Nerve transfer for restoration of lower motor neuron-lesioned bladder, urethral and anal sphincter function. Part 4: Effectiveness of the motor reinnervation.

In pilot work, we showed that somatic nerve transfers can restore motor function in long-term decentralized dogs. We continue to explore the effectiveness of motor reinnervation in 30 female dogs. After anesthesia, 12 underwent bilateral transection of coccygeal and sacral (S) spinal roots, dorsal roots of lumbar (L)7, and hypogastric nerves. Twelve months postdecentralization, eight underwent transfer of obturator nerve branches to pelvic nerve vesical branches, and sciatic nerve branches to pudendal nerves, followed by 10 mo recovery (ObNT-ScNT Reinn). The remaining four were euthanized 18 mo postdecentralization (Decentralized). Results were compared with 18 Controls. Squat-and-void postures were tracked during awake cystometry. None showed squat-and-void postures during the decentralization phase. Seven of eight ObNT-ScNT Reinn began showing such postures by 6 mo postreinnervation; one showed a return of defecation postures. Retrograde dyes were injected into the bladder and urethra 3 wk before euthanasia, at which point, roots and transferred nerves were electrically stimulated to evaluate motor function. Upon L2-L6 root stimulation, five of eight ObNT-ScNT Reinn showed elevated detrusor pressure and four showed elevated urethral pressure, compared with L7-S3 root stimulation. After stimulation of sciatic-to-pudendal transferred nerves, three of eight ObNT-ScNT Reinn showed elevated urethral pressure; all showed elevated anal sphincter pressure. Retrogradely labeled neurons were observed in L2-L6 ventral horns (in laminae VI, VIII, and IX) of ObNT-ScNT Reinn versus Controls in which labeled neurons were observed in L7-S3 ventral horns (in lamina VII). This data supports the use of nerve transfer techniques for the restoration of bladder function.NEW & NOTEWORTHY This data supports the use of nerve transfer techniques for the restoration of bladder function.

Is Bariatric Procedure Type Associated With Morbidity in Transplant Patients?

INTRODUCTION: Roux-en-Y Gastric Bypass (RYGB) has been associated with increased weight loss but more complications when compared with sleeve gastrectomy (SG). However, a direct comparison between RYGB and SG has never been performed in patients with a history of solid organ transplantation. The aim of this study was to determine the association between procedure type and surgical outcomes. MATERIALS AND METHODS: Patients with a history of solid organ transplantation were identified in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project Participant Use File database from 2017 to 2018. Procedure type (SG versus RYGB) was used to stratify patients. Propensity score matching and multivariable logistic regressions were used, and outcomes were compared. RESULTS: Of 678 cases identified, 80% (n = 542) underwent an SG and 20% (n = 136) had an RYGB. Patients differed significantly (P < 0.05) by multiple demographic variables. Multivariable regression revealed RYGB to be associated with higher overall morbidity (odds ratio [OR] 1.98; P = 0.012), morbidity related to surgery (OR 2.47; P = 0.002), unplanned readmissions (OR 2.48; P = 0.002), and readmissions related to surgery (OR 2.32; P = 0.016). After propensity score matching, RYGB, compared with SG, was also associated with higher morbidity (14% versus 7.4%; P = 0.077) and readmissions (13% versus 6.6%; P = 0.099) related to surgery, although this did not reach statistical significance. CONCLUSIONS: In patients with a history of solid organ transplant, RYGB was associated with increased morbidity and readmissions compared with SG.

Nerve transfer for restoration of lower motor neuron-lesioned bladder function. Part 2: correlation between histological changes and nerve evoked contractions.

We determined the effect of pelvic organ decentralization and reinnervation 1 yr later on urinary bladder histology and function. Nineteen canines underwent decentralization by bilateral transection of all coccygeal and sacral (S) spinal roots, dorsal roots of lumbar (L)7, and hypogastric nerves. After exclusions, eight were reinnervated 12 mo postdecentralization with obturator-to-pelvic and sciatic-to-pudendal nerve transfers, then euthanized 8-12 mo later. Four served as long-term decentralized only animals. Before euthanasia, pelvic or transferred nerves and L1-S3 spinal roots were stimulated and maximum detrusor pressure (MDP) recorded. Bladder specimens were collected for histological and ex vivo smooth muscle contractility studies. Both reinnervated and decentralized animals showed less or denuded urothelium, fewer intramural ganglia, and more inflammation and collagen, than controls, although percent muscle was maintained. In reinnervated animals, pgp9.5+ axon density was higher compared with decentralized animals. Ex vivo smooth muscle contractions in response to KCl correlated positively with submucosal inflammation, detrusor muscle thickness, and pgp9.5+ axon density. In vivo, reinnervated animals showed higher MDP after stimulation of L1-L6 roots compared with their transected L7-S3 roots, and reinnervated and decentralized animals showed lower MDP than controls after stimulation of nerves (due likely to fibrotic nerve encapsulation). MDP correlated negatively with detrusor collagen and inflammation, and positively with pgp9.5+ axon density and intramural ganglia numbers. These results demonstrate that bladder function can be improved by transfer of obturator nerves to pelvic nerves at 1 yr after decentralization, although the fibrosis and inflammation that developed were associated with decreased contractile function.

Nerve transfer for restoration of lower motor neuron-lesioned bladder function. Part 1: attenuation of purinergic bladder smooth muscle contractions.

This study determined the effect of pelvic organ decentralization and reinnervation 1 yr later on the contribution of muscarinic and purinergic receptors to ex vivo, nerve-evoked, bladder smooth muscle contractions. Nineteen canines underwent decentralization by bilateral transection of all coccygeal and sacral (S) spinal roots, dorsal roots of lumbar (L)7, and hypogastric nerves. After exclusions, 8 were reinnervated 12 mo postdecentralization with obturator-to-pelvic and sciatic-to-pudendal nerve transfers then euthanized 8-12 mo later. Four served as long-term decentralized only animals. Controls included six sham-operated and three unoperated animals. Detrusor muscle was assessed for contractile responses to potassium chloride (KCl) and electric field stimulation (EFS) before and after purinergic receptor desensitization with α, ß-methylene adenosine triphosphate (α,ß-mATP), muscarinic receptor antagonism with atropine, or sodium channel blockade with tetrodotoxin. Atropine inhibition of EFS-induced contractions increased in decentralized and reinnervated animals compared with controls. Maximal contractile responses to α,ß-mATP did not differ between groups. In strips from decentralized and reinnervated animals, the contractile response to EFS was enhanced at lower frequencies compared with normal controls. The observation of increased blockade of nerve-evoked contractions by muscarinic antagonist with no change in responsiveness to purinergic agonist suggests either decreased ATP release or increased ecto-ATPase activity in detrusor muscle as a consequence of the long-term decentralization. The reduction in the frequency required to produce maximum contraction following decentralization may be due to enhanced nerve sensitivity to EFS or a change in the effectiveness of the neurotransmission.

Does Steroid Use in Transplant Patients Undergoing Bariatric Surgery Independently Impact Outcomes?

BACKGROUND: Corticosteroids have been a mainstay of immunosuppression in patients after solid organ transplantation. Due to deleterious effects, there is a push to minimize steroid use. The impact of corticosteroid use on prior solid organ transplant patients undergoing metabolic and bariatric surgery (MBS) is unknown. The aim of this study was to determine if corticosteroid use independently impacts surgical outcomes after MBS in solid organ transplant patients. MATERIALS AND METHODS: A retrospective analysis was performed on patients undergoing sleeve gastrectomy and Roux-en-Y gastric bypass in the 2017 Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project Participant Use File database. Patients with a history of solid organ transplantation were identified and further stratified by corticosteroid use. Univariable and multivariable regression for multiple postoperative outcomes were performed. RESULTS: Overall findings are summarized in visual abstract. Of 382 prior solid organ transplant patients, 42% (n = 160) were on corticosteroids. Patients on corticosteroids had significantly higher overall morbidity (16% versus 9%, P < 0.05). After multivariable analysis, corticosteroid use had a two-fold increase in overall morbidity (odds ratio 2.05, P = 0.0034) but without an increased risk for overall morbidity related to MBS (odds ratio 2.06, P = 0.061). CONCLUSIONS: Solid organ transplant patients undergoing MBS on corticosteroids have a significantly increased rate of overall morbidity (P < 0.05) but not morbidity related to bariatric surgery.

Outcomes in conventional laparoscopic versus robotic-assisted revisional bariatric surgery: a retrospective, case-controlled study of the MBSAQIP database.

INTRODUCTION: Revisional bariatric surgery is being increasingly performed and is associated with higher operative risks. Optimal techniques to minimize complications remain controversial. Here, we report a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant User Files (PUF) database, comparing outcomes between revision RBS and LBS. METHODS: The 2015 and 2016 MBSAQIP PUF database was retrospectively reviewed. Revision cases were identified using the Revision/Conversion Flag. Selected cases were further stratified by surgical approach. Subgroup analysis of sleeve gastrectomy and gastric bypass cases was performed. Case-controlled matching (1:1) was performed of the RBS and LBS cohorts, including gastric bypass and sleeve gastrectomy cohorts separately. Cases and controls were match by demographics, ASA classification, and preoperative comorbidities. RESULTS: 26,404 revision cases were identified (93.3% LBS, 6.7% RBS). 85.6% were female and 67% white. Mean age and BMI were 48 years and 40.9 kg/m2. 1144 matched RBS and LBS cases were identified. RBS was associated with longer operative duration (p < 0.0001), LOS (p = 0.0002) and a higher rate of ICU admissions (1.3% vs 0.5%, p = 0.05). Aggregate bleeding and leak rates were higher in the RBS cohort. In both gastric bypass and sleeve gastrectomy cohorts, the robotic-assisted surgery remain associated with longer operative duration (p < 0.0001). In gastric bypass, rates of aggregate leak and bleeding were higher with robotic surgery, while transfusion was higher with laparoscopy. For sleeve gastrectomy cases, reoperation, readmission, intervention, sepsis, organ space SSI, and transfusion were higher with robotic surgery. CONCLUSION: In this matched cohort analysis of revision bariatric surgery, both approaches were overall safe. RBS was associated with longer operative duration and higher rates of some complications. Complications were higher in the robotic sleeve cohort. Robotic is likely less cost-effective with no clear patient safety benefit, particularly for sleeve gastrectomy cases.

Outcomes in conventional laparoscopic versus robotic-assisted primary bariatric surgery: a retrospective, case-controlled study of the MBSAQIP database.

INTRODUCTION: Robotic-assisted bariatric surgery is increasingly performed. There remains controversy about the overall benefit of robotic-assisted (RBS) compared to conventional laparoscopic (LBS) bariatric surgery. In this study, we used a large national risk-stratified bariatric clinical database to compare outcomes between robotic and laparoscopic gastric bypass (RNYGB) and sleeve gastrectomy (SG). METHODS: A retrospective analysis of the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF) was performed. Primary robotic and laparoscopic RYNGB and SG were analyzed. Descriptive analysis was performed of the unmatched cohorts, followed by 1:3 case-controlled matching. Cases and controls were matched by patient demographics and pre-operative comorbidities, and peri-operative outcomes compared. RESULTS: 77,991 Roux-en-Y gastric bypass (RnYGB) (7.5% robotic-assisted) and 189,503 SG (6.8% robotic-assisted) cases were identified. Operative length was significantly higher in both the robotic-assisted RnYGB and SG cohorts (p < 0.0001). Outcomes were similar between the robotic-assisted and laparoscopic RnYGB cohorts, except a lower mortality rate (p = 0.05), transfusion requirement (p = 0.005), aggregate bleeding (p = 0.04), and surgical site infections (SSI) (p = 0.006) in the robotic-assisted cohort. Outcomes were also similar between robotic-assisted and laparoscopic SG, except for a longer length of stay (p < 0.0001) and higher rates of conversion (p < 0.0001), 30-day intervention (p = 0.01), operative drain present (p < 0.0001), sepsis (p = 0.01), and organ space SSI (p = 0.0002) in the robotic cohort. Bleeding was lower in the robotic SG cohort and mortality was similar. CONCLUSION: Both robotic-assisted and laparoscopic RnYGB and SG are overall very safe. Robotic-assisted gastric bypass is associated with a lower mortality and morbidity; however, a clear benefit for robotic-assisted SG compared to laparoscopic SG was not seen. Given the longer operative and hospital duration, robotic SG is not cost-effective.

Systematic review and meta-analysis of high-pressure intermittent limb compression for the treatment of intermittent claudication.

BACKGROUND: High-pressure intermittent limb compression (HPILC) has been proposed as an alternative treatment of disabling intermittent claudication. The objective of this study was to conduct a systematic review and meta-analysis of randomized controlled trials evaluating the efficacy of HPILC in improving walking distance in patients with intermittent claudication. METHODS: A search through December 31, 2016, was performed to identify all randomized controlled trials evaluating the efficacy of HPILC for the management of intermittent claudication. Applicable studies were assessed for quality and pooled using Cochrane systematic review guidelines. The primary outcome measured was absolute claudication distance (ACD). A random-effects model was used for meta-analysis. RESULTS: Eight studies eligible for inclusion were identified. These studies had a combined total of 290 subjects, 172 of whom were randomized to HPILC. All studies identified an increase in walking distance for subjects receiving compression therapy. On meta-analysis, the mean difference of ACD from baseline to follow-up among subjects receiving compression compared with controls was 125 m (95% confidence interval, 58.38-191.63 m; P < .01). CONCLUSIONS: HPILC is associated with a significant increase in ACD compared with controls. Limb compression appears to be an effective, noninvasive treatment option for patients with intermittent claudication. However, there are few studies comparing limb compression with other commonly used therapies. Further studies are needed to better guide the use of HPILC in the treatment of claudication.

Determining integrity of bladder innervation and smooth muscle function 1 year after lower spinal root transection in canines.

AIMS: To assess bladder smooth muscle function and innervation after long-term lower spinal root transection in canines. METHODS: Thirteen female mixed-breed hound dogs underwent bladder decentralization, which included transection of all sacral dorsal and ventral roots caudal to L7 and hypogastric nerves, bilaterally (n = 3); all sacral roots and hypogastric nerves plus transection of L7 dorsal roots, bilaterally (n = 4); or a sham operation (n = 6). At a year after initial surgery, bladder function was assessed in vivo by stimulation of the pelvic plexus. The bladder tissue was harvested for ex vivo smooth muscle contractility studies. Remaining bladder was evaluated for nerve morphology immunohistochemically using neuronal marker PGP9.5, apoptotic activity using terminal deoxynucleotidyl transferase dUTP nick end labeling, and histopathology using a hematoxylin and eosin stain. RESULTS: Sacral root decentralization did not reduce maximum strength of pelvic plexus stimulation-induced bladder contraction, although long-term sacral dorsal and ventral root plus L7 dorsal root transection significantly decreased contraction strength. Electric field stimulation-induced contractions of the detrusor from all decentralized animals were preserved, compared to controls. Viable nerves and intramural ganglia were visualized in the bladder wall, regardless of group. There was no difference in amount of apoptosis in bladder smooth muscle between groups. CONCLUSION: Bladder smooth muscle cells maintain their function after long-term bladder decentralization. While pelvic plexus-induced bladder contractions were less robust at 1 year after lower spinal root transection, the absence of atrophy and preservation of at least some nerve activity may allow for successful surgical reinnervation after long-term injury.

Prehospital tranexamic acid is associated with a survival benefit without an increase in complications: results of two harmonized randomized clinical trials.

INTRODUCTION: Recent randomized clinical trials have demonstrated that prehospital tranexamic acid (TXA) administration following injury is safe and improves survival. However, the effect of prehospital TXA on adverse events, transfusion requirements and any dose response relationships require further elucidation. METHODS: A secondary analysis was performed using harmonized data from two large, double-blinded, randomized prehospital TXA trials. Outcomes, including 28-day mortality, pertinent adverse events and 24-hour red cell transfusion requirements were compared between TXA and placebo groups. Regression analyses were utilized to determine the independent associations of TXA after adjusting for study enrollment, injury characteristics and shock severity across a broad spectrum of injured patients. Dose response relationships were similarly characterized based upon grams of prehospital TXA administered. RESULTS: A total of 1744 patients had data available for secondary analysis and were included in the current harmonized secondary analysis. The study cohort had an overall mortality of 11.2% and a median injury severity score of 16 (IQR: 5-26). TXA was independently associated with a lower risk of 28-day mortality (HR: 0.72, 95% CI 0.54, 0.96, p = 0.03). Prehospital TXA also demonstrated an independent 22% lower risk of mortality for every gram of prehospital TXA administered (HR: 0.78, 95% CI 0.63, 0.96, p = 0.02). Multivariable linear regression verified that patients who received TXA were independently associated with lower 24-hour red cell transfusion requirements (ß: -0.31, 95% CI -0.61, -0.01, p = 0.04) with a dose-response relationship (ß: -0.24, 95% CI -0.45, -0.02, p = 0.03). There was no independent association of prehospital TXA administration on VTE, seizure, or stroke. CONCLUSIONS: In this secondary analysis of harmonized data from two large randomized interventional trials, prehospital TXA administration across a broad spectrum of injured patients is safe. Prehospital TXA is associated with a significant 28-day survival benefit, lower red cell transfusion requirements at 24 hours and demonstrates a dose-response relationship. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

A prospective observational analysis of ambulation after motor vehicle collisions.

OBJECTIVES: Predicting injury patterns of patients based only on mechanism of injury is difficult and is well described in the literature. Characteristics of patients on-scene immediately following injury(ies) may lead to predicting injury patterns. Although reported frequently, the significance of victim ambulation after a motor vehicle crash is poorly understood. It was hypothesized that ambulation at the scene is not predictive of injury severity following a motor vehicle crash (MVC). METHODS: A prospective, cohort study of 117 consecutive injured patients who were ambulatory after MVCs were enrolled. Paramedics in a large urban Emergency Medical Services (EMS) system were mandated to document "ambulatory" or "nonambulatory" for motor vehicle collisions in order to complete their prehospital electronic medical records. This assured accuracy and completeness in the data collection. All charts were abstracted for trauma-induced injury and imaging results. RESULTS: A total of 608 (10.9%) persons were ambulatory at the scene, of which 284 had an injury pattern documented in the prehospital or emergency department record. The average age was 35.9 (SD = 16.8) years, and 158 (55.6%) were male. A total of 707 injuries were identified in the 284 patients who had sustained injuries. CONCLUSIONS: Ambulation after motor vehicle collisions appears to be only infrequently associated with major injuries, although this population still may present with significant injuries. A larger, prospective study is warranted.

A National Study on Training Innovation in US Medical Education.

Introduction Traditional medical education has leaned heavily on memorization, pattern recognition, and learned algorithmic thinking. Increasingly, however, creativity and innovation are becoming recognized as a valuable component of medical education. In this national survey of Association of American Medical Colleges (AAMC) member institutions, we seek to examine the current landscape of exposure to innovation-related training within the formal academic setting. Methods Surveys were distributed to 168 of 171 AAMC-member institutions (the remaining three were excluded from the study for lack of publicly available contact information). Questions assessed exposure for medical students among four defined innovation pillars as follows: (1) medical humanities, (2) design thinking, (3) entrepreneurship, or (4) technology transfer. Chi-squared analysis was used to assess statistical significance between schools, comparing schools ranked in the top 20 by the US News and World Report against non-top 20 respondents, and comparing schools that serve as National Institutes of Health (NIH) Clinical and Translational Science Awards (CTSA) program hubs against non-CTSA schools. Heat maps for geospatial visualization of data were created using ArcGIS (ArcMAP 10.6) software (Redlands, CA: Environmental Systems Research Institute). Results The overall response rate was 94.2% with 161 schools responding. Among respondents, 101 (63%) reported having medical humanities curricula at their institution. Design thinking offerings were noted at 51/161 (32%) institutions. Support for entrepreneurship was observed at 51/161 institutions (32%), and technology transfer infrastructure was confirmed at 42/161 (26%) of institutions. No statistically significant difference was found between top 20 schools and lower 141 schools when comparing schools with no innovation programs or one or more innovation programs (p=0.592), or all four innovation programs (p=0.108). CTSA programs, however, did show a statistically significant difference (p<0.00001) when comparing schools with no innovation programs vs. one or more programs, but not when comparing to schools with all four innovation programs (p=0.639). Conclusion This study demonstrated an overwhelming prevalence of innovation programs in today's AAMC medical schools, with over 75% of surveyed institutions offering at least one innovation program. No statistically significant trend was seen in the presence of zero programs, one or more, or all four programs between top 20 programs and the remaining 141. CTSA hub schools, however, were significantly more likely to have at least one program vs. none compared to non-CTSA hub schools. Future studies would be valuable to assess the long-term impact of this trend on medical student education.

Using Arterial Pressure Index to Predict Arterial Injuries in Penetrating Trauma to the Upper Extremities.

BACKGROUND: Upper extremity (UE) vascular injuries account for 18.4% of all traumatic vascular injuries. Arterial pressure index (API) use in lower extremity injuries to determine the need for further investigations is well established. However, due to collateral circulation in UEs, it is unclear if the same algorithm can be applied. The purpose of this study was to determine if APIs can be used to determine the need for computed tomography angiogram (CTA) in penetrating UE trauma. METHODS: All adult trauma patients with penetrating UE trauma and APIs from 2006 to 2016 were identified at 3 urban US level 1 trauma centers. Sensitivity, specificity, and positive and negative predictive values of APIs <.9 in detecting UE arterial injuries were calculated. RESULTS: During the 11-year study period, 218 patients met our inclusion criteria. Gunshot wounds comprised 76.6% and stab wounds 17.9%. Median injury severity score and API were 9 and 1, respectively. Seventy-two of our patients underwent evaluation with CTA. Of the injuries, the most common were thrombus or occlusion (46.7%), transection (23.1%), and dissection (15.4%), radiographically. Ultimately, 32 patients underwent surgical.

Racial disparities in bariatric perioperative outcomes among the elderly.

BACKGROUND: Bariatric surgery outcomes in elderly patients have been shown to be safe, but with a higher rate of adverse outcomes compared with nonelderly patients. The impact of race on bariatric surgery outcomes continues to be explored, with recent studies showing higher rates of adverse outcomes in black patients. Perioperative outcomes in racial cohorts of elderly bariatric patients are largely unexplored. OBJECTIVE: The goal of this study was to compare outcomes between elderly non-Hispanic black (NHB) and non-Hispanic white (NHW) bariatric surgery patients to determine whether outcomes are mediated by race. SETTING: Academic hospital. METHODS: Patients who had a primary Roux-en-Y (RYGB) and sleeve gastrectomy (SG) in the period 2015-2018 and were at least 65 years of age were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File (MBSAQIP PUF). Selected cases were stratified by race. Outcomes were compared between matched racial cohorts. Multivariate regression analyses were performed to determine whether race independently predicted morbidity. RESULTS: From 2015 to 2018, 29,394 elderly NHW (90.8%) and NHB (9.2%) patients underwent an RYGB or SG. At baseline, NHB elderly patients had a higher burden of co-morbid conditions, resulting in higher rates of overall (7.7% versus 6.4%, P = .009) and bariatric-related (5.4% versus 4.1%, P = .001) morbidity. All outcome measures were similar between propensity-score-matched racial elderly bariatric patient cohorts. On regression analysis, NHB race remained independently correlated with morbidity (odds ratio [OR] 1.3, 95% CI 1.08-1.47, P = .003). CONCLUSION: RYGB and SG are safe in elderly patient cohorts, with no differences in adverse outcomes between NHB and NHW patients, accounting for confounding factors. While race does not appear to impact outcomes in the elderly cohorts, NHB race may play a role in access.

Poor glycemic control in bariatric patients: a reason to delay or a reason to proceed?

BACKGROUND: More than 90% of patients with type 2 diabetes (T2D) have obesity, and over 85% of diabetic patients who undergo metabolic and bariatric surgery (MBS) will see improvement or resolution of diabetes. However, diabetes is a known risk factor for surgical complications. OBJECTIVES: To determine whether poor preoperative glycemic control confers an increased perioperative risk after MBS. SETTING: Academic Hospital. METHODS: Retrospective review of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). From the 2017-2018 MBSAQIP databases, we identified patients with diabetes who underwent Roux-en-Y gastric bypass or gastric sleeve surgery. Unmatched and propensity-matched univariate analyses, as well as multivariate logistic regressions, were performed to compare 30-day postoperative outcomes and complication rates between patients with poor (glycated hemoglobin [HbA1C] > 7.0) and good (HbA1C ≤ 7.0) glycemic control. RESULTS: Of 40,132 T2D patients, 19,094 (52.42%) had an HbA1C level ≤ 7.0. Patients with poor glycemic control had slightly higher rates of overall morbidity (6.53% versus 5.49%, respectively; relative risk = 1.188; P < .001). However, in a 1:1 matched analysis of 23,930 patients controlling for body mass index, surgery type, approach, and co-morbidities, the findings of poorer outcomes were largely mitigated. In a multivariate analysis, poor glycemic control was not associated with morbidity. CONCLUSIONS: In T2D patients, poor glycemic control does not independently increase the risk of 30-day morbidity following MBS. Adverse outcomes in the setting of poor glycemic control appear to be largely mediated by associated co-morbidities. Performing MBS in the setting of suboptimal glycemic control may be justified, with the understanding that delaying or refusing surgery can contribute to worsening of diabetes-related co-morbidities that, in turn, may ultimately have a more deleterious effect on outcomes.

Comparison of eGFR formulas in determining chronic kidney disease stage in bariatric patients and the impact on perioperative outcomes.

BACKGROUND: Chronic kidney disease (CKD) independently increases the risk of 30-day adverse outcomes following metabolic and bariatric surgery (MBS). However, no studies have evaluated the stage of CKD at which increased perioperative risk is manifested. Here, we correlate 30-day major morbidities after MBS with extent of renal disease based on CKD Stage. OBJECTIVES: To determine the impact of CKD stage on perioperative outcomes after bariatric surgery. SETTING: Academic Hospital. METHODS: From the 2017 Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database, we identified patients with CKD who underwent sleeve gastrectomy or laparoscopic gastric bypass surgery. Glomerular filtration rates (GFRs) were calculated and cohorts were generated based on CKD Stage. Complication rates and rates of morbidity and mortality were compared between stages, and strengths of correlation were calculated. RESULTS: GFR and CKD Stage were calculated for 150,283 patients. There was a significant increase in the risk of major morbidity at each progressive stage of CKD (P < .001 for all compared stages). There was a strong positive linear correlation between increasing CKD Stage and total morbidity (r2 = .983), including reoperation ( r2 = .784), readmission (r2 = .936), unplanned ICU transfer (r2 = .853), and aggregate complications such as pulmonary (r2 = .900), bleeding (r2 = .878), or progressive worsening of renal function (r2 = .845). In logistic regression, for every 10-point decrease in GFR, odds of total morbidity increased by 6%. CONCLUSION: An increased risk of perioperative complications may be seen in early stages of CKD, and risk is compounded in more advanced stages. Bariatric surgical candidates should be counseled on their increased risk of surgical complications even with mild CKD, and the benefits of bariatric surgery should be carefully weighed against significantly increased risks of complications in severe CKD.

Exploring racial disparity in perioperative outcomes following revisional bariatric surgery: A case-control matched analysis.

INTRODUCTION: Bariatric surgery is associated with 20-30% weight recidivism. As a result, revisional bariatric operation is increasingly performed. Disparity in bariatric outcomes remains controversial and very little is known about revisional bariatric surgery outcomes in ethnic cohorts. METHODS: Revisional bariatric cases were identified from the 2015 and 2016 Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File. 1:1 case-control matching was performed and perioperative outcomes compared between racial cohorts. RESULTS: 24,197 cases were analyzed, including 20.78% Black patients. At baseline, there were differences in demographics and pre-existing conditions between racial cohorts. Matched analysis compared 7,286 Black and White patients. Operative duration (p = 0.008) and length of stay (p = 0.0003) were longer in Black patients. Readmission (6.8% vs. 5.4%, p = 0.009) was higher in Black patients. Bleeding (0.82% vs. 0.38%, p = 0.02) and surgical site infection (SSI) (2.6% vs. 1.8%, p = 0.01) were higher in White patients. CONCLUSION: Revisional bariatric surgery is safe. Apart from a higher rate of bleeding, SSI and readmission, outcomes were not mediated by race.

Racial disparities in inferior vena cava filter use in metabolic and bariatric surgery patients: Nationwide insights from the MBSAQIP database.

BACKGROUND: Prophylactic inferior vena cava (IVC) filter use in bariatric surgery patients is a physician- and patient-dependent practice pattern with unclear safety and efficacy. Factors that mediate physicians' decisions for IVC filter placement preoperatively remain unclear. The role of race in decision-making also remains unclear. METHODS: From the 2015-2016 MBASQIP database, patient characteristics leading to IVC filter use and outcomes after IVC filter placement were compared between Black and White primary bariatric surgery patients. RESULTS: Prophylactic IVC filter was used in 0.66% of Black and White patients. IVC filter use was three-fold higher in Black patients, despite this cohort having a lower venous thromboembolism (VTE) risk profile than White counterparts. Black race was an independent predictor for IVC filter placement on multivariate analysis. After receiving an IVC filter, Black patients had higher rates of 30-day adverse outcomes. CONCLUSIONS: In this study, Black race was independently associated with the likelihood of receiving a prophylactic IVC filter, despite lower rates of VTE risk factors and lack of recommendations for its use. Further research is needed to explore why this disparity in clinical practice exists.

Exploring perioperative outcomes in metabolic and bariatric surgery amongst the elderly: an analysis of the 2015-2017 MBSAQIP database.

BACKGROUND: Metabolic and bariatric surgery (MBS) is increasingly performed in patients >65 years. Studies of perioperative outcomes have shown equivocal results. OBJECTIVES: Our study objective was to explore perioperative outcomes in elderly MBS patients compared with those <65 years. SETTING: Academic Hospital. METHODS: Primary sleeve (SG) and gastric bypass (RYGB) cases were identified from the 2015-2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Selected cases were stratified by age (≥65 yr versus <65 yr). Univariate and multivariate logistic regression analyses were performed comparing outcomes in the elderly with the general MBS cohort. RESULTS: 26,557 (5.6%) of MBS cases were performed in elderly patients, who were more likely to be white, male, have a lower mean body mass index (BMI), receive a gastric bypass, and robotic-assisted surgery. Elderly patients had a significantly higher disease burden, and most outcome measures were significantly higher in elderly patients, including mortality and morbidity. On multivariate regression analyses, elderly patients undergoing SG have significantly less risk of mortality and morbidity compared with RYGB. In general, co-morbidities were in most cases more strongly predictive of complications than age alone. The number needed to harm (NNH) for overall and related morbidity were 59 and 232, respectively. CONCLUSION: Elderly MBS patients have higher disease burden and higher adverse outcomes following MBS; however, complications in this cohort remain overall rare. When performing bariatric surgery on elderly patients, procedure consideration should favor SG as RYGB is independently associated with worse outcomes.

Outcomes in racial minorities after robotic Roux-en-Y gastric bypass and sleeve gastrectomy: a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

BACKGROUND: The rate of robotic-assisted metabolic and bariatric surgery (MBS) is increasing. While discord remains about racial disparity in primary MBS, there are no data on robotic MBS outcomes in racial cohorts. OBJECTIVES: To determine whether outcomes following robotic-assisted Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are mediated by race or ethnicity. SETTING: University Hospital, United States. METHODS: Robotic RYGB and SG cases were identified from the 2015-2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) databases using Current Procedure Terminology codes 43644, 43645, and 43775. Selected cases were stratified by race and ethnicity. Case-control matched and logistic regression analyses were performed. RESULTS: Matched analyses compared outcomes in 2666 RYGB cases of Black versus White patients and 1794 RYGB cases of Hispanic versus White patients. Black RYGB patients had longer operative lengths (OLs; P = .0008) and postoperative lengths of stay (P = .001), and a higher rate of pulmonary embolism (P = .05). Hispanic (versus White) RYGB patients had longer lengths of stay (P = .007). All other outcomes were similar between RYGB racial and ethnic cohorts. Matched analyses also compared outcomes of 8328 SG cases in Black versus White patients and 4852 SG cases in Hispanic versus White patients. Black patients had longer OLs (P = .004), had longer lengths of stay (P < .0001), had higher overall morbidity (P = .02), had higher bariatric-related morbidity (P = .02), had higher rates of readmission (P = .009), and were more likely to have an operative drain present at 30 days (P = .001). All other outcome measures were similar between racial/ethnic SG cohorts. CONCLUSION: Robotic-assisted SG is associated with higher overall and bariatric-related morbidity, but not mortality. However, robotic-assisted RYGB and SG remain safe, with lower rates of mortality and morbidity.