American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity.

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity.

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

Effect of gender discordance on surgical outcomes in predominantly female patient surgeries in NYS.

BACKGROUND: Preliminary evidence demonstrates female surgeons have improved post-operative outcomes compared to male colleagues despite underrepresentation in surgery. This study explores the effect of patient-surgeon gender discordance on outcomes in three specialties with high female patient populations: bariatric, foregut, colorectal. METHODS: This is a retrospective study using the New York State (NYS) SPARCS database and first study evaluating outcomes based on surgeon/patient concordance in NYS. Bariatric, foregut, and colorectal surgery cases from 2013 to 2017 were identified. RESULTS: Bariatric: female patients (FP) with CC had lower 30-day readmissions but higher complications compared with DC. Male patients (MP) with CC trended towards higher 30-day readmissions but lower complications compared with DC. FP received significantly better influence from CC in 30-day readmission, but disadvantages in complications. There was no significant difference in LOS or ED visits between CC and DC groups for either FP or MP. Foregut: FP with CC had lower LOS, 30-day readmissions, and 30-day ED visits compared with DC. MP showed opposite trends between CC and DC, although non-significant. The benefit from concordance was pronounced in FP compared to MP in LOS, 30-day readmissions, and 30-day ED visit. Concordance vs discordance did not significantly affect complications within either FP or MP group. Colorectal: the difference between CC and DC was not significant within FP or MP groups in any outcomes. When comparing the difference of 30-day readmissions in CC vs DC between FP and MP, there is a significant difference. CONCLUSION(S): Overall, our results show DC between patient and surgeon has significant effect on patient outcomes. A negative effect is seen for female patients in certain specialties, most pronounced in foregut surgery. This emphasizes need for surgeons to be conscious of care provided to opposite gender patients and underscores increasing female surgeons in high FP fields.

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults.

BACKGROUND: As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. METHODS: Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. RESULT: Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. CONCLUSIONS: MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Gender dysphoria and gender-affirming surgery: The New York state experience.

BACKGROUND: Transgender and gender nonconforming (TGNC) individuals experience incongruence between their self-identified gender versus their birth-assigned sex. In some cases, TGNC patients undergo gender-affirming surgical (GAS) procedures. Although GAS is an evolving surgical field, there is currently limited literature documenting patient characteristics and procedures. Addressing this knowledge gap, this retrospective cohort analysis described the characteristics of New York State's TGNC residents with gender dysphoria (GD) diagnosis, including patients undergoing at least one gender-affirming surgical procedure. METHODS: Using the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2002 to 2018, we identified patients' first-time TCNC records and their risk characteristics. Patients who received GAS procedures were sub-classified as top-only, bottom-only, or combined top/bottom procedures and were compared with TGNC patients who did not receive GAS. RESULTS: Of 24,615 records extracted from TGNC SPARCS database, 11,427 (46.4%) were transmasculine (female-to-male) and 13,188 (53.6%) were transfeminine (male-to-female). Overall, 2.73% of transgender patients received at least one GAS procedure. Of these patients, 78.2% had masculinizing and 21.8% had feminizing surgeries. After a diagnosis of GD, the positive predictors for a GAS-based procedure included female birth sex, pediatric age (<18 years) or older age (60+ years), commercial insurance coverage, and Hispanic race. In contrast, negative GAS predictors included male birth sex and government insurance coverage (i.e., Medicare and Medicaid). CONCLUSIONS: Compared with transgender women, transgender men were more likely to receive at least one GAS procedure. Because the race, ethnicity, and payor status of TGNC patients can impact GAS treatment rates, additional research is warranted to examine post-diagnosis GAS treatment disparities among TGNC patients.

Efficacy of Bowel Regimen in Decreasing Postoperative Constipation in Bariatric Surgery Patients.

PURPOSE: Postoperative constipation after bariatric surgery is a common complaint, decreasing patient quality of life. No literature exists examining the efficacy of a preoperative bowel regimen in reducing postoperative constipation in this cohort. This study aims explore the efficacy of a well-established bowel regimen, polyethylene glycol (PEG), in reducing constipation frequency and severity after bariatric surgery. METHODS: This was a retrospective study of adult patients undergoing primary and revisional bariatric procedures. The use of PEG bowel prep for bariatric patients was introduced as an institutional quality improvement measure. Patients during the first 3 months after PEG implementation were surveyed for postoperative constipation. For the year after implementation, patients were followed for 30-day emergency room visits or hospitalization secondary to constipation. This cohort was compared to historical controls from the previous year. Student t-tests were used for statistical analysis. RESULTS: During the 3-month exploratory phase, 28/49 (57.14%) patients fully completed the bowel regimen. In total, 0/56 (0%) patients reported preoperative constipation, and 5/28 (17.9%) patients reported constipation at the 3-week follow-up. In the 1 year post-implementation cohort, 2/234 (0.85%) patients had constipation-related occurrences at 30-day follow-up, compared to 8/219 patients (3.65%) in the historical cohort (p = 0.04). CONCLUSIONS: The implementation of a PEG-based bowel regimen did not eliminate self-reported constipation. However, there were significant differences in rates of constipation-related ED visits and hospital readmissions, suggesting that the bowel regimen decreases rates of severe constipation. Finally, patient compliance was limited. Future work should aim towards increasing compliance.