Impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy: a NSQIP retrospective cohort analysis of 25,848 patients.

BACKGROUND: Efforts to preoperatively risk stratify and optimize patients before pancreaticoduodenectomy continue to improve outcomes. This study aims to determine the impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy and outline optimal hypoalbuminemia cut-off values in this population. METHODS: The ACS-NSQIP (2016-2021) database was used to extract patients who underwent pancreaticoduodenectomy, comparing those with hypoalbuminemia (< 3.0 g/L) to those with normal albumin. Demographics and 30-day outcomes were compared. Multivariable modeling evaluated factors including hypoalbuminemia to characterize their independent effect on serious complications, and mortality. Optimal albumin cut-offs for serious complications and mortality were evaluated using receiver-operating characteristic curves. RESULTS: We evaluated 25,848 pancreaticoduodenectomy patients with 2712 (10.5%) having preoperative hypoalbuminemia. Patients with hypoalbuminemia were older (68.2 vs. 65.1; p < 0.0001), and were significantly more likely to be ASA class 4 or higher (13.9% vs. 6.7%; p < 0.0001). Patients with hypoalbuminemia had significantly more 30-day complications and after controlling for comorbidities hypoalbuminemia remained a significant independent factor associated with 30-day serious complications (OR 1.80, p < 0.0001) but not mortality (OR 1.37, p = 0.152). CONCLUSIONS: Hypoalbuminemia plays a significant role in 30-day morbidity following pancreaticoduodenectomy. Preoperative albumin may serve as a useful marker for risk stratification and optimization.

Persistent hyperbilirubinemia following preoperative biliary stenting in patients undergoing anatomic hepatectomy predicts serious complications.

BACKGROUND: Biliary obstruction before liver resection is a known risk factor for post-operative complications. The aim of this study was to determine the impact of persistent hyperbilirubinemia following preoperative biliary drainage before liver resection. METHODS: The ACS-NSQIP (2016-2021) database was used to extract patients with cholangiocarcinoma who underwent anatomic liver resection with preoperative biliary drainage comparing those with persistent hyperbilirubinemia (> 1.2 mg/dL) to those with resolution. Patient characteristics and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including persistent hyperbilirubinemia to evaluate their independent effect on serious complications, liver failure, and mortality. RESULTS: We evaluated 463 patients with 217 (46.9%) having hyperbilirubinemia (HB) despite biliary stenting. Bivariate analysis demonstrated that patients with HB had a higher rate of serious complications than those with non-HB (80.7% vs 70.3%; P = 0.010) including bile leak (40.9% vs 31.8%; P = 0.045), liver failure (26.7% vs 17.9%; P = 0.022), and bleeding (48.4% vs 36.6%; P = 0.010). Multivariable analysis demonstrated that persistent HB was independently associated with serious complications (OR 1.88, P = 0.020) and mortality (OR 2.39, P = 0.049) but not post-operative liver failure (OR 1.65, P = 0.082). CONCLUSIONS: Failed preoperative biliary decompression is a predictive factor for post-operative complications and mortality in patients undergoing hepatectomy and may be useful for preoperative risk stratification.

Smoking status predicts anastomotic leak after esophagectomy: a systematic review & meta-analysis.

BACKGROUND: Anastomotic leak after esophagectomy is a major contributor to surgery-related morbidity and mortality. The purpose of this systematic review was to evaluate if positive-smoking status is associated with the incidence of this complication. METHODS: A systematic search of MEDLINE, EMBASE, Scopus, Web of Science and Cochrane Library was performed on April 4th, 2023. Inclusion criteria comprised human participants undergoing esophagectomy, age ≥ 18, n ≥ 5, and identification of smoking status. The primary outcome was incidence of anastomotic leak. Sub-group analysis by ex- or current smoking status was performed. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated visually with funnel plots and through the Egger test. RESULTS: A total of 220 abstracts were screened, of which 69 full-text studies were assessed for eligibility, with 13 studies selected for final inclusion. This included 16,103 patients, of which 4433 were ex- or current smokers, and 9141 were never smokers. Meta-analysis revealed an increased odds of anastomotic leak in patients with a positive-smoking status (current or ex-smokers) compared to never smokers (OR 1.44, 95% CI 1.18-1.76, I2 = 44%, p < 0.001. Meta-analysis of six studies comparing active smokers alone to never smokers identified a significant increased odds of anastomotic leak (OR 1.80, 95% CI 1.25-2.59, p = 0.002, I2 = 0%). Meta-analysis of five studies comparing ex-smokers to never smokers identified a significant increased odds of anastomotic leak (OR 1.36, 95% CI 1.02-1.82, p = 0.04, I2 = 0%). The odds of anastomotic leak decreased among ex-smokers compared to active smokers. CONCLUSION: The findings of this systematic review and meta-analysis support the association between positive-smoking status and the risk of anastomotic leak after esophagectomy. Results further emphasize the importance of preoperative smoking cessation to reduce post-operative morbidity.

Endoscopic incisional therapy for benign anastomotic strictures after esophagectomy or gastrectomy: a systematic review and meta-analysis.

BACKGROUND: Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy. METHODS: A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test. RESULTS: A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation. CONCLUSION: Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.

Impact of the COVID-19 pandemic on esophageal cancer resource allocation: a systematic review.

Background: The coronavirus disease 2019 (COVID-19) pandemic challenged global infrastructure. Healthcare systems were forced to reallocate resources toward the frontlines. In this systematic review, we analyze the impact of resource reallocation during the COVID-19 pandemic on the diagnosis, management, and outcomes of esophageal cancer (EC) patients. Methods: PubMed and Embase were systematically searched for articles investigating the impact of the COVID-19 pandemic on EC patients. Of the 1,722 manuscripts initially screened, 23 met the inclusion criteria. Results: Heterogeneity of data and outcomes reporting prohibited aggregate analysis. Reduced detection of EC and considerable variability in disease stage at presentation were noted during the COVID-19 pandemic. EC patients experienced delays in diagnostic and preoperative staging investigations but surgical resection was not associated with greater short-term morbidity or mortality. Modeling the impact of pandemic-related delays in EC care predicts significant reductions in survival with associated economic losses in the coming years. Conclusions: Amidst resource scarcity during the COVID-19 pandemic, the multidisciplinary management of patients with EC was affected at multiple stages in the care pathway. Although the complete ramifications of reductions in EC diagnosis and delays in care remain unclear, EC surgery was able to safely continue as a result of collaboration between centers, strict adherence to COVID-19 protective measures, and reallocation of healthcare resources towards the same. Ultimately, when healthcare systems are pushed to the brink, the downstream consequences of resource reallocation require judicious analysis to optimize overall patient outcomes.

Revisional bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes. METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity. RESULTS: 4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications. CONCLUSION: GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.

Resource allocation during the coronavirus disease 2019 pandemic and the impact on patients with lung cancer: a systematic review.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented tolls on both economies and human life. Healthcare resources needed to be reallocated away from the care of patients and towards supporting the pandemic response. In this systematic review, we explore the impact of resource allocation during the COVID-19 pandemic on the screening, diagnosis, management and outcomes of patients with lung cancer during the pandemic. METHODS: PubMed and Embase were systematically searched for articles investigating the impact of the COVID-19 pandemic on patients with lung cancer. Of the 1605 manuscripts originally screened, 47 studies met the inclusion criteria. RESULTS: Patients with lung cancer during the pandemic experienced reduced rates of screening, diagnostic testing and interventions but did not experience worse outcomes. Population-based modelling studies predict significant increases in mortality for patients with lung cancer in the years to come. CONCLUSIONS: Reduced access to resources during the pandemic resulted in reduced rates of screening, diagnosis and treatment for patients with lung cancer. While significant differences in outcomes were not identified in the short term, ultimately the effects of the pandemic and reductions in cancer screening will likely be better delineated in the coming years. Future consideration of the long-term implications of resource allocation away from patients with lung cancer with an attempt to provide equitable access to healthcare and limited interruptions of patient care may help to provide the best care for all patients during times of limited resources.

Changes in Sarcopenia Status Predict Survival Among Patients with Resectable Esophageal Cancer.

BACKGROUND: Sarcopenia is a predictor of survival in patients with esophageal cancer. The objective of this research was to obtain insight into how changes in sarcopenia influence survival in resectable esophageal cancer. PATIENTS AND METHODS: A retrospective cohort of patients with esophageal cancer undergoing tri-modality therapy was selected. Body composition parameters from the staging, post-neoadjuvant, and 1-year surveillance computed tomography (CT) scans were calculated. Overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan-Meier method and log-rank test, as well as multivariable Cox-proportional hazards models. RESULTS: Of 141 patients, 118 had images at all three timepoints. The median DFS and OS were 33.2 [95% confidence interval (CI) 19.1-73.7] and 34.5 (95% CI 23.1-57.6) months, respectively. Sarcopenia classified by the staging CT was present in 20 (17.0%) patients. This changed to 45 (38.1%) patients by the post-neoadjuvant scan, and 44 (37.3%) by the surveillance scan. In multivariable analysis, sarcopenia at the post-neoadjuvant scan was significantly associated with OS [hazards ratio (HR) 2.65, 95% CI 1.59-4.40; p < 0.001] and DFS (HR 1.80, 95% CI 1.03-3.13; p = 0.038). The net change in skeletal muscle index was associated with OS (HR 0.93, 95% CI 0.90-0.97; p < 0.001) and DFS (HR 0.94, 95% CI 0.91-0.98; p = 0.001). CONCLUSIONS: Patients who develop sarcopenia as a consequence of skeletal muscle wasting during neoadjuvant therapy are at risk for worse DFS and OS. Patients who have a net loss of muscle over time may be at high risk for early disease recurrence.

Optimizing management for early-stage esophageal adenocarcinoma: longitudinal results from a multidisciplinary program.

BACKGROUND: The management of early-stage esophageal cancer is nuanced. A multidisciplinary approach may optimize management through selection of candidates for surgical or endoscopic therapies. The objective of this research was to examine long-term outcomes of patients with early-stage esophageal cancer who undergo treatment with endoscopic resection or surgery. METHODS: Data on patient demographics, co-morbidities, pathology results, OS and RFS were obtained for both the endoscopic resection group and esophagectomy group. Univariate analysis of OS and RFS were conducted using the Kaplan-Meier method with calculation of the log-rank test. Multivariate cox-proportional hazards models were created for OS and RFS using a hypothesis-driven approach. A multivariate logistic regression model was created to identify predictors of esophagectomy among patients undergoing initial endoscopic resection. RESULTS: A total of 111 patients were included. The median OS for the surgery group was 67.0 months compared to 74.0 months in the endoscopic resection group (log-rank p = 0.93). The median RFS for the surgery group was 109.4 months compared to 63.3 months in the endoscopic resection group (log-rank p = 0.0127). On multivariable analysis, patients undergoing endoscopic resection had significantly worse RFS (HR 2.55, 95% CI 1.09-6.00; p = 0.032), but equivalent OS (HR 1.03, 95% CI 0.46-2.32; p = 0.941), compared to patients undergoing esophagectomy. High-grade disease (OR 5.43, 95% CI 1.13-26.10; p = 0.035) and submucosal involvement (OR 7.75, 95% CI 1.90-31.40; p = 0.004) were identified as significant predictors of proceeding to esophagectomy. CONCLUSIONS: Through a multidisciplinary approach, patients with early-stage esophageal cancer achieve excellent RFS and OS. Submucosal involvement and high-grade disease place patients at increased risk for local disease recurrence; these patients may undergo endoscopic resection safely if treated with a multidisciplinary approach incorporating endoscopic surveillance and surgical consultation. Further risk-stratification models may enable better patient selection and optimization of long-term outcomes.

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.

Sarcopenia in Lung Cancer: A Narrative Review.

It has been over 10 years since the relationship between sarcopenia and lung cancer was first explored. Since then, sarcopenia research has progressed substantially, and the prognostic value of this condition is becoming increasingly apparent. Prior systematic reviews and meta-analyses have established sarcopenia to be negatively associated with disease-free and overall-survival, as well as a major risk factor for post-operative complications. The bulk of the literature has explored sarcopenia in the resectable setting, with less emphasis placed on studies evaluating this condition in advanced disease. In this up-to-date review, an examination of the literature exploring the association between sarcopenia and long-term outcomes in advanced lung cancer is provided. We further explore the association between adverse events of medical therapy and the role of sarcopenia as a predictor of tumor response. Finally, the interventions on sarcopenia and cancer cachexia are reviewed, with an emphasis placed on prospective studies.

Oral care reduces incidence of pneumonia after esophagectomy: systematic review and meta-analysis.

PURPOSE: Post-operative pneumonia after esophagectomy is a major contributor to morbidity and mortality. Prior studies have demonstrated a link between the presence of pathologic oral flora and the development of aspiration pneumonia. The objective of this systematic review and meta-analysis was to evaluate the effect of pre-operative oral care on the incidence of post-operative pneumonia after esophagectomy. METHODS: A systematic search of the literature was performed on September 2, 2022. Screening of titles and abstracts, full-text articles, and evaluation of methodological quality was performed by two authors. Case reports, conference proceedings, and animal studies were excluded. A meta-analysis of peri-operative oral care on the odds of post-operative pneumonia after esophagectomy was performed using Revman 5.4.1 with a Mantel-Haenszel, random-effects model. RESULTS: A total of 736 records underwent title and abstract screening, leading to 28 full-text studies evaluated for eligibility. A total of nine studies met the inclusion criteria and underwent meta-analysis. Meta-analysis revealed a significant reduction in post-operative pneumonia among patients undergoing pre-operative oral care intervention compared to those without an oral care intervention (OR 0.57, 95% CI 0.43-0.74, p < 0.0001; I2 = 49%). CONCLUSION: Pre-operative oral care interventions have significant potential in the reduction of post-operative pneumonia after esophagectomy. North American prospective studies, as well as studies on the cost-benefit analysis, are required.

Learning objectives for thoracic surgery: developing a national standard for undergraduate medical education.

BACKGROUND: The Continuing Professional Development (CPD) (Education) Committee of the Canadian Association of Thoracic Surgeons (CATS) has established a goal of describing the essential knowledge of thoracic surgery. We aimed to develop a national standardized set of undergraduate learning objectives for thoracic surgery. METHODS: We obtained these learning objectives from 4 medical schools in Canada. These 4 institutions were selected to provide a broad geographical representation of medical schools of varying sizes and of both official languages. The resulting list of learning objectives underwent critical review by the CPD (Education) Committee, made up of 5 Canadian community and academic thoracic surgeons, 1 thoracic surgery fellow and 2 general surgery residents. A national survey was developed and circulated to all CATS members (n = 209). Respondents were asked to indicate on a 5-point Likert scale whether each objective should be a priority for all medical students. RESULTS: Among 209 CATS members, 56 responded (response rate 27%). The mean length of experience in clinical practice among survey respondents was 10.6 (standard deviation 10.0) years. Respondents most commonly reported teaching or supervising medical students monthly (37.0%), followed by daily (29.6%). Eight of the 10 proposed objectives received a mean Likert score of 4/5 or higher and were selected for inclusion in the final list. A finalized list of 8 learning objectives was created, following a final review from the CATS Executive Committee. CONCLUSION: We developed a standardized set of learning objectives for medical students that was reflective of the core concepts within thoracic surgery.

ERAS guidelines for esophagectomy: adherence patterns among Canadian thoracic surgeons.

Enhanced recovery after surgery (ERAS) guidelines have been incorporated across surgical specialties supported by the publication of evidence-based guidelines. The purpose of this research was to explore adherence to such guidelines among Canadian thoracic surgeons with respect to esophagectomy. A standardized questionnaire was developed comprising 43 validated ERAS recommendations. Additional questions such as the number of annual esophagectomies per institution, the clinical practice environment of the survey responder, preferred operative approach, and responder demographics were included. The survey was circulated to all Canadian Association of Thoracic Surgery (CATS) members and remained open for a four month period. Of the 136 CATS members, 74 (54.4%) completed the survey. Among responders, 29 (40.3%) did have a standard ERAS protocol at their institution. The majority of the responders practiced at an academic center (50, 88.3%). A self-reported adherence rate greater than 80% was observed in six out of 12 of the pre-operative ERAS recommendations, two out of eight of the intraoperative, and seven out of 23 of the post-operative ERAS recommendations. Among the five recommendations associated with high levels of evidence, two had been incorporated into practice by the majority of responders. Out of the 29 strong recommendations, 24 were incorporated into practice by the majority of responders. Canadian thoracic surgeons' express practices that are largely consistent with strongly recommended ERAS guidelines in patients undergoing esophagectomy. ERAS guidelines continue to be instrumental in the improvement of perioperative care; however, high adherence is ultimately necessary for optimal patient outcomes.

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.

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.

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.

Age-related disparities and trends in national healthcare spending for management of appendicitis in the United States: A retrospective cost-analysis.

BACKGROUND: Changes in clinical care for appendicitis have impacted healthcare use associated with treatment. We evaluated national trends and assessed factors associated with healthcare costs for appendicitis in the United States. DESIGN: The Disease Expenditure Project, the Global Burden of Disease study, and the National Inpatient Sample were used to estimate total national expenditures, per-capita costs for incident cases, and factors associated with inpatient costs for appendicitis management, respectively. The national estimates of appendicitis costs were obtained from 1996 to 2016. Appendicitis incidence was estimated to calculate per-capita costs. After application of survey weights for the stratified sample design, 191,180 weighted discharges for appendicitis from the 2016 National Inpatient Sample study were evaluated. The Disease Expenditure Project and the Global Burden of Disease study were used to estimate total and per-capita spending. Temporal trends were evaluated using joinpoint regression, expressed as annual percent change. Multivariable linear regression was used to evaluate patient factors associated with total hospital charges. RESULTS: In 2016, total spending on appendicitis was $9.3 billion (95% confidence interval: $8.0-$10.8], a 2-fold increase from $4.7 billion ($4.0-$5.3) in 1996. Per-capita spending decreased significantly after 2011 (annual percent change -3.7% [-4.4% to -2.9%]). Patients ≥65 years accounted for 64.1% (61.1%-67.3%) of total spending for appendicitis. The hospital charges for older patients were significantly higher among those undergoing appendectomy. CONCLUSION: Overall healthcare spending for appendicitis has doubled from 1996 to 2016, but per capita spending has decreased since 2011, driven by improved efficiency of inpatient care. Nearly two-thirds of spending is on patients ≥65 years, with significantly higher costs associated with surgical management in this population.

Obstructive Sleep Apnea Is Associated with Serious Complications But Not Increased Mortality Following Elective Bariatric Surgery: a Retrospective Cohort Study of 751,952 Patients.

BACKGROUND: The aim of the study was to characterize the prevalence of obstructive sleep apnea (OSA) in elective bariatric surgery patients and to determine if OSA is an independent predictor of 30-day serious complications and 30-day mortality among bariatric surgery patients. METHODS: An analysis of the MBSAQIP database from 2015 to 2019 was conducted, and patients were stratified by OSA diagnosis. Data was extracted on patient age, sex, race, and comorbidities. A multivariate logistic regression model was created to evaluate the impact of OSA on 30-day serious complications and 30-day mortality. RESULTS: Of 751,952 patients, 287,180 (38.2%) were identified as having OSA. OSA patients were older (48.0 ± 11.4 vs. 42.2 ± 11.9 years; p < 0.0001) and were of increased BMI (46.5 ± 8.5 kg/m2 vs. 44.6 ± 7.3 kg/m2; p < 0.0001). OSA was not associated with 30-day mortality in the multivariable logistic regression model (OR 0.98, 95% CI 0.83-1.16; p = 0.829). OSA was associated with increased odds of 30-day serious complications (OR 1.33, 95% CI 1.30-1.36; p < 0.0001). In addition, dialysis (OR 3.07, 95% CI 2.68-3.52; p < 0.0001), positive venous thromboembolism history (OR 2.46, 95% CI 2.32-2.60; p < 0.0001), and oxygen dependence (OR 2.42, 95% CI 2.18-2.68; p < 0.0001) were all identified as major predictors of serious complications. CONCLUSION: We identified OSA as a modifiable factor predictive of serious complications following elective bariatric surgery. OSA is highly prevalent in this patient population, and it appears to be an important risk factor that deserves further attention in terms of peri-operative optimization strategies.

Method of venous thromboembolism prophylaxis is not a predictor of pulmonary embolus following elective bariatric surgery: a retrospective cohort study of 135,409 patients.

BACKGROUND: Patients with obesity are at increased risk of pulmonary embolus (PE), a risk that increases perioperatively and is challenging to manage. OBJECTIVE: An analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed to determine predictors of PE in patients undergoing elective bariatric surgery. SETTING: North American accredited bariatric surgery institutions included in the MBSAQIP database from 2020-2021. METHODS: We extracted data from the MBSAQIP database (2020-2021) on patients who underwent elective Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Data were extracted on patient co-morbidities, race, prior history of deep vein thrombosis (DVT), and type of DVT prophylaxis. A multivariate logistic regression model was developed to determine predictors of PE and impact of PE on 30-day serious complications and mortality. RESULTS: In the MBSAQIP database, a total of 135,409 patients underwent SG or RYGB from 2020 to 2021. PE was reported in 194 patients (.14%). Prior history of DVT (odds ratio [OR] = 3.28; 95% confidence interval [CI]: 1.85-5.83; P < .0001), Black race (OR = 3.03; 95% CI: 2.22-4.13; P < .0001), gastroesophageal reflux disease (OR = 1.51; 95% CI: 1.11-2.04; P = .008), higher body mass index (OR = 1.11; 95% CI: 1.01-1.20; P = .023), male sex (OR = 1.76; 95% CI: 1.26-2.45; P = .001), and older age (OR = 1.27; 95% CI: 1.10-1.46; P = .001) were associated with increased odds of PE. Chronic obstructive pulmonary disease, sleep apnea, and hypertension were not significant predictors of PE (P > .05). Neither combined mechanical and pharmacologic DVT prophylaxis nor pharmacologic prophylaxis alone was a significant predictor of PE (P > .05). CONCLUSION: Prior history of DVT is the strongest predictor of PE after bariatric surgery. African American race, male sex, and gastroesophageal reflux disease are additional risk factors. Method of venous thromboembolism prophylaxis was not identified as significant predictor of PE. Further, studies on the evaluation and optimization of venous thromboembolism prophylaxis are required.