim of this study was to evaluate the association between HNR and emergent ventral hernia repair at our institution. METHODS: A retrospective cohort study was performed of consecutive patients with ventral hernias evaluated at a large safety-net hospital from 2017 to 2019. Patients who required emergent ventral hernia repair were compared to patients who did not require repair at latest follow-up. HNR was calculated using a previously described method: maximal hernia sac size and maximal fascial defect size (termed "hernia neck size") were measured in the sagittal plane on CT scan. Data are described as mean ± standard deviation and median (interquartile range). RESULTS: A total of 166 patients were included: 84 (51%) required emergent hernia repair and 82 (49%) did not undergo repair. Median follow-up was 19 (8-27) months. Patient groups were similar except the emergent repair group had more males (50% vs. 34%, p = 0.03), umbilical hernias (93% vs. 56%, p < 0.01), recurrent hernias (31% vs. 15%, p < 0.01), and lower mean BMI (34.3 ± 9.9 vs. 39.1 ± 6.5, p < 0.01). Hernia sac size did not differ between groups (5.8 [3.8-8.4] cm vs. 6.1 [3.5-11.8] cm, p = 0.45). Hernia neck size was significantly smaller in the emergent repair group (1.5 [2.3-3.5] cm vs. 3.4 [1.8-6.2] cm, p < 0.01). Hernia-to-neck ratio was significantly higher in the emergent repair group (2.4 [1.8-3.1] vs. 1.7 [1.1-2.9], p < 0.01). CONCLUSION: This study demonstrated an association between higher HNR and increased risk of emergent ventral hernia repair. Future studies will evaluate the use of HNR to risk-stratify patients with ventral hernias in a safety-net hospital.

Surgeon Assessment of a Novel Multi-Resolution Foveated Laparoscope.

BACKGROUND: We developed a multi-resolution foveated laparoscope (MRFL) to improve situational awareness in laparoscopic surgery. We assessed surgeon objective task performance and subjective attitudes with MRFL when used for box trainer tasks and porcine surgery. METHODS: The MRFL simultaneously obtains a wide-angle view and a magnified view. The 2 images are displayed simultaneously. 6 urologists and 2 general surgeons performed box trainer and porcine surgery tasks with the MRFL and a standard laparoscope. Task time, use of display options, and subjective assessments were obtained. RESULTS: Subjectively, surgeons rated situational awareness, depth perception, and instrument interference as comparable between the prototype MRFL and laparoscope for trainer tasks. For porcine surgery, the MRFL was rated as having less interference than the standard laparoscope. The image quality of the MRFL was rated interior to the standard laparoscope. Participants found the different viewing modes useful for different roles and reported that they would likely use the MRFL for conventional laparoscopic and robotic surgery. Objectively, box trainer task time was comparable for 2 of 3 tasks with the remaining task shorter for the standard laparoscope. Porcine nephrectomy and oophorectomy were feasible with the prototype MRFL, although nephrectomy task time was significantly longer than traditional laparoscopy. CONCLUSIONS: The MRFL demonstrated feasibility for performing complex surgery. Surgeons had favorable attitudes toward its features and likelihood to use the device if available. Users utilized different view types for different tasks. Longer MRFL task times were attributed to poorer image quality of the prototype.

Impact of smoking on weight loss outcomes after bariatric surgery: a literature review.

BACKGROUND: The association between smoking and surgical complications after bariatric surgery has been well-established. However, given that this patient population is inherently weight-concerned, understanding the effects of tobacco use on postoperative weight loss is essential to guiding clinicians in counseling patients. We aimed to summarize the current literature examining the effects of preoperative and postoperative smoking, as well as changes in smoking status, on bariatric surgery weight loss outcomes. METHODS: Ovid MEDLINE, PubMed, and SCOPUS databases were queried to identify relevant published studies. RESULTS: Overall, 20 studies were included. Preoperative and postoperative smoking rates varied widely across studies, as did requirements for smoking cessation prior to bariatric surgery. Reported preoperative smoking prevalence ranged from 1 to 62%, and postoperative smoking prevalence ranged from 6 to 43%. The majority of studies which examined preoperative and/or postoperative smoking habits found no association between smoking habits and postoperative weight loss outcomes. A minority of studies found relatively small differences in postoperative weight loss between smokers and nonsmokers; these often became nonsignificant with longer follow-up. No studies found significant associations between changes in smoking status and weight loss outcomes. CONCLUSION: While smoking has been associated with weight loss in the general population, most current evidence demonstrates that smoking habits are not associated with weight loss outcomes after bariatric surgery. However, due to the heterogeneity in study design and analysis, no definitive conclusions can be made, and more robust studies are needed to investigate any relationship between smoking and long-term weight loss outcomes. Given the established increased risk of surgical complications and mortality in smokers, smoking cessation should be encouraged.

Effects of smoking on bariatric surgery postoperative weight loss and patient satisfaction.

BACKGROUND: While general population studies have demonstrated a relationship between cigarette smoking and weight loss, this association is not well established among the bariatric patient population. Given that bariatric patients are inherently weight-concerned, understanding the effects of smoking on postoperative weight loss is essential. We examined the association of preoperative smoking, postoperative smoking and changes in smoking status with weight loss after bariatric surgery. In addition, we examined the association of changes in smoking status with subjective indices of patient satisfaction while controlling for weight loss. METHODS: Retrospective chart review of patients who underwent Sleeve Gastrectomy or Roux-en-Y Gastric Bypass for weight loss at a single institution between August 2000 and November 2017. Additional follow up was obtained by telephone survey. Statistical analysis utilized multivariate logistical regressions. RESULTS: Our study included 512 patients. Majority were female (n = 390, 76.2%) and underwent laparoscopic Roux-en-Y gastric bypass (n = 362, 70.7%). Average age was 46.8 years and average follow up was 6.99 years. Preoperative, postoperative and changes in smoking status were not significantly associated with weight loss. Former smokers were significantly more likely to report postoperative satisfaction with self-overall OR 10.62 (p < 0.01), satisfaction with postoperative outcomes OR 4.18 (p = 0.02), and improvement in quality of life OR 4.05 (p = 0.04) compared to continued smokers independent of weight loss. No difference in rates of satisfaction were found between former smokers and never smokers. Smoking cessation and weight loss were independently predictive of positive responses to these satisfaction indices. CONCLUSIONS: We found no association between preoperative smoking, postoperative smoking or changes in smoking status with postoperative weight loss. Smoking cessation was associated with patient satisfaction and improvement in quality of life compared to continued smokers. Smoking cessation and postoperative weight loss were independently predictive of increased patient satisfaction.

Laparoscopy as a Diagnostic and Therapeutic Modality for Chronic Abdominal Pain of Unknown Etiology: A Literature Review.

BACKGROUND: Investigate the diagnostic and therapeutic utility of laparoscopy in the management of patients with chronic abdominal pain of unknown origin. METHODS: Ovid MEDLINE, PubMed, and SCOPUS databases were queried to identify relevant published studies. Data on the diagnostic and therapeutic utility of laparoscopy were abstracted and summarized. RESULTS: Laparoscopy achieved a diagnosis in 65% to 94% of patients with chronic abdominal pain of unknown origin. Common intraoperative findings included adhesions, chronic appendicitis, hernias, and enlarged mesenteric lymph nodes. These findings corresponded with the therapeutic procedures that were performed, including laparoscopic adhesiolysis, appendectomy, and hernia repair. Therapeutic utility of laparoscopy based on pain relief, patient satisfaction, and quality of life ranged from 63% to 94%. CONCLUSIONS: Based on current available evidence, diagnostic laparoscopy (DL) is a safe and effective method for identifying organic causes of chronic abdominal pain. Laparoscopic treatment also resulted in substantial pain relief for a majority of patients. However, the efficacy of laparoscopic adhesiolysis remains controversial. We would recommend the use of DL as an early diagnostic tool, but more robust studies are needed to establish the breadth of its therapeutic utility in clinical practice.

Minimal versus obligatory dissection of the diaphragmatic hiatus during magnetic sphincter augmentation surgery.

BACKGROUND: The magnetic sphincter augmentation (MSA) device was initially implanted with minimal hiatal dissection (MHD) at the diaphragmatic hiatus. Due to concern of possible MSA device dysfunction if herniated into an occult or small hiatal hernia, and increased understanding to the role of defective crura in reflux disease, the operative procedure was changed to planned obligatory dissection (OD) of the hiatus at the time of all implantations. METHODS: Between December 2012 and September 2016, 182 patients underwent MSA implant at a single medical center and have complete records available for review through September 2017. The MHD dissection period extended from December 2012 to September 2015, from September 2015 to 2016 all patients underwent OD. RESULTS: MHD occurred 53% (96/182) versus OD in 47% (86/182), mean follow-up time in days for MHD and OD was 554 (SD 427) versus 374 (298) days. Intraoperative measurement of hernia size for the MHD versus OD was 0.77 (1.1) versus 3.95 (2.4) cm, p < 0.001. At first visit follow-up, there was no difference in any dysphagia (p = 0.11). Recurrent GERD (defined as resumption of PPI after successful initial post-operative wean) was less frequent after OD than after MHD, 3.6 versus 16.3%, p = 0.006. Delayed onset dysphagia was 1.2% in the OD group versus 8.6% in the MHD group, p = 0.04. Recurrent hiatal hernia of 2 cm or greater occurred in 0.0% of the OD and 11.5% of the MHD, p = 0.03. Repeat surgery for hiatal hernia repair has occurred in 0% of the OD and 6.6% of the MHD, p = 0.02. CONCLUSION: OD of the hiatus with crural closure resulted in less recurrence of reflux symptoms and hiatal hernia, despite an increased proportion of patients with larger hiatal hernia and more complex anatomic disease at the time of operation.

Removing the magnetic sphincter augmentation device: operative management and outcomes.

BACKGROUND: Recurrent or persistent symptoms of reflux, dysphagia, or device erosion can lead to removal of the magnetic sphincter augmentation (MSA aka Linx) device. Device removal has been previously reported, and outcomes of various surgical management strategies at the time of removal have not been well described. METHODS: This is a retrospective review of patients undergoing MSA removal from March 2009 to September 2017 in a single institution. Reason for removal, operative management, and short-term outcomes are reported. RESULTS: During the study, 435 MSA devices were implanted, 24 of which required removal (5.5%). Removal was due to refractory dysphagia in 1.8% (8/435), for recurrent or persistent GERD in 2.9% (13/435), and secondary to erosion in 0.5% (2/435). Mean time from implant to removal was 863 days (range 119-1762 days). The most common reasons for removal were recurrent GERD (54%), dysphagia (38%), or erosion (8%). Significant operative findings included recurrent or progressive hiatal hernia (38%), erosion (8%), and normal anatomy (46%). Hiatal hernia was found and repaired at the time of device removal in 38% of patients (9/24). The MSA device was removed through laparotomy (4%), laparoscopically (88%), or through a combination of endoscopy and laparoscopy (8%). After removal patients underwent repeat MSA (33%), fundoplication (21%), gastrectomy (4%), or no additional procedure (42%). Symptoms prompting removal of the MSA device had resolved in 52% of patients and improved in an additional 35% at last contact. Of the 10 patients having no anti-reflux procedure after removal, 9 were available for follow-up at a mean of 97 (106) days of whom 22.2% (2/9) had symptoms of GERD or required any anti-reflux medication. No major complications occurred after removal. CONCLUSION: MSA removal when necessary can be accomplished through minimally invasive means. Repeat Linx or fundoplication can be performed after removal, however may not be necessary in patients with removal for dysphagia.

Routine esophageal manometry is not useful in patients with normal videoesophagram.

BACKGROUND: Videoesophagram (VEG) and esophageal manometry (EM) are components of the preoperative evaluation for foregut surgery. EM is able to identify motility disorders and diminished contractility that may alter surgical planning. However, there are no clearly defined criteria to guide this. Reliable manometry is not always easily obtained, and therefore its necessity in routine preoperative evaluation is unclear. We hypothesized that if a patient has normal videoesophagram, manometry does not reveal clinically significant esophageal dysfunction. METHODS: We reviewed patients who underwent protocolized videoesophagram and manometry at our institution. Measures of esophageal motility including the mean distal contractile integral (DCI), mean wave amplitude (MWA), and percent of peristaltic swallows (PPS) were analyzed. The Chicago Classification was used for diagnostic criteria of motility disorders. Normal VEG was defined as stasis of liquid barium on less than three of five swallows. RESULTS: There were 418 patients included. 231 patients (55%) had a normal VEG, and 187 patients (45%) had an abnormal VEG. In the normal VEG group, only 2/231 (0.9%) patients had both abnormal DCI and PPS, 1/231 (0.4%) patients had both abnormal DCI and MWA and no patients had both abnormal MWA and PPS. There were no patients with achalasia or absent contractility and 1 patient with ineffective esophageal motility (IEM) in the normal VEG group. This was significantly different from the abnormal VEG group which included 4 patients with achalasia, 1 with absent contractility and 22 with IEM (p < 0.0001). The negative predictive value of VEG was 99.6% and the sensitivity was 96.4%. CONCLUSIONS: A normal videoesophagram reliably excluded the presence of clinically significant esophageal dysmotility that would alter surgical planning. Routine manometry is not warranted in patients with normal videoesophagram, and should be reserved for patients with abnormal VEG.

Regression of intestinal metaplasia following magnetic sphincter augmentation device placement.

BACKGROUND: Intestinal metaplasia represents an esophageal mucosal transformation due to uncontrolled gastroesophageal reflux disease. Fundoplication has been shown to lead to regression of disease. Magnetic sphincter augmentation is an alternative to fundoplication that effectively treats reflux disease. Initially, patients with intestinal metaplasia were not considered candidates for device placement, so outcomes in these patients are unknown. METHODS: A retrospective review of all patients who underwent magnetic sphincter augmentation device placement between 2007 and 2017 was performed. All patients underwent pre-operative endoscopic evaluation and were categorized as having ultra-short segment (less than 1 cm), short-segment (1-3 cm), or long-segment (greater than or equal to 3 cm) disease. To be included in the study, pathologic examination demonstrating columnar mucosa with goblet cells was required. RESULTS: There were 86 patients with biopsy-proven non-dysplastic intestinal metaplasia. 35 patients had ultra-short segment, 37 patients had short-segment, and 14 patients had long-segment disease. At a median follow-up of 1.2 years, 67/86 (78%) patients completed endoscopic follow-up. 48/67 (71.6%) patients had regression of intestinal metaplasia. There was no progression to dysplasia or carcinoma. Patients with abnormal post-operative DeMeester scores were less likely to have regression of disease. Regression was more likely in the ultra-short segment (82.8%) and short-segment (73.3%) groups compared to the long-segment group (25.0%). CONCLUSIONS: Magnetic sphincter augmentation is effective in achieving regression of intestinal metaplasia. Longer-term follow-up is needed to assess durability of effect and make meaningful comparisons to fundoplication.

Hiatal hernia recurrence following magnetic sphincter augmentation and posterior cruroplasty: intermediate-term outcomes.

BACKGROUND: We have previously reported short-term outcomes after hiatal hernia repair (HHR) at the time of magnetic sphincter augmentation (MSA) for gastroesophageal reflux disease (GERD). Here we report intermediate-term outcomes and hernia recurrence rate after concomitant MSA and HHR. METHODS: This is a retrospective cohort study of patients who underwent repair of a hiatal hernia 3 cm or larger at the time of MSA implantation between May 2009 and December 2015. The primary endpoint was hiatal hernia recurrence identified by routine postoperative videoesophagography or endoscopy. Recurrence was defined by a 2 cm or greater upward displacement of the stomach through the diaphragmatic esophageal hiatus. Secondary endpoints included cessation of proton-pump inhibitor (PPI), persistent dysphagia requiring intervention, and GERD health-related quality-of-life (HRQL) scores 1 year from surgery. RESULTS: During the study period, 47 of 53 (89%) patients underwent concomitant MSA with HHR and complied with surveillance. Hiatal hernias ranged from 3 to 7 cm (mean 4 ± 1). Mean clinical follow-up time was 19 months (range 1-39). GERD-HRQL score decreased from 20.3 to 3.1 (p < .001), 89% of patients remained off PPIs, and 97% of patients reported improvement or resolution of symptoms. Two recurrent hiatal hernias were identified on surveillance imaging for a recurrence rate of 4.3% at a mean 18 (± 10) months after initial operation. Persistent dysphagia occurred in 13% (6/47) over the first year, which resolved after a single balloon dilation in 67% (4/6). Two patients elected for device removal due to dilation-refractory dysphagia and persistent reflux symptoms. CONCLUSION: Concomitant magnetic sphincter augmentation and hiatal hernia repair in patients with gastroesophageal reflux disease and a moderate-sized hiatal hernia demonstrates durable subjective reflux control and an acceptable hiatal hernia recurrence rate at 1- to 2-year follow-up.

Gastric cancer in the young: An advanced disease with poor prognostic features.

BACKGROUND AND OBJECTIVES: Gastric cancer in young patients is rare. We analyzed the clinicopathological features and prognosis of early-onset gastric carcinoma. METHODS: We retrospectively reviewed patients with gastric adenocarcinoma aged ≤45 years and >45 years at our institution over a 17-year period. Clinicopathological features were compared and survival analysis was performed using Kaplan-Meier curves. RESULTS: A total of 121 patients with gastric carcinoma aged ≤45 years were identified. The young group (YG) had a higher incidence of stage III/IV disease (86.8% vs. 57.9%, P < 0.001), poorly-differentiated carcinoma (95.9% vs. 74.4%, P < 0.001), and signet-cell type tumor (88.4% vs. 32.2%, P < 0.001) relative to the older group (OG). The majority of tumors were in the middle third of the stomach in both groups (P = 0.108). Three-year survival in the YG was 87.1%, 32.2%, and 6.9% in stage I/II, III, and IV disease, respectively. Surgical intervention in young patients with advanced carcinoma was not associated with improved survival. Although median survival was shorter in the YG compared to the OG (11.7 vs. 41.0 months, P < 0.001), stage-specific survival was similar. CONCLUSION: Early-onset gastric cancer demonstrates advanced stage of disease, and a high incidence of poorly-differentiated and signet-cell type carcinoma. Overall survival is poor with no added benefit to surgical intervention in advanced disease.

Efficacy of magnetic sphincter augmentation in patients with large hiatal hernias.

BACKGROUND: Magnetic sphincter augmentation (MSA) has demonstrated long-term safety and efficacy in the treatment of patients with gastroesophageal reflux (GERD), but its efficacy in patients with large hiatal hernias has yet to be proven. The aim of our study was to assess outcomes of MSA in patients with hiatal hernias ≥3 cm. METHODS: We retrospectively reviewed all patients who underwent MSA at our institutions over a 6-year period. Information obtained consisted of patient demographics, symptoms of GERD, preoperative GERD Health-Related Quality-of-Life (HRQL) scores, perioperative details, and implantation of the MSA device. Primary endpoints included postoperative GERD-HRQL scores, proton-pump inhibitor (PPI) use, symptom change, and procedure-related complications. A large hiatal hernia was defined as a hernia measuring ≥3 cm by intraoperative measurement. RESULTS: A total of 192 patients were reviewed. Median follow-up was 20 months (3-75 months). Mean GERD-HRQL scores in the overall population before and after MSA were 18.9 and 5.0, respectively (p < 0.001). In the majority of patients symptoms improved or resolved (N = 177, p < 0.001). Fifty-two patients (27.0 %) had a hiatal hernia ≥3 cm (range 3-7 cm). Their mean GERD-HRQL score decreased from 20.5 to 3.6 (p < 0.001) following MSA. When compared to patients with smaller hernias, patients with large hiatal hernias had decreased postoperative PPI requirement (9.6 vs. 26.6 %, p = 0.011) and lower mean postoperative GERD-HRQL scores (3.6 vs. 5.6, p = 0.027). The percent of patients requiring postoperative intervention for dysphagia was similar (13.5 vs. 17.9 %, p = 0.522), as was the incidence of symptom resolution or improvement (98.1 vs. 91.3 %, p = 0.118). CONCLUSION: MSA in patients with large hiatal hernias demonstrates decreased postoperative PPI requirement and mean GERD-HRQL scores compared to patients with smaller hernias. The incidence of symptom resolution or improvement and the percentage of patients requiring intervention for dysphagia are similar. Short-term outcomes of MSA are encouraging in patients with gastroesophageal reflux disease and large hiatal hernias.

Safety and efficacy of single-stage conversion of failed adjustable gastric band to laparoscopic Roux-en-Y gastric bypass: a case-control study.

BACKGROUND: We conducted the following study to evaluate the safety and efficacy of single-stage conversion of failed laparoscopic adjustable gastric band (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) as compared to a cohort of primary LRYGB patients. METHODS: A single-institution, prospectively maintained bariatric database was used to retrospectively identify consecutive patients who underwent single-stage removal of LAGB with concomitant conversion to LRYGB between the years of 2007 and 2013. The study cohort was matched 1:1 for age, gender, body mass index (BMI), and approximate date of operation to patients who underwent primary LRYGB. Primary endpoints were operative time, complication rate, length of hospital stay (LOS), and percent excess BMI lost (%EBMIL) at 24-month follow-up. RESULTS: Ninety-four conversion patients met inclusion criteria. There were no statistically significant differences in the mean LOS (3.1 vs. 3.0 days, p = 0.97) or the major complication rate (3.2 vs. 1.1 %, p = 0.62) at 30 days postoperatively. Likewise, 30-day minor complication rates, including readmission, were similar between groups (7.5 vs. 6.4 %, p = 0.77). The average operative time was significantly longer for conversion compared to primary LRYGB (193.5 vs. 132 min; p < 0.01). At most recent follow-up after conversion or primary LRYGB, median %EBMIL was 61.3 and 77.3 % (p < 0.01), percent total weight loss was 23.6 and 30.5 % (p < 0.01), and percent change in BMI was 23.4 and 30.5 % (p < 0.01), respectively. Median follow-up time was 17 and 18.6 months after conversion and primary LRYGB, respectively. CONCLUSION: Single-stage conversion of LAGB to LRYGB is safe with an acceptable complication rate and similar LOS compared to primary LRYGB.

Trends and predictors of laparoscopic compared with open emergent inguinal hernia repair.

BACKGROUND: Laparoscopic emergent inguinal hernia repair remains controversial despite studies suggesting it is safe and feasible. Variables associated with laparoscopic compared with open emergent inguinal hernia repair are currently not well described. This study aims to investigate patient characteristics and risk factors associated with laparoscopic emergent inguinal hernia repair. METHODS: The American College of Surgeons National Surgical Quality Improvement database was queried for adult patients (age ≥18 years) who had undergone emergent inguinal hernia repair between 2015 and 2021. The relationships between demographic variables and laparoscopic compared with open emergent inguinal hernia repair were evaluated using univariate and multivariate analyses. RESULTS: A total of 8,215 patients were included in this analysis. Use of laparoscopic emergent inguinal hernia repair increased from 9% in 2015 to 23% in 2021. Female patients (odds ratio, 1.84, P < .001) and patients aged ≤65 years (odds ratio, 1.25, P = .005) were more likely to undergo laparoscopic repair. Black (odds ratio, 0.73, P = .003) and Hispanic (odds ratio, 0.72, P = .006) patients and patients with greater American Society of Anesthesiologists classification (odds ratio, 0.86, P = .037), ascites (odds ratio, 0.39, P = .039), and preoperative dialysis requirement (odds ratio, 0.45, P = .017) were less likely to undergo laparoscopic repair. Aside from a decreased likelihood of readmission in patients who underwent laparoscopic surgery (odds ratio, 0.696, P = .024), there was no difference in other postoperative outcomes, despite a laparoscopic approach being associated with greater rates of concomitant procedures compared with an open approach (24% vs 18%, P < .001). CONCLUSIONS: Female sex, younger age, and lower American Society of Anesthesiologists class were associated with a greater likelihood of laparoscopic surgery. Black and Hispanic patients and patients with ascites and dialysis requirements were less likely to undergo laparoscopic repair. Laparoscopic inguinal hernia repair can be safely performed in an emergent setting.