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Background: Early discharge after laparoscopic sleeve gastrectomy (SG) is common and safe, but two-thirds of patients are still hospitalized longer than 1 day. The purpose of this study was to evaluate factors associated with early discharge at a single institution with intention to discharge on postoperative day 1., Methods: Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing SG at an academic hospital between 2010 and 2016. The primary outcome measure was length of stay (LOS). Multivariate logistic regression was used to identify independent predictors of prolonged LOS., Results: A total of 367 patients undergoing SG were included. Two hundred eighty-seven (78%) were women and 294 (80%) were Caucasian. Mean age was 45.5 years and mean body mass index (BMI) was 48.7 kg/m2. One hundred twenty-three patients (33.5%) had a LOS ≤ 1 day. Compared to patients staying ≥ 2 days, early discharge patients had significantly lower BMI, creatinine, and American Society of Anesthesiologists class, were more likely to be White, married, have private insurance, and were more likely to have a morning start and no postoperative upper gastrointestinal (UGI) swallow study. Regression analysis demonstrated several independent predictors of prolonged LOS including institutional experience (OR 0.5, p < 0.001), case start time (OR 0.6, p = 0.04), and routine UGI swallow (OR 8.8, p < 0.0001) postoperatively., Conclusions: LOS after SG is affected by multiple factors, including patient health, socioeconomic status, case order, and postoperative management. Optimization of these may allow for improvement in preoperative education and streamlined postoperative pathways, resulting in reduced LOS.

Introduction: Bariatric surgery treats morbid obesity resulting in long-lasting weight loss. Elevated body mass index (BMI) increases breast cancer risk. We hypothesized that patients undergoing bariatric surgery would have decreased overall and estrogen receptor (ER)-positive breast cancer incidences compared to a propensity-matched non-surgical cohort., Methods: The bariatric population included all female patients who underwent weight loss surgery at a single institution from 1985 to 2015. Patients from all outpatient visits were propensity score matched 1:1 with bariatric patients using BMI, comorbidities, demographics, and insurance status. The primary outcome was breast cancer incidence. Univariate analyses compared the groups., Results: A total of 4860 patients were included, with 2430 in both groups. Median follow-up time from date of surgery or morbid obesity diagnosis was 5.7 years. There were no differences in age or comorbidities aside from gastroesophageal reflux disease. Seventeen (0.7%) patients in the surgery group were subsequently diagnosed with breast cancer versus 32 (1.3%) in the non-surgery group (p = 0.03). The non-surgery group had more ER-positive tumors [4 (36.4%) vs. 22 (71.0%); p = 0.04]., Conclusion: Female patients who underwent bariatric surgery were less frequently diagnosed with any breast cancer and ER-positive breast cancer versus a propensity-matched cohort suggesting a possible oncologic benefit to weight loss surgery.

Purpose: Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity as a single-stage operation for the treatment of morbid obesity, as patients undergoing LSG have been shown to achieve similar weight loss and resolution of obesity-related comorbidities in comparison to those undergoing Roux-en-Y gastric bypass (RYGB), the "gold standard" bariatric operation. Although LSG poses fewer technical challenges than RYGB, little is known about differences in short-term outcomes among patients undergoing LSG and RYGB. We hypothesized that LSG is associated with lower 30-day risk-adjusted serious morbidity., Methods: Preoperative characteristics and 30-day outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) Participant Use Files (PUF) 2010-2014 were selected for all patients who underwent LSG or RYGB. Descriptive comparisons were performed using chi-square and Wilcoxon's rank-sum tests as appropriate. The primary outcome was a risk-adjusted composite measure of 30-day serious morbidity and mortality., Results: We analyzed records for 47,982 (42.0%) and 66,380 (58.0%) patients undergoing LSG and RYGB, respectively. On univariate analysis, LSG patients had a lower rate of organ space infection (0.45% vs. 0.68%, p < 0.001), lower rate of bleeding requiring transfusions (1.00% vs. 1.60%, p < 0.001), lower rate of sepsis (0.34% vs. 0.49%, p < 0.001), and septic shock (0.12% vs. 0.22%, p < 0.001) and required fewer unplanned reoperations (1.34% vs. 2.56%, p < 0.001) than RYGB patients. Both groups had similar rates of deep venous thrombosis (0.33% vs. 0.28%, p = 0.15) and pulmonary embolism (0.17% vs. 0.21%, p = 0.15). Mortality was lower among LSG patients (0.09% vs. 0.14%, p = 0.01). On multivariate analysis, RYGB was associated with higher risk-adjusted 30-day serious morbidity than LSG (odds ratio 1.61; 95% CI 1.52-1.71, p < 0.001). Older age, female gender, higher BMI, and insulin-dependent diabetes were also associated with risk of serious morbidity (C-statistic = 0.60)., Conclusion: Serious morbidity following bariatric surgery is uncommon; however, LSG may be associated with modest protection from adverse 30-day outcomes in comparison to RYGB. Our conclusion is limited by the difference in baseline risk factors of the populations studied.

Purpose: The purposes of this study are to identify the cumulative incidence of post-bariatric surgery hypoglycemia (PBSH), describe its symptomatology, and characterize treatment patterns at a large academic institution., Materials and Methods: All patients who underwent bariatric surgery at a single institution from 1985 to 2015 were identified using a clinical database, administrative billing data identified patients who were treated for hypoglycemia, and chart reviews were performed to make a diagnosis of PBSH based on Whipple's triad. PBSH cases were reviewed including patient diabetes history, symptomatology, and treatment measures. Univariate analyses were performed to identify correlations based on symptomatology, laboratory values, and treatments utilized., Results: Ninety (2.6%) of 3487 patients were diagnosed with PBSH with preoperative median age of 43 years, mean BMI of 50.0 kg/m 2 , and median glycated hemoglobin of 6.0%. Median time-to-first hypoglycemic event was 40.6 months. No factors were identified which predict symptom severity or resolution. The 24 (27%) patients who received pharmacotherapy to treat hypoglycemia were younger, had lower nadir blood glucose levels, and more frequent symptoms. Sixty-nine (79%) cases eventually resolved., Conclusions: PBSH onset and severity are highly variable. Successful management of these patients can prove difficult and should include dietary therapy, the selective use of pharmacotherapy and surgery, and the use of a multidisciplinary team including bariatric surgeons and endocrinologists.

Bariatric surgery is an effective and durable treatment for individuals with obesity and its associated comorbidities. However, not all patients meet weight loss and/or cardiometabolic goals following bariatric surgery, suggesting that some people are bariatric surgery resistant. The reason for this resistance is unclear, but potential factors, such as adiposity-derived inflammation, insulin resistance, hyperglycemia, and aerobic fitness prior to surgery, have been related to blunted surgery responsiveness. Exercise, diet, and/or pharmacology are effective at reducing inflammation and improving insulin action as well as physical function. Herein, we present data that supports the novel hypothesis that intervening prior to surgery can enhance disease resolution in people who are resistant to bariatric surgery.

Background: Roux-en-Y gastric bypass (RYGB) effectively treats obesity and gastroesophageal reflux disease (GERD). As more surgeons recommend RYGB to treat GERD in patients with obesity, there are concerns about this approach in patients with previous non-bariatric foregut surgery. This study aims to evaluate the effect of previous non-bariatric foregut surgery on subsequent RYGB., Methods: Retrospective review of 2089 patients undergoing RYGB between January 1985 and June 2015 was conducted to identify all patients with previous non-bariatric foregut surgery. Perioperative and postoperative data was collected by retrospective chart review., Results: A total of 11 patients with prior non-bariatric foregut surgery underwent RYGB with median time between operations of 95.6 months. Of note, 7/11 (63.6%) had previous Nissen fundoplication. Conversion to open operation was required in 3/7 (42.9%) with previous Nissen compared to 1/4 (25%) in those without previous Nissen. The average length of stay (LOS) was 3.9 ± 0.9 days, significantly longer than our institutional average for RYGB of 3.2 ± 3.2 days (p = 0.02). Mean percentage of excess body mass index loss (%EBMIL) was 64.7 ± 23.5 at 4-year median follow-up, comparable to our institution's previously reported data. No mortalities were attributed to RYGB and the overall complication rate was 18.2%, compared to our institutional complication rate for RYGB of 8.5% (p = 0.253)., Conclusion: Despite increased technical difficulty and increase perioperative morbidity, patients undergoing RYGB with previous non-bariatric foregut surgery had long-term symptom resolution and robust weight loss. This indicates that in the right hands, RYGB after non-bariatric foregut surgery may be performed safely and effectively.

Background: Following weight-loss surgery, patients who failed to achieve or sustain weight loss have nevertheless reported high satisfaction with their long-term bariatric experience. Understanding this phenomenon better will likely improve patients' experiences., Objective: The purpose of this study was to explore patients' long-term experiences following bariatric surgery., Setting: A 604-bed academic health system in the USA., Methods: Participants rated satisfaction and shared spontaneous comments regarding their gastric bypass experience. A phenomenological mode of inquiry explored participants' experiences. Transcribed phrases were categorized and themes identified., Results: In a 2004 surgical cohort, with 55% (155/281) participation, 99% of participants rated bariatric experience satisfaction (mean score 8.4) and 74% (115/155) shared comments regarding experiences. Responses were categorized as positive (63% 72/115), neutral (25% 29/115), or negative (12% 14/115). Satisfaction, Appreciation, and Gratefulness emerged as themes from positive comments, with 8% (6/72) explicitly acknowledging amount of weight loss achieved. Twenty-five percent (18/72) spontaneously mentioned undergoing surgery again or recommending the procedure to others. Neutral comments contained the themes of Reflection, Acknowledgment, and Wistfulness. Themes of Dissatisfaction, Disappointment, and Regret emerged from negative comments. Forty-three percent (6/14) of negative comments remarked on regaining weight or not reaching goal weight. Twenty-one percent (3/14) of negative comments explicitly stated regret at having undergone surgery., Conclusions: Participants readily shared comments regarding their gastric bypass experience. Exploring themes provided insight into patients' satisfaction with bariatric surgery even when weight-loss goals were not met and conversely substantial dissatisfaction even when weight loss occurred. This study underscores the importance of understanding the patients' long-term experience following bariatric surgery.

Objective(s): Monitoring and prevention of long-term nutrient deficiency after laparoscopic Roux-en-Y gastric bypass (LRYGB) remains ill defined due to limited surgical follow-up after bariatric surgery. This study compared nutrient supplementation as well as surgeon and primary care physician (PCP) follow-up between patients with short-term versus long-term follow-up., Methods: All patients undergoing LRYGB at a single institution in 2004 (long-term group, n = 281) and 2012-2013 (short-term group, n = 149) were evaluated. Prospectively collected database, electronic medical record (EMR) review and telephone survey were used to obtained follow-up for both cohorts. Multivariate logistic regression was used to assess factors independently predicting multivitamin use., Results: Complete follow-up was achieved in 172 (61 %) long-term and 107 (72 %) short-term patients. We demonstrate a significant difference (p < 0.0001) in time since last surgeon follow-up (13.3 ± 7.8 vs 86.9 ± 39.9 months) for the long-term group with no difference in PCP follow-up, (3.1 ± 4.3 vs 3.7 ± 3.4). Nutrient supplementation was higher in the short-term group, including multivitamin (70.3 vs 58.9 %, p < 0.05), iron (84.2 vs 67.1 %, p = 0.02), and calcium (49.5 vs 32.9 %, p = 0.01). After adjusting for interval since surgery, %EBMI and current comorbidities logistic regression (c = 0.797) demonstrated shorter time since last surgeon visit was independently predictive of multivitamin use (p = 0.001)., Conclusions: While it appears patients prefer to follow-up with their PCP, this study reveals a large disparity in malnutrition screening and nutrient supplementation following LRYGB. Therefore, implementation of multidisciplinary, best-practice guidelines to recognize and prevent malnutrition is paramount in the management of this growing population of high-risk patients.

Background: Laparoscopic adjustable gastric banding (LAGB) is a common surgical treatment for obesity. Evidence for and against the association of aerobic exercise (AE) and weight loss after LAGB exists. We hypothesize that aerobic exercise is associated with improved weight loss and resolution of comorbidities after LAGB., Methods: A review of a prospectively collected database identified patients who underwent LAGB over a 3-year period at a single institution. Body mass index (BMI), comorbidities, frequency, and duration of exercise were collected preoperatively and at 6, 12, 24, and 36 months postoperatively. Excess weight loss (EWL) was calculated. Groups were analyzed using Fisher's exact test and ANOVA., Results: Of the 145 LAGB patients, 120 had adequate data for analysis. AE had no association with weight loss at 6 months. At 12, 24, and 36 months following LAGB, patients who reported 150 min or more per week of exercise had an EWL of 35.5, 47.3, and 54.1 %, respectively, while those reporting 0-59 min per week of AE had an EWL of 25.3, 32.1, and 33.0 % (p = 0.03, 0.03, and 0.02, respectively). BMI and age was not statistically different among groups. Diabetes and obstructive sleep apnea were significantly improved in patients exercising at least 60 min per week as compared to those exercising 0-59 min., Conclusions: AE is significantly associated with weight loss and comorbidity resolution after LAGB. We propose that patients who perform more AE will have higher levels of EWL.

Background: Roux-en-Y gastric bypass (RYGB) surgery is one of the most commonly performed bariatric surgeries in the United States. Patients with prior RYGB are not amenable to conventional endoscopic retrograde cholangiopancreaticography (ERCP). Surgical gastrostomy (SG) tube placement enables transgastrostomy ERCP (TG-ERCP)., Materials and Methods: Eleven patients with RYGB anatomy received open Stamm gastrostomy after which the tract was then allowed to mature for an average of 45 days before therapeutic TG-ERCP. The success rate and procedure-related complications of both gastrostomy and ERCP were assessed., Results: TG-ERCP was performed on eleven patients (median age 52 years, range 37-61 years) with prior RYGB and pancreatobiliary diseases. Indications for ERCP in these patients included suspected gallstone pancreatitis (n = 4), ampullary/biliary strictures (n = 5), pancreas divisum (n = 1), and common bile duct clipping as a result of RYGB surgery (n = 1). Two individuals developed post surgical complications with stomal-related infections. TG-ERCP with therapeutic intervention was successfully performed in all patients. Intervention included stone extractions (n = 11), biliary stricture dilation (n = 11), biliary sphincterotomy (n = 11), biliary (n = 3) and pancreatic (n = 1) stent placement, ampullary biopsies (n = 3), choledochoscopy (n = 1), and pseudocyst drainage (n = 1). Complications included post-ERCP pancreatitis (n = 2), post-sphincterotomy bleeding (n = 1), gastrostomy site bleed (n = 1), and gastric perforation (n = 1). The total number of ERCP sessions for the eleven patients was 15 (1 or 2 per patient). Median follow-up was 42 days (range 7-123 days)., Conclusion: Surgical open gastrostomy followed by TG-ERCP enables therapeutic intervention but is associated with significant complications.

Background: As our bariatric program matured, we noted that length of stay (LOS) steadily decreased. This led us to analyze our experience to identify factors contributing to this abbreviated LOS and to evaluate the safety of discharging patients with only a 2-day LOS., Methods: All patients undergoing open Roux-en-Y gastric bypass (RYGBP) from March, 1998 to December 31, 2002 were evaluated. Contrast swallow study was performed on Day 1. Patient demographics, complications, and readmission rates were reported for all patients. Discharge criteria included adequate oral intake, pain control with oral analgesia, and an adequate understanding of the operation and its effects demonstrated by a written test before discharge., Results: 316 patients underwent open RYGBP with mean BMI 52.3. Operative time decreased from 241 minutes in 1998 to 156 minutes in 2002. No patient was discharged at 2 days during the first 2 years of the program. In 2000, 1 of 52 patients (2%) went home on the second day. In 2001, the year we fully enacted our multidisciplinary approach, 14 of 96 patients (15%) returned home on the second day. In 2002, 73 of 145 patients (50%) were discharged on the second postoperative day, with no increase in readmission rates. Three of the 73 patients (4.1%) required readmission within 30 days of discharge. No difference in co-morbid diseases or BMI was noted between groups., Conclusions: Our data support the hypothesis that patients undergoing open RYGBP can be discharged safely at Day 2, provided that aggressive preoperative education and screening are performed.