The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on revisional bariatrics.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program designated bariatric surgery as a clinical pathway. Among the tiers of the Masters Program, revisional bariatric surgery is the highest tier of "mastery" within the pathway. This article presents the top 10 seminal studies representing the current landscape of revisional bariatrics. METHODS: The literature was systematically searched and seminal articles designated by consensus agreement of the SAGES Metabolic and Bariatric Surgery committee using multiple criteria, including impact on the field, citation frequency, and expert opinion. Articles were reviewed by committee members and presented in summarized fashion. RESULTS: The top 10 papers are presented in grouped thematic categories covering the early evolution of revisional bariatrics, changing criteria for reoperative bariatric surgery, divergence of revision versus conversion bariatric surgery, and recent technologic innovations in revisional bariatric surgery. Each summary is presented with expert appraisal and commentary. CONCLUSION: These seminal papers represent a snapshot of the dynamic field of revisional bariatric surgery and emphasize the need to not only remain current with contemporary trends but also keep a patient-oriented perspective on patient and intervention selection for optimal success.

Collaborative Approach Toward Transplant Candidacy for Obese Patients with End-Stage Renal Disease.

BACKGROUND: An elevated BMI is a major cause of transplant preclusion for patients with end-stage renal disease (ESRD). This phenomenon exacerbates existing socioeconomic and racial disparities and increases the economic burden of maintaining patients on dialysis. Metabolic bariatric surgery (MBS) in such patients is not widely available. Our center created a collaborative program to undergo weight loss surgery before obtaining a kidney transplant. STUDY DESIGN: We studied the outcomes of these patients after MBS and transplant surgery. One hundred eighty-three patients with ESRD were referred to the bariatric team by the transplant team between January 2019 and June 2023. Of these, 36 patients underwent MBS (20 underwent Roux-en-Y gastric bypass and 16 underwent sleeve gastrectomy), and 10 underwent subsequent transplantation, with another 15 currently waitlisted. Both surgical teams shared resources, including dieticians, social workers, and a common database, for easy transition between teams. RESULTS: The mean starting BMI for all referrals was 46.4 kg/m 2 and was 33.9 kg/m 2 at the time of transplant. The average number of hypertension medications decreased from 2 (range 2 to 4) presurgery to 1 (range 1 to 3) postsurgery. Similarly, hemoglobin A1C levels improved, with preoperative averages at 6.2 (range 5.4 to 7.6) and postoperative levels at 5.2 (range 4.6 to 5.8) All transplants are currently functioning, with a median creatinine of 1.5 (1.2 to 1.6) mg/dL (glomerular filtration rate 46 [36.3 to 71]). CONCLUSIONS: A collaborative approach between bariatric and transplant surgery teams offers a pathway toward transplant for obese ESRD patients and potentially alleviates existing healthcare disparities. ESRD patients who undergo MBS have unique complications to be aware of. The improvement in comorbidities may lead to superior posttransplant outcomes.

Comparative analysis of sleeve conversions of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2020 Database.

BACKGROUND: Although the sleeve gastrectomy (SG) is the dominant bariatric procedure, studies have shown conversion rates of up to 30%. These conversions are generally for weight regain (WR), insufficient weight loss (IWL) or gastroesophageal reflux disease (GERD). Before 2020, details on why conversions were being performed were not collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF). Now, the indication for sleeve conversion is noted in the PUF, allowing identification and reporting sleeve conversion reasons. OBJECTIVE: We aimed to examine the reasons for SG conversions nationwide. SETTING: The 2020 MBSAQIP PUF. METHODS: The 2020 MBSAQIP PUF was examined to determine the reasons why SG were converted to other operations. The data field of "Revision/Conversion Final Indication" was used along with "Procedure type." Primary bariatric operations were excluded. Descriptive statistics were applied. Different reasons for conversion and operations were compared by preoperative characteristics and operative outcomes. RESULTS: There were 103,782 primary SG reported in the 2020 PUF. There were 7181 SG that were converted to other operations. The most common conversion (86.2%) was to Roux-en-Y gastric bypass (RYGB). The main reason for SG conversion was GERD at 48.4%, followed by WR/IWL (41.9%). Biliopancreatic diversion with duodenal switch and single-anastomosis duodenoileal bypass with sleeve patients differed significantly from RYGB patients in specific preoperative characteristics and operative outcomes. CONCLUSION: The most common procedure SG is converted to is the RYGB. GERD was the most common reason for SG conversion, followed by WR/IWL.

A cognitive task analysis of expert surgeons performing the robotic roux-en-y gastric bypass.

BACKGROUND: The safe and effective performance of a robotic roux-en-y gastric bypass (RRNY) requires the application of a complex body of knowledge and skills. This qualitative study aims to: (1) define the tasks, subtasks, decision points, and pitfalls in a RRNY; (2) create a framework upon which training and objective evaluation of a RRNY can be based. METHODS: Hierarchical and cognitive task analyses for a RRNY were performed using semi-structured interviews of expert bariatric surgeons to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed verbatim, supplemented with literary and video resources, coded, and thematically analyzed. RESULTS: A conceptual framework was synthesized based on three book chapters, three articles, eight online videos, nine field observations, and interviews of four subject matter experts (SME). At the time of the interview, SME had practiced a median of 12.5 years and had completed a median of 424 RRNY cases. They estimated the number of RRNY to achieve competence and expertise were 25 cases and 237.5 cases, respectively. After four rounds of inductive analysis, 83 subtasks, 75 potential errors, 60 technical tips, and 15 decision points were identified and categorized into eight major procedural steps (pre-procedure preparation, abdominal entry & port placement, gastric pouch creation, omega loop creation, gastrojejunal anastomosis, jejunojejunal anastomosis, closure of mesenteric defects, leak test & port closure). Nine cognitive behaviors were elucidated (respect for patient-specific factors, tactical modification, adherence to core surgical principles, task completion, judicious technique & instrument selection, visuospatial awareness, team-based communication, anticipation & forward planning, finessed tissue handling). CONCLUSION: This study defines the key elements that formed the basis of a conceptual framework used by expert bariatric surgeons to perform the RRNY safely and effectively. This framework has the potential to serve as foundational tool for training novices.

GERD-screening before bariatric surgery: the predictive value of the GERD-HRQL questionnaire score compared with preoperative EGD findings.

BACKGROUND: There is an ongoing debate on how to best identify patients with gastroesophageal reflux disease (GERD) before bariatric surgery. The value of routine preoperative esophagogastroduodenoscopy (EGD) is questioned, and patient reported symptoms are commonly used for screening. The goal of this study is to determine if patient reported symptoms using a validated questionnaire correlate with preoperative EGD findings. METHODOLOGY: A prospective cohort study at a single institution was performed. Patients undergoing bariatric surgery between December 2020 and March 2023 were required to report symptoms of reflux by completing a preoperative GERD. Health-Related Quality of Life (GERD-HRQL) questionnaire and undergo a mandatory preoperative screening EGD. Patients were stratified into two cohorts: (group A) asymptomatic (score = 0) and (group B) symptomatic (score > 0). Statistical analysis was conducted using Pearson's chi-squared test and Wilcoxon rank-sum test in RStudio version 4.2.2. The predictive value of the GERD-HRQL score was analyzed using Areas Under the Curve (AUC; AUC = 0.5 not predictive, 0.5 < AUC ≥ 6 poor prediction & AUC > 0.9 excellent prediction) calculated from Receiver Operating Characteristic (ROC) curves. RESULTS: 200 patients were included; median age was 42.0 years (IQR 36.0 to 49.2). There were 79 patients (39.5%) in Group A and 121 patients (60.5%) in Group B. There was no difference in the frequency esophagitis (27.8% vs 32.2%, p = 0.61) or hiatal hernias (49.4% vs 47.1%, p = 0. 867) between group A and group B, respectively. ROC analysis revealed that the total GERD HRQL scores, heartburn only scores and regurgitation only scores, were poor predictors of esophagitis found on EGD (AUC 0.52, 0.53, 0.52), respectively. In asymptomatic patients, higher BMI was significantly associated with esophagitis (OR 1.15, 95% CI 1.06-1.27, p = 0.002). CONCLUSION: Symptoms, identified through the GERD-HRQL questionnaire, are a poor indicator of esophagitis or its severity in patients undergoing workup for bariatric surgery. Therefore, liberal screening upper endoscopy is recommended for pre-bariatric surgery patients to guide appropriate procedure selection.

Feasibility and Outcomes of Simultaneous Gastric Bypass with Paraesophageal Hernia Repair in Elderly Patients.

BACKGROUND: Paraesophageal hernias (PEH) have a higher incidence in patients with obesity. Roux-en-Y gastric bypass (RYGB) with concomitant PEH repair is established as a valid surgical option for PEH management in patients with obesity. The safety and feasibility of this approach in the elderly population are not well elucidated. METHODS: We performed a multicenter retrospective cohort study of patients aged 65 years and older who underwent simultaneous PEH repair and RYGB from 2008 to 2022. Patient demographics, hernia characteristics, postoperative complications, and weight loss data were collected. Obesity-related medical conditions' resolution rates were evaluated at the last follow-up. A matched paired t-test and Pearson's test were used to assess continuous and categorical parameters, respectively. RESULTS: A total of 40 patients (82.5% female; age, 69.2 ± 3.6 years; BMI, 39.4 ± 4.7 kg/m2) with a mean follow-up of 32.3 months were included. The average hernia size was 5.8 cm. Most cases did not require mesh use during surgery (92.5%) with only 3 (7.5%) hernial recurrences. Postoperative complications (17.5%) and mortality rates (2.5%), as well as readmission (2.5%), reoperation (2.5%), and reintervention (0%) rates at 30-day follow-up were reported. There was a statistically significant resolution in gastroesophageal reflux disease (p < 0.001), hypertension (p = 0.019), and sleep apnea (p = 0.014). CONCLUSIONS: The safety and effectiveness of simultaneous PEH repair and RYGB are adequate for the elderly population. Patient selection is crucial to reduce postoperative complications. Further studies with larger cohorts are needed to fully assess the impact of this surgery on elderly patients with obesity.

Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD.

INTRODUCTION: Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. METHODS: A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups. RESULTS: 187 surgeons completed the survey. 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35 kg/m2 and 30 kg/m2 respectively as cutoff for the RYGB. 89% viewed RYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary to failed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGB for GERD indications in their patient populations. CONCLUSION: For many patients, GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.

Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database.

BACKGROUND: Vertical sleeve gastrectomy (VSG) has demonstrated to be safe; however, controversy remains on how to decrease major complications, particularly bleeding and leaks. There are variations in staple-line reinforcement techniques, including no reinforcement, oversewing, and buttressing. We sought to evaluate the effect of those methods on post-operative complications using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSAQIP) database. METHODS: The MBSAQIP was queried for patients who underwent VSG during 2015-2019. A propensity-matched analysis was performed between different staple-line reinforcement (SLR) methods, specifically No reinforcement (NR), Oversewing (OS), and Buttressing (BR). The primary outcome of interest was complications within 30 days. RESULTS: A total of 513,354 VSG cases were analyzed. The cohort was majority female (79.0%), with mean (SD) age of 44.2 ± 11.9 years and mean BMI of 45 ± 7.8 kg/m2. Frequency of SLR methods used was 54%BR, 25.6%NR, 10.8% BR + OS, and 9.8%OS. There were no differences in rate of leaks among SLR methods. Compared to NR, BR was associated with decreased rate of reoperations, overall bleeding, and major bleeding (p < 0.05) but prolonged operative time and length of stay (LOS) (p < 0.05). OS was associated with decreased overall bleeding (p < 0.05) but prolonged operative times and length of stay (p < 0.05) compared to NR. Compared to BR, OS was associated with increased operative times, LOS, and rates of post-operative ventilator use, pneumonia, and venous thrombosis (p < 0.05). Patients with bleeding were associated with lower rate of BR (56% vs 61%) and higher rate of NR (34% vs 28%) compared to patients with no bleeding. Bleeding was associated with a greater frequency of leaks (4.4% vs 0.3%), along with higher morbidity and mortality (p < 0.05). CONCLUSIONS: Of the reinforcement methods evaluated, BR and OS were both associated with decreased bleeding despite longer operative times. No method was found to significantly reduce incidence of leaks; however, bleeding was associated with increased incidence of leaks, morbidity, and mortality. The liberal use of SLR techniques is recommended for further optimization of patient outcomes after VSG.

A 5-year propensity-matched analysis of perioperative outcomes in patients with chronic kidney disease undergoing bariatric surgery.

BACKGROUND: Bariatric surgery can improve renal function in patients with comorbid chronic kidney disease (CKD) and obesity. Additionally, bariatric surgery can enhance outcomes following renal transplantation. The safety of bariatric surgery in patients with CKD has been debated in the literature. This study evaluates the frequency of perioperative complications associated with CKD. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried from 2015-2019. Patients were included if they had a vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) and were stratified based on CKD status. An unmatched and propensity-matched analysis was performed comparing 30-day perioperative outcomes between the groups. RESULTS: A total of 717,809 patients included in this study, 5817(0.8%) had CKD, of whom 2266(0.3%) were on dialysis. 74.3% of patients with CKD underwent VSG with 25.7% underwent RYGB. Comparing RYGB to VSG, patients who underwent RYGB had a higher rate of deep organ space infection (0.7%vs.0.1%,p = 0.021) and re-intervention (5.0% vs. 2.2%,p < 0.001). Within the VSG cohort, a matched analysis was performed for those with CKD and without CKD. The CKD cohort had higher risk of complications such as bleeding (2.1%vs. 0.9%,p < 0.001), readmission (9.3%vs.4.9%,p < 0.001), reoperation (2.7%vs.1.3%,p < 0.001), and need for reintervention (2.2%vs.1.3%,p < 0.001). Notably, patients with CKD also had a higher mortality (0.6%vs.0.2%,p = 0.003). No difference was seen between patients with renal insufficiency and patients on dialysis. CONCLUSION: VSG has been the operation of choice in patients with CKD. Our results showed it is the safer option for patients with CKD compared to RYGB. Although this patient population does have an increased risk of adverse perioperative events, dialysis didn't affect the outcome. Bariatric surgeons who operate on patients with CKD should be well informed and remain vigilant given the increased perioperative risk. The risk is still considerably low, and the potential benefit on renal function and improvement in candidacy for renal transplant outweigh the risk. They should be considered as surgical candidates.

Single Versus Double Anastomosis Duodenal Switch in the Management of Obesity: A Meta-analysis and Systematic Review.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective yet technically challenging bariatric surgery with many complications. Alternatively, single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) was recently introduced as a simplified bariatric procedure. This meta-analysis aimed to assess the safety and efficacy of SADI-S compared with BPD-DS in the management of patients with obesity. METHODS: Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to May 2022 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022333521). RESULTS: From 123 studies screened, 6 studies met the eligibility criteria, with a total of 1847 patients with obesity undergoing either SADI-S (n=818) or BPD-DS (n=1029). Preoperative body mass index was similar between the 2 groups, and the BPD-DS group had a greater % excess body mass index loss (EBMIL) (MD=-10.16%, 95% confidence interval: -11.80, -8.51, I 2 =0%) at 2 years compared with the SADI-S group. There was no difference observed in preoperative comorbidities and remission, including diabetes, hypertension, and dyslipidemia between SADI-S and BPD-DS cohorts. Compared with BPD-DS, SADI-S had shorter hospital stays (MD=-1.36 d, 95% CI: -2.39, -0.33, I 2 =86%), and fewer long-term (>30 d) complications (OR=0.56, 95% CI: 0.42, 0.74, I 2 =20%). Conversely, among nutritional deficiency outcomes, the SADI-S group had few patients with abnormal vitamin D (OR=0.51, 95% CI: 0.36, 0.72, I 2 =0%) values than the BPD-DS group. CONCLUSIONS: SADI-S has shown to be a possible alternative treatment option to BPD-DS in managing patients with obesity. Despite the promising results, further randomized controlled studies with more extended follow-up periods are necessary to ascertain the safety and efficacy of the treatment.

Tulane STAR (Sending Texts, Advancing Results): impact of text messaging on bariatric post-operative protocol compliance.

BACKGROUND: Text messaging is frequently employed in the outpatient setting to communicate with or send reminders to patients. However, there is a paucity of literature on the impact of text messaging on inpatient care. In this study, the use of text messaging in hospitalized patients is evaluated by assessing patient compliance to a post-operative bariatric protocol. METHODS: This was a randomized controlled trial that studied compliance to a post-operative bariatric protocol in patients who underwent bariatric surgery at a tertiary, academic medical center between February and May 2021. Patients were randomized to either the control group, in which they received standard post-operative education alone or the Tulane Sending Texts, Advancing Results (STAR) intervention arm, in which participants received the same post-operative education along with two text message reminders to drink water, use their incentive spirometers, and ambulate (per post-operative instructions) on post-operative day (POD) # 0 and POD # 1. The primary outcome was compliance with the protocol, defined as the number of 1-oz cups of water consumed, incentive spirometry usage, and ambulation frequency and distance. Secondary outcomes include length of stay and complications. RESULTS: A total of 35 patients were enrolled in the study (17 control, 18 STAR intervention). There was no significant difference in age, BMI, or type of surgery performed between the two groups. Clear liquid consumption was significantly higher in the STAR intervention group with an average of 27.7 ± 3.5 cups as compared to 18.2 ± 8.9 in the control group (p < 0.001). Similarly, statistically significant increases in incentive spirometry usage (p < 0.01) and ambulation distance and frequency (p < 0.02) were observed in the STAR intervention group. CONCLUSIONS: While patients are in the hospital, text messaging can improve compliance to post-operative protocols. Peri-operative text messaging can enhance patient education and communication.

Bile Reflux After Single Anastomosis Duodenal-Ileal Bypass with Sleeve (SADI-S): a Meta-analysis of 2,029 Patients.

BACKGROUND: Single anastomosis duodenal-ileal bypass with sleeve (SADI-S) is a novel bariatric surgery modified from the classic biliopancreatic diversion with duodenal switch (BPD-DS). These surgical modifications address most BPD-DS hurdles, but the risk of bile reflux may hinder SADI-S acceptance. We aimed to evaluate the event rate of bile reflux after SADI-S. METHODS: PubMed, ScienceDirect, Cochrane, Web of Science, and Google Scholar were used to search English articles between 2008 and 2021 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The risk of bias was assessed using Newcastle-Ottawa Scale and the JBI tool. Event rates were meta-analyzed using Comprehensive Meta-Analysis (CME) V3. RESULTS: Out of 3,027 studies analyzed, seven were included. Studies were published between 2010 and 2020. Six out of 7 studies were retrospective. Three studies had a low risk of bias, three studies had a moderate risk of bias, and one had a high risk of bias. The mean follow-up was 10.3 months. The total number of patients was 2,029, with 25 reports of bile reflux, resulting in an incidence of 1.23%, with an event rate of 0.016 (95% CI 0.004 to 0.055). CONCLUSIONS: Bile reflux has not been demonstrated to be problematic after SADI-S in this meta-analysis. Further long-term studies are needed.

The impact of intensive laparoscopic training course with structured assessment and immediate feedback on residents' operative performance in animal lab.

INTRODUCTION: The objective of this study was to examine the impact of an intensive laparoscopic training course incorporating structured assessment and immediate feedback on residents' operative performance in animal lab. METHODS: Surgical residents participated in a 2-day intensive laparoscopic training course. They performed the same procedures on two consecutive days on live pigs. Junior residents (PGY1-2) performed laparoscopic cholecystectomy and incisional hernia repair and the senior residents (PGY3-5) performed laparoscopic Nissen fundoplication, splenectomy, and low anterior colon resection. Assessment tools with proven validity evidence (global and procedure-specific rating tools for operative assessment of laparoscopic skills) were used to assess their operative performance. Faculty assessment and self-assessments were completed immediately after each procedure on both days. The Wilcoxon rank test was used to examine the effect of training on resident performance after one repetition. RESULTS: Forty surgical residents (20 junior and 20 senior residents) participated. There was a significant improvement in general laparoscopic skills during incisional hernia repair and Nissen fundoplication using global rating scales (p < 0.05). Moreover, there was an improvement in their performance during cholecystectomy, incisional hernia repair, and low anterior colectomy when procedure-specific skills assessments were used (p < 0.05). There was a positive correlation between residents' self-reported confidences and their operative performance CONCLUSION: Trainees showed significant improvements in performance in general and procedure-specific laparoscopic skills in a wide range of procedures after an intensive training course. This study demonstrates the benefit of a structured training curriculum in improving operative performance in basic and advanced laparoscopic skills in a simulated environment. Future studies are needed to examine the duration of training required to achieve skill retention and competency.

The Impact of Navigation Grid Overlay on Performance of Camera Assistants during Laparoscopic Abdominal Procedures: A Randomized Controlled Trial.

OBJECTIVE: Camera assistance is important for proper visualization of the operative field in laparoscopic surgery. Navigation grid (NG) has been designed to help the camera assistants focus the camera on the target operative field. This is a randomized, controlled trial to study the effect of the NG on performance of camera assistants. DESIGN: Minimally invasive operations were randomized (1:1) to either with or without use of NG for the camera assistant. The operations were recorded and the time spent inside and outside of the target area were reported. SETTING: A tertiary care teaching hospital. RESULTS: Fifty-eight operations (30 with and 28 without NG) were recorded. Sixteen camera assistants participated. Time spent outside the target area was significantly less with the use of NG (64.5 ± 63 seconds vs 396 ± 226.5 seconds; p < 0.0001). This impact of NG on performance of the camera assistants was significant regardless of their level of training. CONCLUSIONS: NG improved performance of the camera assistant during laparoscopic abdominal procedures. This is a feasible tool that can help camera holders better assist the operating surgeons.

Obesity and the prevention of thyroid cancer: Impact of body mass index and weight change on developing thyroid cancer - Pooled results of 24 million cohorts.

BACKGROUND: Body weight may be a modifiable risk factor predisposing to different cancers. To establish a potential impact of weight change on thyroid cancer risk, we conducted a meta-analysis to evaluate the effect of body mass index (BMI) and weight change over time as a risk of developing thyroid cancer (TC). METHODS: A systematic search was performed up to February 25, 2020. Pooled relative risk (RR) were estimated using fixed and random models. Heterogeneity between articles was examined using Q-test and I2 index. Evaluation of publication bias was conducted with Egger's regression test. RESULTS: A total of 31 studies including 24,489,477 cohorts were eligible. Pooled analysis revealed that normal and underweight cohorts were associated with a decreased risk of TC (RR = 0.68, 95%CI = 0.65-0.71, p < 0.001) and (RR = 0.92, 95%CI = 0.91-0.93, p < 0.001), respectively. In contrast, overweight and obese cohorts were more likely to develop TC (RR = 1.26, 95%CI = 1.24-1.28, p < 0.001 and RR = 1.50, 95%CI = 1.45-1.55, p < 0.001, respectively). Obesity was associated with higher risk of developing TC among women (RR = 1.29, 95%CI = 1.14-1.46, p < 0.001), but not men (RR = 1.25, 95%CI = 0.97-1.62, p = 0.08). Furthermore, weight gain increased the risk of developing TC (RR = 1.18, 95%CI = 1.14-1.22, p < 0.001), while weight loss decreased the risk (RR = 0.89, 95%CI = 0.85-0.93, p < 0.001). Results showed similar trends of weight change effect in both males and females. CONCLUSIONS: Obesity is associated with higher risk of developing TC in women. However, maintaining a healthy weight is associated with reduced risk of TC in both women and men. Shifting our practice to include weight control strategies will help lead to cancer prevention.

Preoperative Endoscopic and Radiologic Evaluation of Bariatric Patients: What Do They Add?

BACKGROUND: Preoperative esophagogastroduodenoscopy (EGD) and barium swallow (BS) are commonly performed for evaluation in bariatric surgery patients. The routine use of these modalities has been controversial. METHODS: A retrospective review of a prospectively maintained database was performed to include primary bariatric surgery patients between March 2013 and August 2016. RESULTS: Two hundred nine patients were included. All the patients underwent preoperative EGD and BS. The mean age was 43.12 years and BMI 46.4 kg/m2. Reflux symptoms were present in 58.5% of patients. Preoperative EGD revealed abnormalities in 87.5% of patients: esophagitis (54.5%), Barrett's esophagus (5.3%), dysplasia (1%), and gastritis (51%). Endoscopic evidence of HH was documented in 52.2% of patients while only 34% of patients had evidence of HH in their BS. Of the asymptomatic patients, 80.2% had abnormal EGD. Helicobacter pylori on biopsy was found in 17.2% patients, out of which 47.2% were asymptomatic. Based on EGD findings, the choice of surgical procedure was changed in 3.34% of patients. Repair of HH was performed in 107 patients, with 68.2% (n = 73) symptomatic patients and 31.8% (n = 34) asymptomatic patients. On ROC analysis, EGD was better predictive of the presence of HH (AUC = 0.802, OR 5.20, p  =   < 0.0001) and symptoms were a poor indicator for GERD. CONCLUSIONS: Preoperative EGD is abnormal in the majority of patients regardless of their symptoms. EGD is the only modality that can provide tissue sample, which can potentially determine the type of bariatric surgery. Given the low diagnostic accuracy of BS, its routine use can be eliminated.

Enhanced Recovery in Bariatric Surgery: A Study of Short-Term Outcomes and Compliance.

INTRODUCTION: The implementation of Enhanced Recovery After Surgery (ERAS) guidelines has been widely studied among various surgical specialties. We aimed at comparing the perioperative outcomes and compliance with ERAS protocol in bariatric surgery at our center. METHODS: An observational review of a prospectively maintained database was performed. Patients who underwent primary bariatric surgery (gastric bypass or sleeve gastrectomy) between January 2011 and June 2018 were included. Patients were divided into pre- and post-ERAS groups. Data including basic demographic information, length of hospital stay, 30-day perioperative complications, and readmission rates were collected. Compliance with elements of ERAS was assessed using a combination of chart review and a prospectively implemented checklist. P < 0.05 was chosen to be statistically significant. RESULTS: A total of 435 patients were included: 239 patients in the pre-ERAS group and 196 patients in the post-ERAS group. There were no statistical differences in baseline demographics and major comorbidities between the 2 groups. The post-ERAS group had shorter length of hospital stay (2.23 vs 1.23, p < 0.001) and lower rates of 30-day postoperative morbidity (8.7 vs 4%, p = .04). There was no significant difference between the 2 groups with respect to readmissions rates. There was no mortality in either group. Overall compliance rates with ERAS elements were 85%; compliance increased significantly with the implementation of a checklist (p < 0.001). CONCLUSIONS: Implementation of ERAS program for bariatric surgery is safe and feasible. It reduces hospital stay and postoperative morbidity. Easy to implement strategies such as checklists should be encouraged in bariatric programs to aid in implementation and compliance with ERAS elements for perioperative care.

Metabolic Surgery as a Treatment Option for Type 2 Diabetes Mellitus: Surgical View.

PURPOSE OF REVIEW: Type 2 diabetes mellitus (T2DM) is increasing in prevalence and associated with numerous metabolic complications leading to increased mortality and costs. Metabolic surgery, or surgery to treat T2DM and obesity, is effective at achieving remission from T2DM. This review discusses the most commonly used surgical options including the adjustable gastric band, the Roux-en-Y gastric bypass, the sleeve gastrectomy, and the biliopancreatic diversion with duodenal switch and their ability to treat and prevent T2DM. RECENT FINDINGS: There is an increasing body of literature that justifies the inclusion of metabolic surgery into the treatment algorithm for patients with obesity and T2DM. Metabolic procedures should be performed at centers that offer comprehensive treatment of metabolic disorders and have expertise in gastrointestinal surgery. The incremental improvement in the quality and safety of metabolic surgery has significantly reduced the risk of serious post-operative complications. Metabolic surgery is a safe and effective treatment option for obese patients with T2DM.

Faculty feedback versus residents' self-assessment of operative performance: Different but complementary.

BACKGROUND: Surgical training requires development of both technical and cognitive skills. The study analyzed feedback by faculty and residents' self-assessments during a laparoscopic training course to identify structure of feedback in this context and compared the focus of trainees to faculty. METHODS: This study collected assessments by surgical residents and faculty during an intensive laparoscopic training course at a single institution. The residents' operative performance was assessed using validated assessment tools including free text feedback. Assessments were completed immediately following procedures. Feedback was analyzed using qualitative method. RESULTS: Eighty (80) residents participated. Three themes were identified: Assessment, instruction and occasion. Faculty provided significantly more feedback than trainees. Moreover, the content of feedback was different. Residents focused on technical performance, while faculty commented on technical and cognitive skills, efficiency and level of independence. Errors were mainly addressed by faculty. CONCLUSION: This study demonstrated differences in cognitive focus of trainees and faculty. Text feedback is informative in understanding perceived challenges. Faculty provided explicit assessment and instruction for improvement. The effectiveness of self-assessment and feedback should be further studied.

Robotic-Assisted Simultaneous Repair of Paraesophageal Hernia and Morgagni Hernia: Technical Report.

Morgagni hernias are a rare form of congenital diaphragmatic hernia, accounting for 2%-3% of cases. The presence of a simultaneous Morgagni hernia and paraesophageal hernia (PEH) is even more rare, with only a few reported cases in the surgical literature. Both open and laparoscopic surgical approaches have been previously described. Herein we discuss a robotic-assisted surgical approach to the repair of simultaneous Morgagni hernia and PEH in a 65-year-old woman. Simultaneous repair of Morgagni hernia and PEH is indicated mainly when symptoms are generally indistinctive. The use of robotic technology allowed for both hernias to be repaired both primarily and with mesh reinforcement.