The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on adjustable gastric banding.

BACKGROUND: Bariatric surgery is one of the clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, and laparoscopic adjustable gastric banding (LAGB) is one of the three anchoring bariatric procedures. To improve surgeon lifelong learning, the Masters Program seeks to identify sentinel articles of each of the 3 bariatric anchoring procedures. In this article, we present the top 10 articles on LAGB. METHODS: A systematic literature search of papers on LAGB was completed, and publications with the most citations and citation index were selected and shared with SAGES Metabolic and Bariatric Surgery Committee members for review. The individual committee members then ranked these papers, and the top 10 papers were chosen based on the composite ranking. RESULTS: The top 10 sentinel publications on LAGB contributed substantially to the body of literature related to the procedure, whether for surgical technique, novel information, or outcome analysis. A summary of each paper including expert appraisal and commentary is presented here. CONCLUSION: These seminal articles have had significant contribution to our understanding and appreciation of the LAGB procedure. Bariatric surgeons should use this resource to enhance their continual education and acquisition of specialized skills.

Incidence of GERD, esophagitis, Barrett's esophagus, and esophageal adenocarcinoma after bariatric surgery.

BACKGROUND: Some bariatric procedures have been associated with increased gastroesophageal reflux disease (GERD) symptoms; however, there are limited data on the long-term changes to the esophagus across bariatric procedures, and how preoperative esophageal disease is impacted by bariatric surgery. OBJECTIVES: To estimate incidence of GERD, esophagitis, Barrett's esophagus, and esophageal adenocarcinoma before and after bariatric surgery and to identify potential risk factors for these conditions. SETTING: Retrospective analysis of New York State Database (SPARCS). METHODS: Adult patients undergoing bariatric surgery (Roux-en-Y gastric bypass, adjustable gastric banding, laparoscopic sleeve gastrectomy, and biliopancreatic diversion) from 1995 to 2010. Multivariable Cox proportional hazard models were used to examine the association between preoperative diagnosis, surgery type, and postoperative diagnosis. RESULTS: A total of 48,967 records were analyzed; 30.3% had a diagnosis of GERD at the time of surgery and .4% had a diagnosis of esophagitis and Barrett's. Preoperative GERD/esophagitis/Barrett's was associated with higher risk of GERD, esophagitis, and Barrett's, but not esophageal adenocarcinoma, postoperatively. Roux-en-Y gastric bypass patients had lowest risk of being diagnosed with GERD postoperatively. Overall, esophageal adenocarcinoma incidence in the sample was .04%; the rate among patients with preoperative GERD and Barrett's was .1% and .9%, respectively. Incidence of esophageal adenocarcinoma did not differ by bariatric surgery type. CONCLUSIONS: Preoperative diagnosis is a risk factor for postoperative esophageal disease after bariatric surgery. Adjustable gastric banding and laparoscopic sleeve gastrectomy are associated with higher risk of postoperative GERD and esophagitis compared with Roux-en-Y gastric bypass. Incidence of esophageal adenocarcinoma did not differ by surgery type.

Surgeon variation in severity of reflux symptoms after sleeve gastrectomy.

BACKGROUND: Prior studies have demonstrated an increase in gastroesophageal reflux after laparoscopic sleeve gastrectomy (LSG). However, it is unknown whether symptom severity varies or if outcomes are surgeon-specific. METHODS: A validated reflux symptom survey was obtained at baseline and at 1 year after primary LSG on 7358 patients participating in a state-wide quality improvement collaborative between 2013 and 2018. Patients with worsening symptoms after surgery were divided into terciles based on the degree of increase in survey score (0 = no symptoms, 50 = max symptoms). Surgeon-level data was obtained on 52 bariatric surgeons performing at least 25 LSG cases/year during the study period. Surgeon characteristics, operative experience, and risk-adjusted 30-day complication rates were compared between surgeons in the highest tercile for moderate worsening of symptoms vs those in the lowest. RESULTS: A total of 2294 (31.2%) patients had worsening symptoms of reflux after sleeve gastrectomy. Overall mean increase in severity score was 6.11 (range 1 to 48) and patients with minimal, mild, and moderate symptoms had a mean increase of 1.4, 4.2, and 13.8, respectively. There were no significant differences in surgeon-specific characteristics when comparing surgeons in the highest tercile for moderate worsening of symptoms (44.7% of patients) vs those in the lowest tercile (18.7% of patients). In addition, there were no significant differences in risk-adjusted rates of overall complications (3.70% vs. 4.33%, p = 0.686), endoscopic dilations (2.83% vs. 1.91%, p = 0.417), or concurrent hiatal hernia repair (34.3% vs. 27.0%, p = 0.415) between surgeons in the highest and lowest terciles. CONCLUSIONS: We found that 1/3 of patients had worsening symptoms of reflux after LSG and that severity of symptoms varied. Surgeons with the highest rates of worsening reflux had similar operative experience and complication rates than those with the lowest. Further assessment of operative technique and skill may be informative.

Is it worth it? Determining the health benefits of sleeve gastrectomy in patients with a body mass index <35 kg/m2.

BACKGROUND: Criteria for undergoing sleeve gastrectomy (SG) is restricted among patients with a body mass index (BMI) <35 kg/m2. OBJECTIVES: To determine if low-BMI patients experience similar health benefits after SG compared with patients with a BMI ≥35 kg/m2. SETTING: Teaching and nonteaching hospitals in Michigan. METHODS: Patients with a BMI <35 kg/m2 at the time of primary SG were identified between 2006 and 2018 (n = 1073, 2.4%). Patient characteristics, 30-day risk-adjusted complication rates, and patient reported outcomes were compared with all patients who underwent SG with a BMI ≥35 kg/m2 (n = 44,511, mean BMI 46.7 kg/m2). RESULTS: Low-BMI patients were more likely to be older (50.7 versus 45.4 yr, P < .0001), have diabetes (36.7 versus 30.9%, P < .0001), hypertension (54.2% versus 51.0%, P = .0372), and hyperlipidemia (57.1% versus 44.8%, P < .0001). Both groups had comparable rates of discontinuation of medications for hypertension (59.7% versus 54.1%, P = .0570), hyperlipidemia (54.3% versus 52.2%, P = .5537), and diabetes (oral, 79.2% versus 78.1%, P = .7294; insulin, 64.2% versus 62.2%, P = .7438). However, low-BMI patients were more likely to achieve a healthy BMI (i.e., BMI ≤25 kg/m2; 36.3% versus 6.01%, P < .0001), and had higher body image scores (50.6 versus 42.4, P < .0001). CONCLUSIONS: Despite being older and with higher rates of metabolic disease, low-BMI patients reported high-resolution rates for diabetes, hypertension, and hyperlipidemia (>50%) and were more likely to achieve a healthy weight after SG. Abolishing the BMI threshold for SG among patients with metabolic disease should be considered.

The influence of gastroesophageal reflux symptoms on patient satisfaction after sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy has become the most common procedure performed for weight loss. But emerging data indicate that this procedure can result in lifestyle-limiting gastroesophageal reflux disease. The influence of these gastroesophageal reflux disease symptoms on patient satisfaction with the procedure has not been explored. METHODS: Using a statewide, bariatric-specific data registry, we studied 6,608 patients who underwent laparoscopic sleeve gastrectomy from 2013 to 2017. We used the Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire, which is 10 questions, each ranging from 0 (no symptoms) to 5 (severe symptoms). To assess the impact of sleeve gastrectomy on patient satisfaction, we calculated the change in this score at baseline versus 1 year after the procedure. We stratified the change in the gastroesophageal reflux disease score into 5 even-sized groups (quintiles). We then examined the relationship between change in the gastroesophageal reflux disease score and patient satisfaction at 1 year. We used generalized linear mixed models to assess the variation in patient satisfaction explained by the change in the gastroesophageal reflux disease score, excess body weight loss at 1 year, and other patient outcomes (serious complications, readmission, and reoperations). We controlled for patient factors (age, sex, race, and comorbidities) and year of sleeve gastrectomy. RESULTS: The average change in the gastroesophageal reflux disease score was 1.62 (range: -48 to 48); however, the change in the gastroesophageal reflux disease score varied across quintiles with a -7.3-point (range: -48 to -3) worsening in the bottom quintile versus a 2.6-point (range: 7 to 48) improvement in the top quintile. Overall, 77.7% of patients were satisfied, but the proportion of patients satisfied was highly dependent on whether their reflux symptoms improved or worsened. Only 48.9% in the bottom quintile were satisfied, compared with 78.1% in the top quintile (<.0001). In the multivariate model, changes in patient-reported gastroesophageal reflux disease score were the most predictive of patient satisfaction, explaining 10.1% of the variation in 1 year satisfaction. Among patients in the bottom quintile, reflux symptoms explained 30.2% of variation compared with 2.3% in quintiles with little change or improvement in reflux. Moreover, excess body weight loss explained only 2% of variation in satisfaction and <1% was explained by patient outcomes (serious complications, readmissions, reoperations, or surgical complications). CONCLUSION: In this statewide study of sleeve gastrectomy, we demonstrated that gastroesophageal reflux symptoms are an important determinant of 1 year satisfaction, particularly among patients whose symptoms worsened the most.

Early postoperative diet after bariatric surgery: impact on length of stay and 30-day events.

BACKGROUND: Pathways for enhanced recovery after surgery (ERAS) have been shown to improve length-of-stay (LOS) and post-operative complications across various surgical fields, however there is a lack of evidence-based studies in bariatric surgery. Specifically, the value of early feeding within an ERAS program in bariatric surgery is unclear. The objective of the current study was to determine the effect of early feeding on LOS for patients who underwent primary or revisional laparoscopic sleeve gastrectomy (LSG) and Roux-en-y gastric bypass (RYGB). METHODS: Retrospective single institution study of implementation of a new diet protocol in which initiation of oral intake changed from post-operative day 1 to day 0. LOS and 30-day events were compared. Patients were excluded if they were planned for 23-h stay, had significant intra-operative complications, or required reoperation within the same admission. Mann-Whitney U tests were done to compare LOS and chi-squared tests to compare 30-day events pre- and post-intervention. RESULTS: A total of 244 patients were included; 84.4% were primary cases. 50.8% of cases occurred prior to early feeding implementation. Median age was 43.5 years (IQR 33-53) and majority of patients were female (78.7%). Median LOS was 32.6 (IQR 30.0-50.6). Median LOS across the whole sample was shorter in the early feeding group (36.2 vs. 31.0 h; p < 0.001). This difference remained statistically significant for primary, but not revisional cases. Post-operative events at 30 days were similar between pre- and post-intervention groups. CONCLUSIONS: Early feeding the day of surgery is associated with significantly shorter LOS for patients who undergo bariatric surgery with no difference in 30-day readmissions.

Routine contrast imaging after bariatric surgery and the effect on hospital length of stay.

BACKGROUND: Although multiple studies demonstrate that routine postoperative contrast studies have a low yield in diagnosing patients with early gastrointestinal (GI) leak after bariatric surgery, the practice pattern is unknown. Additionally, routine imaging may hinder procedural pathways that lead to accelerated postoperative discharge. OBJECTIVES: To report on the nationwide use of routine upper GI studies (UGI) and evaluate the effect on hospital resource utilization. SETTING: Nationwide analysis of accredited centers. METHODS: The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file for 2015 was used to identify patients who underwent routine UGI after nonrevisional Roux-en-Y gastric bypass or sleeve gastrectomy. Multivariable logistic regression models were developed to identify risk factors for early hospital discharge. RESULTS: Bariatric surgery was performed on 130,686 patients. Routine UGI was performed in 30.9% of Roux-en-Y gastric bypass and 43% of sleeve gastrectomy patients (P<.0001). Patients undergoing routine UGI were less likely to be discharged by postoperative day 1 (odds ratio .7, 95%; confidence interval .69-0.72). There was no difference in postoperative leak rate between the routine UGI versus nonroutine UGI group (.7% versus .8%, P = .208). Among patients who developed a GI leak, there was no significant difference in the rate of reoperation, readmission, and reintervention between the 2 groups. The time interval between index operation and any further management for the leak was longer in the routine UGI group. CONCLUSIONS: Routine UGI evaluation after bariatric surgery remains a common practice in accredited centers. This practice is associated with prolonged hospital length of stay, with no effect on the diagnosis of leak rate.

Patterns of reoperation after failed fundoplication: an analysis of 9462 patients.

BACKGROUND: Little is known about the choice of reoperation after failed fundoplication for gastroesophageal reflux disease. Both redo fundoplication and conversion procedure to Roux-en-Y gastric bypass (RYGB) are safe and effective. We aimed to characterize the rates of different revisional procedures and to identify risk factors associated with failed fundoplication. METHODS: Using a statewide database, we examined records for patients who underwent fundoplication between 2000 and 2010. The primary outcomes were the rate of each type of reoperation and the pattern of subsequent procedures. Demographics and comorbidities were used in a multivariable logistic regression model to identify risk factors associated with reoperation after fundoplication. RESULTS: A total of 9462 patients were included. Overall, 430 (4.5%) patients underwent reoperation. Of those, 46 (10.7%) patients underwent RYGB at first reoperation, with the remainder having a redo fundoplication. An additional five patients were converted to RYGB after undergoing a redo fundoplication (51 total patients converted to RYGB at any point, 11.9%). Eighty-three percent of patients converted to RYGB were obese, as opposed to 8% for redo fundoplication. A single redo fundoplication was done in 81% of patients, while 35 patients (8.1%) underwent two or more revisional procedures. On average, any reoperation was performed 2.9 years after fundoplication, with redo fundoplication 2.5 years and RYGB 6.5 years later. Age 30-49 years (vs. >70 years; OR 2.01, p = 0.011) and 50-69 years (vs. >70 years; OR 1.61, p = 0.011), female gender (OR 1.56, p = < 0.0001), and chronic pulmonary disease (OR 1.40, p = 0.0044) were associated with revisional surgery. CONCLUSIONS: Fundoplication has a low reoperation rate within a mean 8.3 years of follow-up. Redo fundoplication is more commonly performed and at an earlier point than conversion to RYGB. Younger age, female gender, and chronic pulmonary disease are associated with reoperation after fundoplication.

Single stage conversion from adjustable gastric banding to sleeve gastrectomy or Roux-en-Y gastric bypass: an analysis of 4875 patients.

BACKGROUND: The previous popularity of adjustable gastric banding (AGB), along with inconsistent long-term results, has resulted in the need for conversion to other procedures. The perioperative safety of laparoscopic sleeve gastrectomy (SG) and gastric bypass (RYGB) as single-stage conversion procedures is unclear. OBJECTIVES: To compare the early safety of SG and RYGB when performed as single-stage conversion procedures at the time of AGB removal. SETTING: Nationwide analysis of accredited centers. METHODS: The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file for 2015 was queried for all patients who underwent single-stage conversion to SG or RYGB. Multivariable logistic regression was performed to control for baseline differences, and odds ratios (ORs) with 95% confidence intervals are reported. RESULTS: There were 4865 patients who underwent a single-stage AGB conversion. SG was performed in 3364 (69.1%). The 30-day reoperation (1.6% versus 2.7%, P = .008), readmission (4% versus 5.7%, P = .006), reintervention (1.7% versus 2.7%, P = .024), and overall morbidity (2.9% versus 6.5%, P<.0001) were significantly less common in the SG group. After controlling for baseline characteristics, RYGB was independently associated with higher overall 30-day reoperation (OR 1.81, 1.19-2.75), readmission (OR 1.42, 1.07-1.88), reintervention (OR 1.59, 1.06-2.4), and overall morbidity (OR 2.17, 1.62-2.9). CONCLUSIONS: AGB conversions are associated with low overall 30-day event rates. Patients undergoing RYGB as a single-stage conversion experience higher complication rates and the need for additional early procedures compared with SG.

Fatal Falls in New York City: An Autopsy Analysis of Injury Patterns.

INTRODUCTION: Falls from heights are an important cause of unintentional fatal injury. We investigated the relationship between the characteristics of fatal falls and resulting injury patterns. MATERIALS AND METHODS: We reviewed prospectively collected data from the Office of Chief Medical Examiner in New York City between 2000 and 2010. Data included fall height, work or non-work related, use of safety equipment, intentionality, specific organ injuries, and death on impact. The primary outcome was organ injury based on fall height. RESULTS: Higher falls were associated with hemorrhage as well as rib and various organ injuries. Organ injury pattern did not differ based on work status. The presence of equipment misuse or malfunction was associated with more deaths upon impact. Victims of falls from 200 ft or higher were 11.59 times more likely to die on impact than from lower than 25 ft. CONCLUSIONS: Fall height and work-related falls were significantly associated with death on impact. This is a public health issue, as 13% of falls were work related and 4% of falls were due to improper use of safety equipment. Some work-related falls are potentially preventable with proper safety equipment use. Understanding patterns of injury may play a role in prevention and management of survivors in the acute period.

Weight loss outcomes among patients referred after primary bariatric procedure.

BACKGROUND: Bariatric patients may not always obtain long-term care by their primary surgeon. Our aim was to evaluate weight loss outcomes in patients who had surgery elsewhere. METHODS: We conducted a retrospective analysis. Postreferral management included nonsurgical, revision, or conversion. Primary outcomes were percent excess weight loss (%EWL) overall, according to original operation, and based on postreferral management. RESULTS: Between 2001 and 2013, there were 569 patients. Mean follow-up was 3.1 years. Management was 42% nonsurgical, 41% revision, and 17% conversion. Overall, mean %EWL was 45.3%. Based on original surgery type, %EWL was 41.2% for adjustable gastric banding vs 58.3% for Roux-en-Y gastric bypass (P ≤ .0001). Management affected %EWL (41.2% nonsurgical vs 45.3% revision vs 55.1% conversion, P ≤ .0001). CONCLUSIONS: Patients referred after bariatric surgery can achieve satisfactory weight loss. This differs based on surgery type and management strategy.

Long-term outcomes after Roux-en-Y gastric bypass: 10- to 13-year data.

BACKGROUND: Short- and mid-term data on Roux-en-Y gastric bypass (RYGB) indicate sustained weight loss and improvement in co-morbidities. Few long-term studies exist, some of which are outdated, based on open procedures or different techniques. OBJECTIVES: To investigate long-term weight loss, co-morbidity remission, nutritional status, and complication rates among patients undergoing RYGB. SETTING: An academic, university hospital in the United States. METHODS: Between October 2000 and January 2004, patients who underwent RYGB≥10 years before study onset were eligible for chart review, office visits, and telephone interviews. Revisional surgery was an endpoint, ceasing eligibility for study follow-up. Outcomes included weight loss measures and rates of co-morbidity remission, complications, and nutritional deficiencies. RESULTS: RYGB was performed in 328 patients with a mean preoperative body mass index of 47.5 kg/m(2). Of 294 eligible patients, 134 (46%) were contacted for follow-up at ≥ 10 years (10+Year follow-up). Mean percentage excess weight loss (%EWL) was 58.9% at 10+Year. Higher %EWL was achieved by non-super-obese versus super-obese (61.3% versus 52.9%, P = .034). Blood pressure, lipid panel, and hemoglobin A1c improved significantly. At 10 years, remission of co-morbidities was 46% for hypertension and hyperlipidemia and 58% for diabetes mellitus. Thirty patients (9%) had revisional surgery for weight regain. Sixty-four patients (19.5%) had long-term complications requiring surgery. All-cause mortality was 2.7%. Nutritional deficiencies were seen in 87% of patients. CONCLUSIONS: Weight loss after RYGB appears to be significant and sustainable, especially in the non-super-obese. Co-morbidities are improved, with a substantial number in remission a decade later. Nutritional deficiencies are almost universal.

Safety of laparoscopic adjustable gastric banding with concurrent cholecystectomy for symptomatic cholelithiasis.

BACKGROUND: The prevalence of cholelithiasis correlates with obesity. Patients often present for bariatric surgery with symptomatic cholelithiasis. There is a concern of cross-contamination when performing laparoscopic adjustable gastric banding (LAGB) with concurrent cholecystectomy. The primary goal of this study is to address the safety and feasibility of this practice. METHODS: A retrospective cohort study was designed from a prospectively collected database. All LAGB patients from July 2005 to April 2013 were included. Patients undergoing LAGB with concurrent cholecystectomy comprised the study group (LAGB/chole). The control group (LAGB) consisted of patients undergoing LAGB alone, and was selected using a 3:1 (control:study) case-match based on demographic and comorbidity data. The primary outcome was overall complication rate, with secondary outcomes including operating room (OR) time, length of stay (LOS), 30-day readmission/reoperation, erosion, infection, and band/port revisional surgery. RESULTS: There were 4,982 patients who met criteria. Of these, 28 patients had a LAGB with concurrent cholecystectomy, comprising the LAGB/chole (study) group. The remaining 4,954 patients were eligible controls, of which 84 were selected for the LAGB (control) group. Demographic and comorbidity data, along with mean follow-up time, were similar between the two groups. OR time was longer in the LAGB/chole group, but LOS was the same. The overall complication rate in the LAGB/chole group was 21 (n = 6) versus 20% (n = 17) in the LAGB group (p = 0.893). Thirty-day readmission and reoperation were similar. There was also no difference in port site, wound, and intra-abdominal infections. There were no band erosions in either group. CONCLUSIONS: Performing a concurrent cholecystectomy at the time of LAGB does not result in increased immediate or delayed morbidity. Although longer to perform, this safe operation would avoid a second surgery for a patient already diagnosed with symptomatic cholelithiasis.

Single-stage versus 2-stage sleeve gastrectomy as a conversion after failed adjustable gastric banding: 30-day outcomes.

BACKGROUND: Sleeve gastrectomy (SG) is being performed as a conversion after adjustable gastric banding (AGB), often in a single stage. However, some argue that it should be performed in 2 stages to improve safety. Few studies compare complications between 1-stage and 2-stage procedures. Our aim is to compare the 30-day complication rates among these two groups. METHODS: We retrospectively reviewed patients converted from AGB to SG between 8/2008 and 10/2013 and compared patients undergoing 1-stage and 2-stage techniques. Primary outcome was overall 30-day adverse event rate (postoperative complication, readmission, or reoperation). Secondary outcomes included operating room (OR) time, length of stay (LOS), leak, infection, and bleeding rates, as well as mortality. RESULTS: A total of 83 patients underwent SG after band removal; three were excluded due to short follow-up, leaving 60 1-stage and 20 2-stage. Mean time from band removal to SG for 2-stage was 438 days. Demographics, intraoperative technique (bougie size, staple reinforcement, oversewing staple line, and leak test), and mean follow-up were not statistically different. Mean OR time (132.1 min 1-stage vs. 127.8 min 2-stage, p = 0.702) and LOS (3.1 vs. 2.4 days, p = 0.676) were similar. Overall 30-day adverse event rate was 12 % for 1-stage versus 15 % for 2-stage procedures (p = 0.705). Differences in 30-day readmission (8 vs. 5 %) and reoperation (5 vs. 0 %) were not statistically significant (p = 0.999 and 0.569, respectively). Leak (3 vs. 0 %, p = 0.999), abscess (2 vs. 5 %, p = 0.440), and bleeding rates (2 vs. 0 %, p = 0.999) were not different. There were no deaths. CONCLUSIONS: SG performed as a conversion after AGB is safe and feasible. Our findings indicate no statistical difference in 30-day outcomes when performed in 1 or 2 stages. Future studies with larger sample sizes are necessary to further investigate these differences.

Location and number of sutures placed for hiatal hernia repair during laparoscopic adjustable gastric banding: does it matter?

BACKGROUND: It has been demonstrated that hiatal hernia repair (HHR) during laparoscopic adjustable gastric banding (LAGB) decreases the rate of reoperation. However, the technical aspects (location and number of sutures) are not standardized. It is unknown whether such technical details are associated with differing rates of reoperation for band-related problems. METHODS: A retrospective analysis was performed from a single institution, including 2,301 patients undergoing LAGB with HHR from July 1, 2007 to December 31, 2011. Independent variables were number and location of sutures. Data collected included demographics, operating room (OR) time, length of stay (LOS), follow-up time, postoperative BMI/%EWL, and rates of readmission/reoperation. Statistical analyses included ANOVA and Chi squared tests. Kaplan-Meier, log-rank, and Cox regression tests were used for follow-up data and reoperation rates, in order to account for differential length of follow-up and confounding variables. RESULTS: There was no difference in length of follow-up among all groups. The majority of patients had one suture (range 1-6; 55 %). Patients with fewer sutures had shorter OR time (1 suture 45 min vs. 4+ sutures 56 min, p < 0.0001). LOS, 30-day readmission, band-related reoperation, and postop BMI/%EWL were not statistically significant. Anterior suture placement (vs. posterior vs. both) was most common (61 %). OR time was shorter in those with anterior suture (41 min vs. posterior 56 min vs. both 59 min, p < 0.0001). Patients with posterior suture had a longer LOS (84 % 1 day vs. anterior 74 % 1 day vs. both 74 % 1 day, p < 0.0001). There was no difference in 30-day readmission, band-related reoperation, and postoperative BMI/%EWL. CONCLUSIONS: Patients with fewer or anterior sutures have shorter OR times. However, 30-day readmission, band-related reoperation, and postoperative weight loss were unaffected by number or location of suture. The technical aspects of HHR did not appear to be associated with readmission or reoperation, and therefore a standardized approach may not be necessary.

Organ donation after cardiac determination of death (DCD): a swine model.

Donors after Cardiac Death (DCD) may reduce the organ scarcity; however, their use is limited because of warm ischemia time. Fortunately, this is less important in a subclass of DCD called expected (e-DCD), those with irreversible but incomplete brain injury. This study analyzed hemodynamic/pulmonary data to establish a clinically relevant model of cardiac death that would simulate an e-DCD setting. Hemodynamics, pulmonary artery flows, arterial blood gasses, and left atrial pressure were recorded q 5 minutes in anesthetized swine. After baseline data collection, the ventilator was discontinued and heparin was administered. Cardiac death was defined: as asystole, or mean arterial presusure < or = 25 mm Hg with a pulse pressure < or = 20 mm Hg. The time to death was approximately 14.8 minutes. Within 5 minutes of removal of the ventilator, there was a hyperdynamic period. Blood gases throughout the apneic time showed a rapid hypercapnia and acidosis. The hyperdynamic reflex response was followed by hypotension, bradycardia, and finally asystole or ventricular fibrillation. The protocol of withdrawal of ventilation, systemic anticoagulation, determination of death was developed to closely resemble the clinical e-DCD scenario. The physiologic changes that happen before death in DCD were described. An e-DCD model that can be used in studies related to organ transplantation was established.