3D printed cannulas for use in laparoscopic surgery in feline patients: A cadaveric study and case series.

OBJECTIVE: To evaluate custom 3D printed laparoscopic cannulas (3DPC) in a feline cadaveric abdominal surgery model and report their use in two live feline subjects. STUDY DESIGN: Experimental cadaver study, live subject case series. ANIMALS: Ten feline cadavers; two feline subjects. METHODS: Custom 3DPCs were initially modeled in a PLA filament material and then created in an autoclavable dental resin for use in live patients. The surgery time, number of surgical collisions and cannula complications were recorded during cadaver procedures before and after use of 3DPCs. Cannula complications were recorded during live procedures and patients were followed to suture removal to record any incisional complications. RESULTS: There was a significant reduction in mean surgical time (125.6 vs. 95.2 min, p = 0.03), mean number of instrument collisions (6.8 vs. 2.6, p = 0.03), and mean number of cannula complications (10 vs. 2.2, p = 0.03) with the use of only 3DPCs during the procedure. During the live procedures the use of the 3DPCs was successful and no postoperative complications occurred at the incision sites. CONCLUSION: The use of customized 3DPCs may improve surgical dexterity and decrease complications in advanced procedures and was not associated with any clinical complications in two cats. The use of 3DPCs in veterinary medicine may allow for wider practice of laparoscopic techniques in small animals.

Laparoscopic vertical sleeve gastrectomy in felines: A cadaveric feasibility study and experimental case series in two cats.

OBJECTIVE: To evaluate the feasibility of laparoscopic vertical sleeve gastrectomy (LVSG) in feline cadavers using endoscopic stapling equipment and report clinical outcomes in two live feline subjects. STUDY DESIGN: Cadaveric study and experimental case series. ANIMALS: Ten feline cadavers; two feline subjects. METHODS: LVSG technique was refined on feline cadavers and included retraction of the liver, dissection of the stomach, assessment of proper location for gastrectomy via stapling, and leak testing. Appropriateness of gastrectomy, gastrectomy %, surgical times and complications were recorded. The procedure was performed on two live feline subjects, and they were followed for 4 months to report surgical complications. RESULTS: LVSG was completed in 9/10 cadavers and both live patients. Stenosis at the incisura was recorded in 2/9 cadavers. No obvious leaks were seen in the 8 cadavers that were tested or either live patient. The mean surgical time for all cadaver procedures and live patients was 110.4 and 115 minutes, respectively. Mean weight of resected cadaver stomach was 10 g and the mean % of the total stomach weight resected was 27.6%. No intra- or postoperative surgical complications occurred in the live subjects. CONCLUSION: LVSG technique appears feasible and safe for use in live patients. CLINICAL RELEVANCE: This LVSG technique may be safely used for partial gastric resection in cats. Further studies are necessary to determine if it is effective at reversing the effects of obesity and diabetes in this population.

Serum biomarkers of inflammation and adiposity in the LABS cohort: associations with metabolic disease and surgical outcomes.

BACKGROUND: The utility of serum biomarkers related to inflammation and adiposity as predictors of metabolic disease prevalence and outcomes after bariatric surgery are not well-defined. METHODS: Associations between pre- and post-operative serum levels of four biomarkers (C-reactive protein (CRP), cystatin C (CC), leptin, and ghrelin) with baseline measures of adiposity and metabolic disease prevalence (asthma, diabetes, sleep apnea), and weight loss and metabolic disease remission after bariatric surgery were studied in the Longitudinal Assessment of Bariatric Surgery (LABS) cohort. RESULTS: Baseline CRP levels were positively associated with the odds of asthma but not diabetes or sleep apnea; baseline CC levels were positively associated with asthma, diabetes, and sleep apnea; baseline leptin levels were positively associated with asthma and negatively associated with diabetes and sleep apnea; baseline ghrelin levels were negatively associated with diabetes and sleep apnea. Increased weight loss was associated with increased baseline levels of leptin and CRP and decreased baseline levels of CC. Remission of diabetes and asthma was not associated with baseline levels of any biomarker. A higher likelihood of asthma remission was associated with a greater decrease in leptin levels, and a higher likelihood of diabetes remission was predicted by a lesser decrease in CC. Bariatric surgery was associated with decreased post-operative CC, CRP, and leptin levels, and increased post-operative ghrelin levels. CONCLUSION: This is the largest study to date of serum biomarkers of inflammation and adiposity in a bariatric surgery cohort. Biomarker levels correlate with metabolic disease prevalence prior to bariatric surgery, and with weight loss but not metabolic disease remission after surgery. Bariatric surgery regulates serum biomarker levels in a manner consistent with anti-inflammatory and compensatory orexigenic effects. These data contribute to our understanding of the mechanisms underlying the biologic effects of bariatric surgery.

Objectively-measured sedentary time and cardiometabolic health in adults with severe obesity.

It is unknown whether sedentary behavior is independently associated with the cardiometabolic health of adults with severe obesity. Additionally, there is debate regarding how best to derive meaningful indices of sedentary time (ST) from activity monitor data. A convenience sample of adults with severe obesity (N=927; 79% female, median age 45y, median body mass index (BMI) 46kg/m(2)) completed a research assessment at one of ten US hospitals in 2006-2009 prior to bariatric surgery. Cardiometabolic health was assessed via physical measures, fasting blood samples and medication use. Indices of ST were derived from StepWatch™ activity monitor data with minimum bout durations of 1min, 10min and 30min. Cross-sectional associations were examined. Median (25th, 75th percentile) ST was 9.3h/d (8.1, 10.5) in ≥1min bouts, 6.5h/d (5.2, 8.0) in ≥10min bouts, or 3.2h/d (2.1, 4.5) in ≥30min bouts. Associations with ST were generally strongest with the ≥10min bout duration. Independent of moderate-to-vigorous intensity physical activity, BMI and other potential confounders, 1h/day ST in ≥10min bouts was associated with higher odds of diabetes by 15% (95%CI: 1.05-1.26), metabolic syndrome by 12% (95%CI: 1.01-1.24) and elevated blood pressure by 14% (95%CI: 1.02-1.26), and was associated with 1.4cm (95%CI: 0.9-1.9) larger waist circumference. Findings indicate the importance of considering ST as a distinct health risk among adults with severe obesity, and suggest a 10min minimum duration may be preferable to 1min or 30min for establishing ST from activity monitor data.

Change in Pain and Physical Function Following Bariatric Surgery for Severe Obesity.

IMPORTANCE: The variability and durability of improvements in pain and physical function following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) are not well described. OBJECTIVES: To report changes in pain and physical function in the first 3 years following bariatric surgery, and to identify factors associated with improvement. DESIGN, SETTING, AND PARTICIPANTS: The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study at 10 US hospitals. Adults with severe obesity undergoing bariatric surgery were recruited between February 2005 and February 2009. Research assessments were conducted prior to surgery and annually thereafter. Three-year follow-up through October 2012 is reported. EXPOSURES: Bariatric surgery as clinical care. MAIN OUTCOMES AND MEASURES: Primary outcomes were clinically meaningful presurgery to postsurgery improvements in pain and function using scores from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) (ie, improvement of ≥5 points on the norm-based score [range, 0-100]) and 400-meter walk time (ie, improvement of ≥24 seconds) using established thresholds. The secondary outcome was clinically meaningful improvement using the Western Ontario McMaster Osteoarthritis Index (ie, improvement of ≥9.7 pain points and ≥9.3 function points on the transformed score [range, 0-100]). RESULTS: Of 2458 participants, 2221 completed baseline and follow-up assessments (1743 [78.5%] were women; median age was 47 years; median body mass index [BMI] was 45.9; 70.4% underwent RYGB; 25.0% underwent LAGB). At year 1, clinically meaningful improvements were shown in 57.6% (95% CI, 55.3%-59.9%) of participants for bodily pain, 76.5% (95% CI, 74.6%-78.5%) for physical function, and 59.5% (95% CI, 56.4%-62.7%) for walk time. Additionally, among participants with severe knee or disability (633), or hip pain or disability (500) at baseline, approximately three-fourths experienced joint-specific improvements in knee pain (77.1% [95% CI, 73.5%-80.7%]) and in hip function (79.2% [95% CI, 75.3%-83.1%]). Between year 1 and year 3, rates of improvement significantly decreased to 48.6% (95% CI, 46.0%-51.1%) for bodily pain and to 70.2% (95% CI, 67.8%-72.5%) for physical function, but improvement rates for walk time, knee and hip pain, and knee and hip function did not (P for all ≥.05). Younger age, male sex, higher income, lower BMI, and fewer depressive symptoms presurgery; no diabetes and no venous edema with ulcerations postsurgery (either no history or remission); and presurgery-to-postsurgery reductions in weight and depressive symptoms were associated with presurgery-to-postsurgery improvements in multiple outcomes at years 1, 2, and 3. CONCLUSIONS AND RELEVANCE: Among a cohort of participants with severe obesity undergoing bariatric surgery, a large percentage experienced improvement, compared with baseline, in pain, physical function, and walk time over 3 years, but the percentage with improvement in pain and physical function decreased between year 1 and year 3. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00465829.

Achalasia 5 years following Roux-en-y gastric bypass.

Oesophageal achalasia is a rare, but serious condition in which the motility of the lower oesophageal sphincter (LES) is inhibited. This disorder of idiopathic aetiology complicates the peristaltic function and relaxation of the LES that may cause symptoms such as dysphagia, epigastric pain, and regurgitation of an obstructed food. The following case describes achalasia in a patient 5 years following a laparoscopic Roux-en-Y gastric bypass (RYGB). The patient underwent a laparoscopic Heller myotomy without a fundoplication. Although achalasia seems to be a rare occurrence in obese patients, this is the third case documented in a patient who previously had an RYGB. The role of performing a fundoplication in these patients remains to be elucidated.

Body contouring after bariatric surgery: how much is really being done?

The proportion of postbariatric surgery patients who undergo body contouring (BC) procedures is unknown. We designed a study to explore demographic features and patient education regarding BC in the bariatric surgery (BS) population. A survey was mailed to 1158 patients who underwent BS by 2 surgeons between 2003 and 2011. A total of 284 (24.5%) patients responded. Seventy-two patients (25.4%) reported discussing BC surgery with their bariatric surgeon perioperatively. Forty patients (14.1%) were referred for plastic surgery consultation. Thirty-three patients (11.6%) underwent BC procedures. The most frequent reasons cited for not undergoing BC were expense (29.2%) and lack of awareness regarding options (23.6%). Thirty-nine percent of respondents reported that they might have chosen differently, had they received more information. As a result of insufficient perioperative counseling, the majority of BS patients are unaware of the multitude of BC procedures available. Additional efforts toward improving patient (and surgeon) education regarding postbariatric BC options are warranted.

Imaging of patients after the Lap-Band System application.

OBJECTIVE: We describe the use of imaging in the management of adjustable gastric-banding patients, and describe complications of banding that are diagnosed by imaging. MATERIALS & METHODS: Using a four-year period as an example of complications of this type of laparoscopic approach, we have retrospectively identified all patients with laparoscopic bands who were imaged in the radiology department at our large multispecialty hospital. Included are patients who had their bands placed by the hospital's surgeons as well as patients referred for consultation from other practices. RESULTS: Twenty-two of 165 patients who had banding as their sole weight loss surgery had 23 complications diagnosed by imaging. Complications included band slip (3), device issues (4), esophageal dilation (8), esophageal dysmotility (5), symptomatic gallstones (2) and a gastroesphageal diverticulum (1). Complications were detected by fluoroscopy (17), CT (4) or ultrasound (2). 17 patients had banding as one of multiple bariatric surgeries, with 13 complications: band slip (4), port infection (1), esophageal dilation (1), esophageal dysmotility (5), anastomotic leak (1) and internal hernia (2). Complications were detected with fluoroscopy (12) and CT (1). CONCLUSIONS: Fluoroscopy is generally the primary imaging modality used to diagnose complications of gastric banding. Esophageal dilation and dysmotility, which appear to be long-term sequelae of banding, were the most common complications identified by imaging.

Selective targeting of visceral adiposity by polycation nanomedicine.

Obesity is a pandemic health problem with poor solutions, especially for targeted treatment. Here we develop a polycation-based nanomedicine polyamidoamine generation 3 (P-G3) that-when delivered intraperitoneally-selectively targets visceral fat due to its high charge density. Moreover, P-G3 treatment of obese mice inhibits visceral adiposity, increases energy expenditure, prevents obesity and alleviates the associated metabolic dysfunctions. In vitro adipogenesis models and single-cell RNA sequencing revealed that P-G3 uncouples adipocyte lipid synthesis and storage from adipocyte development to create adipocytes that possess normal functions but are deficient in hypertrophic growth, at least through synergistically modulating nutrient-sensing signalling pathways. The visceral fat distribution of P-G3 is enhanced by modifying P-G3 with cholesterol to form lipophilic nanoparticles, which is effective in treating obesity. Our study highlights a strategy to target visceral adiposity and suggests that cationic nanomaterials could be exploited for treating metabolic diseases.

Video. Laparoscopic lumbar hernia repair with bone anchor fixation.

INTRODUCTION: Lumbar hernias are rare defects of the posterolateral abdominal wall. Surgical repair of lumbar hernias is challenging because they are bounded inferiorly by the iliac bone, which makes adequate mesh fixation difficult. We demonstrate a method of a laparoscopic lumbar hernia repair utilizing bone anchor fixation at the inferior border. METHODS: The patient is a 37-year-old male who had been in a motor vehicle collision and presented with a large left lumbar hernia and nonspecific abdominal pain. The patient had a Petit-type hernia that was bordered by the external oblique muscle, the latissimus dorsi, and the iliac crest. We opted to perform a laparoscopic mesh repair. Two Mitek GII QuickAnchor sutures were placed in the anterior superior iliac crest to provide inferior fixation of the mesh, with sufficient overlap of the mesh to prevent recurrence. The remainder of the mesh was fixed with standard laparoscopic tacks and sutures under good visualization to avoid damage of underlying structures. RESULTS: The patient did well postoperatively and left the hospital on the first postoperative day. He has had no signs of recurrence at follow-up. CONCLUSIONS: The anatomic features of lumbar hernias create several challenges. A number of surgical approaches for lumbar hernia repair have been described, including laparoscopic and open methods as well as intraperitoneal and preperitoneal approaches and the use of flaps to cover the defects. However, limited fixation points for the mesh can lead to high recurrence rates. Bone anchors have been used in a variety of surgical disciplines, including orthopedics, plastic surgery, and gynecologic surgery, with low complication rates of bone pain or infection. We demonstrated a method that utilizes bone anchor fixation in a laparoscopic approach to overcome the challenge of inferior fixation. This securely repairs the hernia with good coverage of the defect while maintaining the benefits of the minimally invasive approach.

Single-access laparoscopic cholecystectomy with routine intraoperative cholangiogram.

BACKGROUND: While laparoscopy is now the standard for cholecystectomy, recent papers have focused on single-incision approaches. Intraoperative cholangiography remains an integral part of laparoscopic cholecystectomy but has not yet been well described within the single-access literature. We discuss our method of single-incision laparoscopic cholecystectomy with routine intraoperative cholangiograms. METHODS: A retrospective review of our surgical database was completed. One hundred twenty-three patients undergoing laparoscopic cholecystectomy were identified (83 standard laparoscopy, 40 single-incision laparoscopy). Patient demographics including age and body mass index (BMI), and indications for surgery, operative time, intra- and postoperative complications, and ability to complete cholangiography were analyzed. RESULTS: All patients with standard laparoscopy had successful cholangiograms. Two patients did not undergo cholangiography based on a preoperative decision (pregnancy). In the 40 patients who underwent single-incision cholecystectomy, 38 cholangiograms were completed (95%). One patient with acute cholecystitis had a small cystic duct which could not be cannulated. The second had a cystic duct through which the cholangiocatheter could not be advanced. Comparative analysis of patient demographics showed a significant difference in patient age between the two groups, as well as a significantly greater number of patients undergoing single-incision cholecystectomy for symptomatic cholelithiasis as opposed to acute cholecystitis. DISCUSSION: Completion of intraoperative cholangiography is an important aspect of cholecystectomy in order to identify choledocholithiasis and verify anatomy. With the advent of single-access laparoscopy, standard operative principles should not be compromised. Cholangiography may provide a safer approach to cholecystectomy when adopting a new technique. We present our technique of single-incision cholecystectomy and routine cholangiography with a 95% success rate. The ability to perform single-incision intraoperative cholangiograms will allow a safe, more minimally invasive approach to cholecystectomy with suspected choledocholithiasis and obviate the need to convert to standard multiport laparoscopy for the sole reason of completing cholangiograms.

Analysis of Early Job Market Experiences and Perceptions Among Bariatric Surgery Fellowship Graduates and Bariatric Surgery Program Directors.

PURPOSE: Over the past decade, an increasing number of bariatric surgeons are trained in fellowships annually despite only a modest increase in nationwide bariatric surgery volume. The study surveys the bariatric surgery job market trend in order to inform better career-choice decisions for trainees interested in this field. MATERIALS AND METHODS: A national retrospective cohort survey over an 11-year period was conducted. Bariatric surgery fellowship graduates from 2008 to 2019 and program directors (PDs) were surveyed electronically. Univariate analysis was performed comparing responses between earlier (2008-2016) and recent graduates (2017-2019). RESULTS: We identified a total of 996 graduates and 143 PDs. Response rates were 9% and 20% respectively (n = 88, 29). Sixty-eight percent of graduates felt there are not enough bariatric jobs for new graduates. Seventy-nine percent of PDs felt that it is more difficult to find a bariatric job for their fellows now than 5-10 years ago. Forty-eight percent of PDs felt that we are training too many bariatric fellows. Seventy-seven percent of all graduates want the majority of their practice to be comprised bariatric cases; however, only 42% of them reported achieving this. In the univariate analysis, recent graduates were less likely to be currently employed as a bariatric surgeon (64% vs. 86%, p = 0.02) and were less satisfied with their current case volume (42% vs. 66%, p = 0.01). CONCLUSIONS: The temporal increase in bariatric fellowship graduates over the past decade has resulted in a significant decline in the likelihood of employment in a full-time bariatric surgical practice and a decline in surgeons' bariatric case volumes.

The PreOp Program: Intensive Preclinical Surgical Exposure is Associated With Increased Medical Student Surgical Interest and Competency.

OBJECTIVE: As medical students' interest in surgical fields wanes, we investigated the impact of a preclinical surgical exposure program on students' attitudes toward pursuing surgical careers. DESIGN: This is a prospective longitudinal study of PreOp, a preclinical rotation-based surgical exposure program for first-year medical students, from 2013 to 2017. Surveys assessed PreOp rotation quality, students' surgical interest, and students' self-reported preparedness for the surgical clerkship. Surgery clerkship grades were obtained as a measure of surgical competency and compared to class-wide peers. Match data was collected and compared to class-wide peers as well as historical norms. SETTING: NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY; tertiary care center. PARTICIPANTS: Fifty-four PreOp students from 2013 to 2017. RESULTS: Fifty-four PreOp participants were recruited. After completing the PreOp program, 66.7% of PreOp students reported being very likely to apply into a surgical field compared to 29.4% when they started medical school. Ultimately, 71.4% of PreOp students versus 21.7% of non-PreOp class-wide peers matched into surgical fields (p < 0.001). From the preceding 5 match years before PreOp implementation, 21.4% of all students matched into surgical fields compared to 25.6% of all students after PreOp was started (p = 0.26). In terms of preparedness, 75% of PreOp students reported feeling more prepared for the third-year surgery clerkship than their non-PreOp peers after the second year of medical school. PreOp students were significantly more likely than non-PreOp class-wide peers to receive honors in the surgery clerkship when controlling for cumulative clerkship GPA (p = 0.012, adjusted odds ratio = 5.5 [95% confidence interval 1.5-22.1]). CONCLUSIONS: Hands-on preclinical surgical exposure was associated with student-reported increased surgical interest that was maintained longitudinally and reflected in significantly increased surgical matches relative to non-PreOp class-wide peers. This study uniquely demonstrates that participation in PreOp was also associated with increased self-reported surgical preparedness and significantly higher surgery clerkship grades relative to overall academic performance.

Conception rates and contraceptive use after bariatric surgery among women with infertility: Evidence from a prospective multicenter cohort study.

BACKGROUND: Lack of prospective trials have resulted in a dearth of information regarding postbariatric surgery conception rates in women with a preoperative history of infertility. OBJECTIVE: To examine associations between preoperative history of infertility and postbariatric surgery conception. SETTING: A multicenter cohort study at 10 United States hospitals (2006-2009). METHODS: Participants completed a preoperative reproductive health questionnaire, with annual postoperative assessments for up to 7 years until January 2015. This report was restricted to women 18- to 44-years old with no history of menopause, hysterectomy, or hormone replacement therapy. The primary outcomes were postoperative (0 to <90 mo) conception rate, early conception rate (0 < 18 mo), and postoperative unprotected intercourse with a male partner while not trying to conceive. RESULTS: Of 740 eligible women, 650 (87.8%) provided required responses. Median interquartile range (IQR) preoperative age was 34 (30-39) years and follow-up was 6.5 (5.9-7.0) years. Nulliparous women with a preoperative history of infertility represented 8.0% (52/650) of the total cohort, 63.5% (33/52) of whom had never conceived. Compared with women without this history, these women had a higher postoperative conception rate (121.2 [95% confidence interval (CI), 102.3-143.5]/1000 versus 47.0 [95%CI, 34.2-62.9]/1000 woman-yr; P < .001), early conception rate (115.4 [95%CI, 96.1-138.5]/1000 versus 33.9 [95%CI, 23.6-47.1]/1,000 woman-yr; P < .01), and a higher risk of unprotected intercourse (ARR 1.48 [95% CI, 1.14-1.90], P = 0.003). CONCLUSION: After bariatric surgery, preoperative history of infertility and nulliparity was associated higher conception rates and unprotected intercourse.

Perioperative outcome of laparoscopic left lateral liver resection is improved by using a bioabsorbable staple line reinforcement material in a porcine model.

HYPOTHESIS: Laparoscopic liver surgery is significantly limited by the technical difficulty encountered during transection of substantial liver parenchyma, with intraoperative bleeding and bile leaks. This study tested whether the use of a bioabsorble staple line reinforcement material would improve outcome during stapled laparoscopic left lateral liver resection in a porcine model. STUDY DESIGN: A total of 20 female pigs underwent stapled laparoscopic left lateral liver resection. In group A (n = 10), the stapling devices were buttressed with a bioabsorbable staple line reinforcement material. In group B (n = 10), standard laparoscopic staplers were used. Operative data and perioperative complications were recorded. Necropsy studies and histopathological analysis were performed at 6 weeks. Data were compared between groups with the Student's t-test or the chi-square test. RESULTS: Operating time was similar in the two groups (64 +/- 11 min in group A versus 68 +/- 9 min in group B, p = ns). Intraoperative blood loss was significantly higher in group B (185 +/- 9 mL versus 25 +/- 5 mL, p < 0.05). There was no mortality. There was no morbidity in the 6-week follow-up period; however, two animals in group B had subphrenic bilomas (20%) at necropsy. At necropsy, methylene blue injection via the main bile duct revealed leakage from the biliary tree in four animals in group B and none in group A (p < 0.05). Histopathological examination of the resection site revealed minor abnormalities in group A while animals in group B demonstrated marked fibrotic changes and damaged vascular and biliary endothelium. CONCLUSION: Use of a bioabsorbable staple line reinforcement material reduces intraoperative bleeding and perioperative bile leaks during stapled laparoscopic left lateral liver resection in a porcine model.

Physical activity levels of patients undergoing bariatric surgery in the Longitudinal Assessment of Bariatric Surgery study.

BACKGROUND: Bariatric surgery candidates' physical activity (PA) level might contribute to the variability of weight loss and body composition changes following bariatric surgery. However, there is little research describing the PA of patients undergoing bariatric surgery to inform PA recommendations in preparation for, and following, surgery. We describe the PA assessment in the Longitudinal Assessment of Bariatric Surgery-2 study at 6 sites in the United States and report preoperative PA level. We also examined the relationships between objectively determined PA level and the patient's body mass index and self-reported purposeful exercise. METHODS: The participants wore an accelerometer and completed a PA diary. Standardized measures of height and weight were obtained. RESULTS: Of the 757 participants, 20% were sedentary (<5000 steps/d), 34% had low activity (5000-7499 steps/d), 27% were somewhat active (7500-9999 steps/d), 14% were active (10,000-12,499 steps/d), and 6% were highly active (>or=12,500 steps/d). Body mass index was inversely related to the mean number of steps daily and the mean number of steps each minute during the most active 30 minutes of each day. The most commonly reported activities were walking (44%), gardening (11%), playing with children (10%), and stretching (7%). The self-reported minutes of exercise accounted for 2% of the variance in the objectively determined steps. CONCLUSION: Patients present for bariatric surgery with a wide range of PA levels, with almost one half categorized as somewhat active or active. Body mass index was inversely related to the total amount and intensity of PA. Few patients reported a regular preoperative exercise regimen, suggesting most PA is accumulated from activities of daily living. Patients' report of daily minutes of walking or exercise might not be a reliable indication of their PA level.

A Randomized, Double-Blind, Placebo-Controlled Trial of Intravenous Acetaminophen on Hospital Length of Stay in Obese Individuals Undergoing Sleeve Gastrectomy.

BACKGROUND: Retrospective studies indicate that acetaminophen iv administration reduces hospital length of stay (LoS) and opiate consumption in patients undergoing bariatric surgery. OBJECTIVE: This study sought to determine whether using acetaminophen iv in morbidly obese subjects undergoing sleeve gastrectomy decreased LoS and total hospital charges as compared to patients receiving saline placebo. SETTING: Single-center university hospital METHODS: Using a randomized, double-blind, placebo-controlled design, subjects were assigned to receive either acetaminophen iv (group A) or saline placebo iv (group P). Data were collected between Jan 1 and Dec 31, 2016. Group A received acetaminophen every 6 h for a total of four doses. The first dose was administered following the induction of general anesthesia; group P received saline iv on the same schedule. Anesthetic management and prophylactic antiemetic regimen were standardized in all subjects. Postoperative pain management consisted of hydromorphone via patient-controlled infusion pump. Primary outcomes include hospital LoS and associated hospital costs. Secondary outcomes include patient satisfaction and postoperative nausea and pain scores. RESULTS: Subject demographics (n = 127) and intraoperative management were similar in the two groups. Across all subjects, median hospital LoS in group A (n = 63) was 1.87 vs. 1.97 days in group P (n = 64) (p = 0.03, Wilcoxon rank-sum test). Postoperatively, daily quality-of-recovery (QoR-15) scores, narcotic consumption, and the use of rescue antiemetics were not significantly different between groups. Median hospital costs were as follows: group A, $12,885 vs. group P, $12,977 (n = 64). CONCLUSIONS: Acetaminophen iv may reduce hospital LoS in subjects undergoing sleeve gastrectomy.

Endoscopic Sleeve Gastroplasty, Laparoscopic Sleeve Gastrectomy, and Laparoscopic Band for Weight Loss: How Do They Compare?

BACKGROUND: Endoscopic sleeve gastroplasty (ESG) is a novel endobariatric procedure. Initial studies demonstrated an association of ESG with weight loss and improvement of obesity-related comorbidities. Our aim was to compare ESG to laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB). METHODS: We included 278 obese (BMI > 30) patients who underwent ESG (n = 91), LSG (n = 120), or LAGB (n = 67) at our tertiary care academic center. Primary outcome was percent total body weight loss (%TBWL) at 3, 6, 9, and 12 months. Secondary outcome measures included adverse events (AE), length of stay (LOS), and readmission rate. RESULTS: At 12-month follow-up, LSG achieved the greatest %TBWL compared to LAGB and ESG (29.28 vs 13.30 vs 17.57%, respectively; p < 0.001). However, ESG had a significantly lower rate of morbidity when compared to LSG or LAGB (p = 0.01). The LOS was significantly less for ESG compared to LSG or LAGB (0.34 ± 0.73 vs 3.09 ± 1.47 vs 1.66 ± 3.07 days, respectively; p < 0.01). Readmission rates were not significantly different between the groups (p = 0.72). CONCLUSION: Although LSG is the most effective option for weight loss, ESG is a safe and feasible endobariatric option associated with low morbidity and short LOS in select patients.

Association of Obesity Subtypes in the Longitudinal Assessment of Bariatric Surgery Study and 3-Year Postoperative Weight Change.

OBJECTIVE: The study objective was to empirically identify subgroups of patients with obesity and investigate their association with postoperative weight change. METHODS: A longitudinal analysis of 2,458 adults in the Longitudinal Assessment of Bariatric Surgery (LABS) study was used. Baseline data were used to identify subgroups. The outcome was 3-year weight change after bariatric surgery. RESULTS: We identified four classes (subtypes) of obesity, which could be characterized as diabetes with low rates of high-density lipoprotein (Class 1), disordered eating (Class 2), mixed (Class 3), and extreme obesity with early onset (Class 4). Approximately 98% of participants in Class 1 had diabetes compared with < 40% in the other classes. There were high rates of binge eating in Class 2, and more than 92% of those in this class reported eating when not hungry. Class 4 was characterized by a higher BMI at baseline. Adults in Class 4 lost an average of 25.0% (males) and 30.3% (females) of their baseline weight over 3 years. In contrast with participants in Class 1, those in Classes 2 and 3 had significantly larger 3-year weight losses than their peers in Class 4. CONCLUSIONS: Obesity is a heterogeneous disease. Bariatric surgery may be most beneficial for adults with disordered eating.

Fat-free mass is not lower 24 months postbariatric surgery than nonoperated matched controls.

OBJECTIVE: Concerns about an excessive loss of fat-free mass (FFM) after bariatric surgery prompted this comparison of operated versus matched nonoperated controls regarding FFM. SETTING: University Hospital and University Research Unit in an urban medical center. METHODS: Body composition with bioelectric impedance (Tanita 310, Tanita Corp, Arlington Heights, IL) was measured approximately 2 years after bariatric surgery in weight stable patients and nonoperated weight stable controls matched for body mass index (BMI), gender, and age. t tests provided comparisons. Analysis of variance was used to compare FFM changes for 4 procedures. Levene's test evaluated variance. RESULTS: Patients (n = 252; 24.7±15 mo after surgery) and nonoperated controls (n = 252) were matched for gender (71.8% female), age (44.5±11.0 yr), and BMI (32.8±7.0 kg/m2). Patients had different surgical procedures: 107 gastric bypasses (RYGBs), 62 biliopancreatic diversions with duodenal switch (BPD/DSs), 40 adjustable gastric bands (AGBs), and 43 sleeve gastrectomies (LSGs). FFM percentage was significantly higher in the operated patients than controls, 66% versus 62%, P<.0001. For 3 procedures, the FFM was significantly higher; however, AGBs changed only 7.3 BMI units and FFM was not significantly different from their matched controls, 59.8% versus 58.2%. Across surgical groups, FFM percentage differed, P<.0001 (RYGB 66.5±9.2%, BPD/DS 74.0±9.3%, AGB 59.8±7.0%, LSG 59.6±9.3%). Variance was not different (P = .17). CONCLUSION: Weight-reduced bariatric surgery patients have greater FFM compared with nonoperated matched controls. These findings support surgically assisted weight loss as a physiologic process and in general patients do not suffer from excessive FFM depletion after bariatric procedures.