Harnessing artificial intelligence in bariatric surgery: comparative analysis of ChatGPT-4, Bing, and Bard in generating clinician-level bariatric surgery recommendations.

BACKGROUND: The formulation of clinical recommendations pertaining to bariatric surgery is essential in guiding healthcare professionals. However, the extensive and continuously evolving body of literature in bariatric surgery presents considerable challenge for staying abreast of latest developments and efficient information acquisition. Artificial intelligence (AI) has the potential to streamline access to the salient points of clinical recommendations in bariatric surgery. OBJECTIVES: The study aims to appraise the quality and readability of AI-chat-generated answers to frequently asked clinical inquiries in the field of bariatric and metabolic surgery. SETTING: Remote. METHODS: Question prompts inputted into AI large language models (LLMs) and were created based on pre-existing clinical practice guidelines regarding bariatric and metabolic surgery. The prompts were queried into 3 LLMs: OpenAI ChatGPT-4, Microsoft Bing, and Google Bard. The responses from each LLM were entered into a spreadsheet for randomized and blinded duplicate review. Accredited bariatric surgeons in North America independently assessed appropriateness of each recommendation using a 5-point Likert scale. Scores of 4 and 5 were deemed appropriate, while scores of 1-3 indicated lack of appropriateness. A Flesch Reading Ease (FRE) score was calculated to assess the readability of responses generated by each LLMs. RESULTS: There was a significant difference between the 3 LLMs in their 5-point Likert scores, with mean values of 4.46 (SD .82), 3.89 (.80), and 3.11 (.72) for ChatGPT-4, Bard, and Bing (P < .001). There was a significant difference between the 3 LLMs in the proportion of appropriate answers, with ChatGPT-4 at 85.7%, Bard at 74.3%, and Bing at 25.7% (P < .001). The mean FRE scores for ChatGPT-4, Bard, and Bing, were 21.68 (SD 2.78), 42.89 (4.03), and 14.64 (5.09), respectively, with higher scores representing easier readability. CONCLUSIONS: LLM-based AI chat models can effectively generate appropriate responses to clinical questions related to bariatric surgery, though the performance of different models can vary greatly. Therefore, caution should be taken when interpreting clinical information provided by LLMs, and clinician oversight is necessary to ensure accuracy. Future investigation is warranted to explore how LLMs might enhance healthcare provision and clinical decision-making in bariatric surgery.

Machine learning prediction of major adverse cardiac events after elective bariatric surgery.

BACKGROUND: Machine learning (ML) is an emerging technology with the potential to predict and improve clinical outcomes including adverse events, based on complex pattern recognition. Major adverse cardiac events (MACE) after bariatric surgery have an incidence of 0.1% but carry significant morbidity and mortality. Prior studies have investigated these events using traditional statistical methods, however, studies reporting ML for MACE prediction in bariatric surgery remain limited. As such, the objective of this study was to evaluate and compare MACE prediction models in bariatric surgery using traditional statistical methods and ML. METHODS: Cross-sectional study of the MBSAQIP database, from 2015 to 2019. A binary-outcome MACE prediction model was generated using three different modeling methods: (1) main-effects-only logistic regression, (2) neural network with a single hidden layer, and (3) XGBoost model with a max depth of 3. The same set of predictor variables and random split of the total data (50/50) were used to train and validate each model. Overall performance was compared based on the area under the receiver operating curve (AUC). RESULTS: A total of 755,506 patients were included, of which 0.1% experienced MACE. Of the total sample, 79.6% were female, 47.8% had hypertension, 26.2% had diabetes, 23.7% had hyperlipidemia, 8.4% used tobacco within 1 year, 1.9% had previous percutaneous cardiac intervention, 1.2% had a history of myocardial infarction, 1.1% had previous cardiac surgery, and 0.6% had renal insufficiency. The AUC for the three different MACE prediction models was: 0.790 for logistic regression, 0.798 for neural network and 0.787 for XGBoost. While the AUC implies similar discriminant function, the risk prediction histogram for the neural network shifted in a smoother fashion. CONCLUSION: The ML models developed achieved good discriminant function in predicting MACE. ML can help clinicians with patient selection and identify individuals who may be at elevated risk for MACE after bariatric surgery.

Hiatal hernia repair after previous laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Symptomatic hiatal hernia (HH) with pouch migration after previous laparoscopic Roux-en-Y gastric bypass (RYGB) is an uncommon complication, with limited extant evidence for the utility of surgical repair. OBJECTIVE: To evaluate the presentation and resolution of symptoms in patients with HH repair after previous RYGB. SETTING: Multicenter University Hospital. METHODS: A retrospective review was conducted from 2010 to 2022. Patients with prior RYGB who were undergoing subsequent isolated HH repair were included. Patients undergoing incidental HH repair during concomitant revisional bariatric surgery were excluded. Baseline characteristics and surgical outcomes were evaluated and presented as medians (25th-75th percentile). RESULTS: Forty-four patients met the inclusion criteria. The time from RYGB to HH repair was 59 months (39-88). Body mass index at HH repair was 31 kg/m2 (27-39). The most common presenting symptoms of hernia were dysphagia (52%), gastric reflux (39%), and abdominal pain (36%). All HH repairs were completed with a minimally invasive approach (98% laparoscopic, 2% robotic). Nonabsorbable suture was used in 98% of patients, with bioabsorbable mesh in 30%. At a median 28-day (12-117) follow-up, 70% of patients reported full symptom resolution and 23% partial resolution. At follow-up, 2 patients had radiologic HH recurrence, with 1 requiring reoperation. CONCLUSIONS: This is the largest series of isolated HH repair for symptomatic pouch migration after previous RYGB. Common presenting symptoms are dysphagia and reflux, and surgical repair yields a high rate of symptom resolution in the short term. Longer follow-up is needed to evaluate the durability of this intervention.

Primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) versus sleeve gastrectomy to SADI conversions: a comparison study of prevalence and safety.

BACKGROUND: Conversion from sleeve gastrectomy (SG) to single anastomosis duodeno-ileal bypass (SADI) is becoming increasingly common, but data regarding safety is of these conversions is scarce. As such, the objective of this study was to compare the 30-day rate of serious complications and mortality of primary SADI (p-SADI-S) with SG to SADI (SG-SADI) conversions. METHODS: This retrospective cohort study analyzed the MBSAQIP database. Patients undergoing p-SADI-S and SG-SADI were included. Data collection was limited to 2020 and 2021. A multivariable logistic regression analysis was performed between groups to determine if SG-SADI was an independent predictor of 30-day serious complications or mortality. RESULTS: A total of 783 patients were included in this study, 488 (62.3%) underwent p-SADI-S and 295 (37.6%) underwent SG-SADI. The mean body mass index (BMI) at the time of surgery was lower in the SG-SADI cohort (45.1 vs 51.4 kg/m2, p < 0.001). Indications for revision in the SG-SADI cohort included weight recurrence (50.8%), inadequate weight loss (41.0%), other (3.0%), GERD (2.7%), and persistent comorbidities (2.5%). SG-SADI had longer operative times (156.7 vs 142.1 min, p < 0.001) and was not associated with a higher rate of serious complications (5.7 vs 6.9%, p = 0.508) compared to p-SADI-S. p-SADI-S was associated with a higher rate of pneumonia (1.2 vs 0.0%, p < 0.001), and SG-SADI was not correlated with higher rates of reoperation (3.0 vs 3.2%, p = 0.861), readmission (5.4 vs 5.5%, p = 0.948) and death (0.0 vs 0.2%, p = 0.437). On multivariable analysis, SG-SADI was not independently predictive of serious complications (OR 0.81, 95% CI 0.43 to 1.52, p = 0.514) when adjusting for age, sex, BMI, comorbidities, and operative time. CONCLUSIONS: The prevalence of SG-SADI is high, representing 37.6% of SADI-S procedures. Conversion from sleeve to SADI, is safe, and as opposed to other studies of revisional bariatric surgery, has similar 30-day complication rates to primary SADI-S.

Presence of SARS-CoV-2 in abdominal tissues and biologic fluids during abdominal surgery: a systematic review.

BACKGROUND: Viral transmission to healthcare providers during surgical procedures was a major concern at the outset of the COVID-19 pandemic. The presence of the severe acute respiratory disease syndrome coronavirus (SARS-CoV-2), the virus responsible for COVID-19, in the abdominal cavity as well as in other abdominal tissues which surgeons are exposed has been investigated in several studies. The aim of the present systematic review was to analyze if the virus can be identify in the abdominal cavity. METHODS: We performed a systematic review to identify relevant studies regarding the presence of SARS-CoV-2 in abdominal tissues or fluids. Number of patients included as well as patient's characteristics, type of procedures, samples and number of positive samples were analyzed. RESULTS: A total of 36 studies were included (18 case series and 18 case reports). There were 357 samples for detection of SARS-CoV-2, obtained from 295 individuals. A total of 21 samples tested positive for SARS-CoV-2 (5.9%). Positive samples were more frequently encountered in patients with severe COVID-19 (37.5% vs 3.8%, p < 0.001). No health-care provider related infections were reported. CONCLUSION: Although a rare occurrence, SARS-CoV-2 can be found in the abdominal tissues and fluids. It seems that the presence of the virus in the abdominal tissues or fluids is more likely in patients with severe disease. Protective measures should be employed in the operating room to protect the staff when operating patients with COVID-19.

Endoscopic mucosal incision and muscle interruption (MIMI) for the treatment of Zenker's diverticulum.

BACKGROUND: In peroral endoscopic myotomy for Zenker's diverticulum (Z-POEM), the cricopharyngeus muscle is divided within a submucosal tunnel started in the hypopharynx. We aimed to evaluate the safety and preliminary outcomes in patients who underwent a modified version of the Z-POEM where the tunnel is made directly overlying the cricopharyngeus, the mucosal incision and muscular interruption (MIMI) approach, and to compare these with patients who underwent a non-tunneled flexible endoscopic approach. METHODS: All patients with ZD who were treated by flexible endoscopy at our institution between January 2015 and February 2020 were identified by a retrospective chart review. Dysphagia symptoms were assessed using a validated scoring system. RESULTS: Nineteen patients with ZD underwent MIMI (mean age 76.1 years, 68.1% male) and seven patients underwent non-tunneled flexible endoscopic approach (mean age 64.4 years, 85.7% male) during the study period. Mean ZD size was 2.8 cm in the MIMI group and 1.9 cm in the non-tunneled group (p = 0.03). Clinical success was achieved in 17/19(89.5%) MIMI patients and 7/7(100%) of non-tunneled flexible endoscopic patients (p = 0.101). Dysphagia scores improved in both groups, although this difference was only significant in the MIMI group (p ≤ 0.001). Recurrence occurred in 2/17(11.7%) MIMI patients and 3/7(42.9%) non-tunneled flexible endoscopic patients (p = 0.096). There were 4 complications, including one pharyngeal perforation requiring open surgical repair in a patient with a small ZD with an associated cricopharyngeal bar in the MIMI group. Median length of follow-up was 290 [142; 465] days in the MIMI group and 1056 [258; 1206] days in the non-tunneled group (p = 0.094). CONCLUSIONS: MIMI is a technically feasible and effective treatment for ZD. Care should be taken in patients with a cricopharyngeal bar and small ZD, as this may increase the risk of perforation. Larger studies with long-term follow-up are needed to determine if MIMI reduces the risk of symptom recurrence when compared to non-tunneled flexible endoscopic approaches.

A History of Flexible Gastrointestinal Endoscopy.

Surgeons have been involved, since the beginning, in the development and evolution of endoscopy. They have been instrumental in developing new methods and have been actively involved in most of the therapeutic applications. The continued evolution of endoscopic technique is inevitable and will involve the integration of new technology with innovative thinking.

Gastrectomy versus stomach left in situ with Roux-en-Y reconstruction for the treatment of gastroparesis.

BACKGROUND: Gastroparesis is a debilitating functional disorder of the stomach marked by delayed gastric emptying in the absence of mechanical obstruction. Patients with severe, refractory symptoms may ultimately be managed with Roux-en-Y reconstruction; however, it is unclear whether the stomach should be left in situ, similar to a conventional gastric bypass, or resected as in gastrectomy. METHODS: All patients undergoing Roux-en-Y for the treatment of gastroparesis (GP) at our institution from September 2010 through March 2018 were retrospectively reviewed. Patients with prior gastric resection or whose primary operative indication was not gastroparesis were excluded from analysis. RESULTS: Twenty-six patients underwent Roux-en-Y with stomach left in situ (RY-SIS) and twenty-seven patients underwent gastrectomy with Roux-en-Y reconstruction during the study period. The mean age was 49.7 years in the RY-SIS cohort and 48.5 years in the gastrectomy cohort. Etiology of GP was similar between the two cohorts. Patients undergoing gastrectomy were more likely to have previous interventions for GP (63.0% vs. 26.9%). RY-SIS was associated with a shorter operative time (155 vs. 223 min), less blood loss (24 vs. 130 mL), and shorter length of stay (4.0 vs. 7.2 days). Twelve patients (44.4%) had complications within 30 days following gastrectomy compared to two patients (7.7%) following RY-SIS (p = 0.001). Patients in the RY-SIS cohort were more likely to require further subsequent surgical intervention for GP (23.1% vs. 3.7%, p = 0.04). At last follow-up, there were no differences in reported GP symptoms or symptom scoring. CONCLUSIONS: Gastrectomy was associated with greater perioperative morbidity compared to leaving the stomach in situ. Symptomatic improvement at intermediate follow-up was equivalent following either procedure. However, patients undergoing RY-SIS were more likely to require subsequent surgical intervention, suggesting that gastrectomy may be a more definitive operation for the management of medically refractory gastroparesis.

Minimally invasive Roux-en-Y reconstruction as a salvage operation after failed nissen fundoplication.

BACKGROUND: Conversion of Nissen fundoplication to Roux-en-Y (RnY) anatomy may be indicated in patients with post-surgical complications or who fail to achieve durable control of their disease. Herein we describe the largest series of patients at a single institution who underwent minimally invasive conversion of Nissen fundoplication to RnY reconstruction. METHODS: All patients with prior Nissen fundoplication which were converted to RnY anatomy at our institution from March 2009 through November 2017 were retrospectively reviewed and analyzed. Patients were identified based on CPT codes and the description of the operation performed. All cases with attempted minimally invasive approach were included for analysis. RESULTS: Fifty patients underwent conversion from prior Nissen fundoplication to RnY anatomy during the study period. The cohort was 84.0% female with a mean age of 53.5 years and a median body mass index of 36.7 kg/m2. Thirteen patients (26.0%) had multiple prior foregut operations. Complications from fundoplication that warranted revision included recurrent hiatal hernia (n = 16), post-surgical gastroparesis (n = 10), and mechanical complications from the wrap (n = 8). An additional fourteen patients underwent conversion to RnY for metabolic disease. The mean operative time and estimated blood loss were 266 min and 132 mL, respectively, with all but one (98.0%) completed with a minimally invasive approach. The median length of stay was 5 days. Complications included marginal ulcer (n = 2), superficial surgical site infection (n = 2), anastomotic leak (n = 2), and one case each of pulmonary embolism, small bowel obstruction, and gastrointestinal bleeding. There were no mortalities at a median follow-up of 12.4 months. CONCLUSIONS: Conversion of prior Nissen fundoplication to RnY anatomy is technically challenging, although it is safe and feasible even in the setting of multiple prior foregut operations. A minimally invasive approach should be offered to patients by surgeons with experience in revisional foregut and bariatric surgery.

Enhanced recovery outcomes following per-oral pyloromyotomy (POP): a comparison of safety and cost with same-day discharge versus inpatient recovery.

BACKGROUND: While per-oral pyloromyotomy (POP) has shown promise as a novel endoscopic procedure to treat medically refractory gastroparesis, standardized care pathways are not well-defined. We aimed to compare the safety and cost of same-day discharge (SDD) after POP with inpatient stay overnight or longer. METHODS: All patients with SDD after POP between January 2016 and May 2018 were retrospectively identified from a prospectively maintained registry. Propensity scores considering gender, age, gastroparesis etiology, and American Society of Anesthesiologists (ASA) class were used to match a comparison group which stayed overnight or longer. Statistical tests included two-sample t tests for continuous variables, Fisher's exact test for categorical variables, and paired sample t tests for within-group comparisons with repeated measures. RESULTS: Fifty-four patients who underwent POP with SDD during the study period were propensity-matched with 54 patients with inpatient recovery. The SDD cohort was 85.2% female with a mean age of 44.8 years and median ASA class 3. The etiology of gastroparesis was idiopathic in 53.7% (n = 29), diabetic in 29.6% (n = 16), and post-surgical in 11.1% (n = 6). Operative time was shorter in the SDD cohort (25.4 vs. 31.3 min, p = 0.02). The mean post-procedure recovery time was 4 h in patients with SDD and 29.3 h in the inpatient cohort (p < 0.001). There was a trend towards less readmissions with SDD (7.4% vs. 18.5%, p = 0.08). There was no increased risk of complications with SDD (1.9% vs. 3.7%, p = 0.57). Compared to inpatient recovery, the average total cost for the procedure, recovery, and all subsequent care within 30 days was 26.0% less with SDD (p < 0.001). CONCLUSIONS: Following POP, patients can be safely discharged the same day with low risk of both complications and readmission. Total costs in the complete perioperative period are significantly less with SDD compared to inpatient recovery.

Conversion of one-anastomosis gastric bypass to Roux-en-Y gastric bypass: short-term results from a tertiary referral center.

BACKGROUND: One-anastomosis gastric bypass (OAGB), also known as minigastric bypass, is an increasingly popular bariatric surgery option worldwide. While OAGB offers advantage in terms of procedure time and technical ease, revisional operations to correct complications may be necessary. OBJECTIVES: We aimed to describe the indications and perioperative outcomes for OAGB conversions to Roux-en-Y gastric bypass (RYGB) at a single-referral center. SETTING: Academic hospital, Abu Dhabi, United Arab Emirates. METHODS: All patients undergoing conversion from OAGB to RYGB from February 2016 through September 2018 were retrospectively identified from a prospectively maintained database of revisional bariatric surgeries. RESULTS: Sixteen patients underwent conversion from previous OAGB to RYGB during the study period. The cohort was 62.5% female (n = 10) with a mean age of 40.2 years and median body mass index of 30.7 kg/m2. Indications for conversion included intractable nausea/vomiting (n = 8, 50.0%), biliary reflux (n = 3, 18.8%), weight recidivism (n = 3, 18.8%), and protein-calorie malnutrition (n = 2, 12.5%). Twelve cases (75.0%) were successfully completed with a laparoscopic approach, with 4 cases (25.0%) converted to open. The median length of stay was 5.5 days. Six patients (37.5%) experienced minor and major complications within 30 days of discharge. Fourteen patients (87.5%) were available for follow-up at 6 months, with 100% of these patients reporting resolution of their preoperative symptoms. There were no mortalities. CONCLUSIONS: Data from this largest reported single-center experience demonstrates that conversion of OAGB to RYGB is safe and technically feasible. Further studies and longer-term follow-up are needed to definitively describe outcomes after this revisional bariatric surgery.

Safety and Feasibility of Per-Oral Pyloromyotomy as Augmentative Therapy after Prior Gastric Electrical Stimulation for Gastroparesis.

BACKGROUND: For medically refractory diabetic or idiopathic gastroparesis, gastric electrical stimulation (GES) is an excellent option for symptom control; however, a small subset of patients may develop recurrent or persistent symptoms. Per-oral pyloromyotomy (POP, also described by some authors as gastric per-oral endoscopic myotomy or G-POEM) is an emerging therapy for medically refractory gastroparesis. This study investigated the safety and feasibility of POP after previous GES for recurrent or persistent gastroparesis. STUDY DESIGN: We retrospectively identified all patients undergoing POP between January 2016 and December 2017, with GES in situ. Patient characteristics, gastroparesis etiology, and procedural data were collected. Symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI) both before and 30 to 90 days after POP. Standard pre- and post-procedure 4-hour gastric emptying tests were obtained when available. RESULTS: There were 22 patients who met inclusion criteria (81.8% female, mean age 42.3 ± 12.4 years). Causes of gastroparesis were diabetes in 38.1%, and idiopathic in 61.9%. The average time since GES insertion was 3.45 years. Mean preoperative 4-hour gastric retention was 50.1%. Most POP procedures were performed in the operating room (90.9%), with mean operative time of 40 minutes and a 1.4-day length of stay. There were 4 readmissions within 30 days, but no POP-related complications. Overall, GCSI improved by an absolute reduction of 1.63 points (p = 0.002), with significant improvements in all sub-scores. Of 11 patients with post-procedural motility or emptying studies available, 7 were normal. CONCLUSIONS: Per-oral pyloromyotomy appears to be safe and feasible for patients with recurrent gastroparesis symptoms after GES. Both symptoms and motility significantly improved in the short-term. These data replicate similar data suggesting laparoscopic pyloroplasty as an effective augmentative therapy after GES, but may provide a less invasive option for patients.

Educational Targets to Reduce Medication Errors by General Surgery Residents.

OBJECTIVE: Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers. DESIGN: This study used a retrospective cohort design to review inpatient medication orders placed via a computerized physician order entry system by general surgery residents at a single academic medical center from July 2011 to February 2018. SETTING: A single large academic medical center located in the Midwest, United States. PARTICIPANTS: General surgery residents completing residency between July 2011 and February 2018 and their respective inpatient medication orders. RESULTS: Of 571,811 included medication orders placed by 169 unique general surgery residents, 4.2% (n = 24,177) triggered pharmacist intervention, and 11 (0.001%) resulted in significant near-miss events. Of orders requiring pharmacist intervention, most were either duplicate therapies (n = 8703, 36.1%) or errors in renal dosing (n = 7576, 31.3%). Error rates were higher within pharmaceutical classes ordered less frequently, with the notable exception of antimicrobials and anticoagulants, which accounted for 20.1% (n = 5280) and 13.5% (n = 3270) of all order errors, respectively. In a multivariable model, errors were more likely to occur in the intensive care unit versus other units (OR = 1.21, 95%CI = 1.14-1.29) and in August versus other months (OR = 1.09, 95%CI = 1.01-1.17), but were independent of other resident and order characteristics. CONCLUSIONS: This study identified that resident medication order errors are common and are associated with specific therapeutic classes, the beginning of academic years, and intensive care unit patients. These findings represent potential targets for educational interventions and highlight the role of interdisciplinary teams in providing quality surgical care.

Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis.

BACKGROUND: Post-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP. METHODS: Patients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded. RESULTS: During the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m2 and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging. CONCLUSION: POP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.

Gender and Letters of Recommendation: A Linguistic Comparison of the Impact of Gender on General Surgery Residency Applicants✰.

OBJECTIVE: We investigated letters of recommendation for general surgery residency applicants to determine if any gender-based disparities exist. DESIGN: A dictionary of over 400 terms describing applicants and 24 unique categories into which these terms were classified was created. Word count and language comparisons were performed using linguistic analysis software to assess for differences in applicant characterization, letter length, and writing style between male and female applicants and letter writers. SETTING: A large, Midwest, academic general surgery residency program. PARTICIPANTS: Five hundred and fifty-nine letters of recommendation received during the 2015 and 2016 interview cycles were selected for analysis. RESULTS: Average word count was approximately equal for male and female applicants (503 vs 508, respectively). Female writers wrote longer letters (mean word count 545.5 vs 497.1, p = 0.028). "Standout" terms were more likely to be used to describe female applicants. Otherwise no statistically significant differences in applicant characterization were discovered. CONCLUSIONS: Letters of recommendation for general surgery are written using similar descriptive terms and lengths for male and female applicants. This suggests that there is no specific gender disadvantage with regard to letters of recommendation when applying for general surgery residency.

Common bile duct dilation after bariatric surgery.

BACKGROUND: Biliary dilation suggests obstruction and prompts further work up. Our experience with endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in the symptomatic post-bariatric surgery population revealed many patients with radiographically dilated bile ducts, but endoscopically normal studies. It is unclear if this finding is phenomenological or an effect of surgery. Additionally, it is unknown whether the type of bariatric surgery alters biliary pathophysiology. Thus, we studied whether a change occurs in biliary diameter following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). METHODS: A single-center retrospective study assessing biliary diameter before and after RYGB or SG based on radiographic imaging. All adult patients undergoing RYGB or SG from January 2010 to December 2013 who had imaging studies before and > 3 months after surgery were included. Those with known obstructive etiologies and those without post-operative imaging were excluded. Common bile duct (CBD) diameter was re-read by a radiologist at the same location in the CBD for pre- and post-operative imaging. Baseline clinical factors and cholecystectomy status were collected. RESULTS: 269 patients met inclusion criteria (193 RYGB;76 SG). Between the groups, there were no significant differences in pre-operative characteristics. Average time from surgery to repeat imaging was 24.1 months. After adjusting for pre-operative factors, subjects who underwent an RYGB had an increase in CBD diameter of 1.4 mm (95% CI 0.096, 0.18), which was greater than the change following SG 0.5 mm(95% CI - 0.007, 0.11). The magnitude of this change did not depend on prior cholecystectomy in the RYGB cohort. Within the SG group, for patients without a prior cholecystectomy, there was a significant increase in post-operative CBD diameter of 0.8 mm(95% CI 0.02, 0.14). CONCLUSION: Bariatric surgery results in CBD dilation, with changes more pronounced after RYGB. Biliary dilation occurs irrespective of cholecystectomy status. Further work is necessary to determine the cause and clinical implications of this phenomenon.

Hernia repair in patients with chronic liver disease - A 15-year single-center experience.

BACKGROUND: Elective hernia repairs in chronic liver disease (CLD) patients are often avoided due to the fear of hepatic decompensation and mortality, leaving the patient susceptible to an emergent presentation. METHODS: CLD patients undergoing ventral or inguinal hernia repair in emergent and non-emergent settings at our institution (2001-2015) were analyzed. Predictors of 30-day morbidity and mortality (M&M) were determined using univariate analysis and multivariate logistic regression. RESULTS: A total of 186 non-emergent repairs identified acceptable rates of M&M (27%) and 90-day mortality (3.7%, 0/21 for MELD≥15). Meanwhile, 67 emergent repairs had higher rates of M&M (60%) and 90-day mortality (10%; 25% for MELD≥15). M&M was associated with elevated MELD scores in emergent cases (14 ±â€¯6 vs 11 ±â€¯4; p = 0.01) and intraoperative drain placement in non-emergent cases (OR1.31,p < 0.01). CONCLUSION: In patients with advanced CLD, non-emergent hernia repairs carry acceptable rates of M&M, while emergent repairs have increased M&M rates associated with higher MELD scores.

Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis.

BACKGROUND: Gastroparesis is a debilitating functional disorder of the stomach characterized by delayed gastric emptying absent an obstructive etiology. Surgical or endoscopic disruption of the pylorus has been utilized to treat this disease, but there is little evidence comparing laparoscopic pyloroplasty (LP) with endoscopic per-oral pyloromyotomy (POP). Herein we describe our experience at our institution using a propensity-matched cohort study to compare outcomes between these procedures. METHODS: All patients who underwent LP for the treatment of gastroparesis from October 2014 through September 2017 at our institution were retrospectively reviewed. Propensity scoring was used to match these patients 1:1 to patients undergoing POP during this time period based on gender, age, and etiology of gastroparesis. Symptom scores using the Gastroparesis Cardinal Symptom Index (GCSI), scintigraphic gastric emptying studies (GES), and perioperative outcomes were compared between matched cohorts. Thirty patients underwent LP for gastroparesis during the study period which were matched 1:1 with patients undergoing POP. The etiology of gastroparesis was 63.3% idiopathic (n = 19), 20.0% post-surgical (n = 6), and 16.7% diabetic (n = 5) in both cohorts. RESULTS: Patients who underwent LP had a longer average length of stay (4.6 vs. 1.4 days, p = 0.003), operative time (99.3 vs. 33.9 min, p < 0.001), and estimated blood loss (12.9 vs. 0.4 mL, p < 0.001). There were more complications in the LP cohort (16.7 vs. 3.3%, p = 0.086), which included surgical site infection (6.7 vs. 0%, p = 0.153), pneumonia (6.7 vs. 0.0%, p = 0.153), and unplanned ICU admission (10.0 vs. 0.0%, p = 0.078). LP and POP both resulted in similar, significant improvements in both in GCSI scores and objective gastric emptying. CONCLUSIONS: Per-oral endoscopic pyloromyotomy (POP) is safe and effective for the treatment of medical refractory gastroparesis. POP has less perioperative morbidity compared to LP with comparative functional outcomes.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass.

INTRODUCTION: A subset of patients undergoing laparoscopic sleeve gastrectomy (SG) require eventual conversion to Roux-en-Y gastric bypass (RYGB) due to complications from SG or to enhance weight loss. The aim of this study is to characterize the indications for conversion and perioperative outcomes in a large cohort of these patients at a single institution. METHODS: Patients who underwent revisional surgery to convert SG to RYGB at our institution from January 2008 through January 2017 were retrospectively reviewed. RESULTS: Eighty-nine patients with previous SG underwent conversion to RYGB as part of a planned two-stage approach to gastric bypass (n = 36), for weight recidivism (n = 11), or for complications related to SG (n = 42). Complications from SG that warranted conversion included refractory GERD (40.5%), sleeve stenosis (31.0%), gastrocutaneous (16.7%), or gastropleural (7.1%) fistula, and gastric torsion (4.1%). The mean (SD) age was 47.2 years (11.4 years) and median BMI at the time of revision was 43.2 kg/m2. A laparoscopic approach was successfully completed in 76 patients (85.4%), with an additional of four completed robotically (4.5%). The median length of stay was 3 days. Twenty-eight patients (31.5%) had complications which included surgical site infection (20.2%), re-operation (6.7%), anastomotic stricture (3.4%), and one pulmonary embolism. There were no mortalities with a median follow-up of 15 months. CONCLUSIONS: Conversion of SG to RYGB is safe and technically feasible when performed for complications of SG or to enhance weight loss. This operation can be successfully performed laparoscopically with a low rate of conversion and reasonable complication profile.