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Background: Bariatric surgery has been associated with numerous micronutrient deficiencies. Several observational studies have found that these deficiencies are more common in racially/ethnically minoritized patients., Objectives: To conduct a systematic review to investigate whether racially/ethnically minoritized patients experience worse nutritional outcomes after bariatric surgery., Setting: University of Wisconsin-Madison., Methods: PubMed, CINAHL, PsychINFO, and Cochrane databases were queried. We searched for manuscripts that reported micronutrient levels or conditions related to micronutrient deficiencies according to race/ethnicity (White, African American/Black, and Hispanic) after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between 2002 and 2022. Eleven micronutrients (vitamins A, B1 [thiamine], B12, D, E, K, calcium, copper, folate, iron, and zinc), and four conditions (anemia, bone loss, fractures, and hyperparathyroidism) were assessed., Results: Abstracts from 953 manuscripts were screened; 18 full-text manuscripts were reviewed for eligibility, and ten met the inclusion criteria. Compared to White patients, African Americans had a higher prevalence of thiamine, vitamin D, and vitamin A deficiencies. There were no differences in calcium and vitamin B12 deficiencies. The other six micronutrients were not assessed according to race/ethnicity. Hyperparathyroidism was more prevalent in African Americans than White patients in the three studies that evaluated it. The prevalence of fractures was mixed. Anemia and bone loss were not evaluated according to race/ethnicity., Conclusions: Although the literature on micronutrient outcomes following bariatric surgery according to race/ethnicity is limited, African Americans appear to experience a higher prevalence of vitamin deficiencies and associated conditions. Qualitative and quantitative research to explore these disparities is warranted., (Published by Elsevier Inc.)

Background: Disparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery., Methods: We performed semi-structured interviews with bariatric surgery patients and providers from April-November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model., Results: 24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy., Conclusions: Interventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged., (Published by Elsevier Inc.)

Objective: To characterize patient and provider perceptions of the impact of coronavirus disease 2019 (COVID-19) on weight loss following bariatric surgery., Background: COVID-19 has disrupted routines and healthcare throughout the United States, but its impact on bariatric surgery patients' postoperative experience is unknown., Methods: Semistructured interviews with bariatric surgery patients, primary care providers, and health psychologists were conducted from April to November 2020. As part of a secondary analysis, patients and providers described how the COVID-19 pandemic affected the postoperative experience within 3 domains: dietary habits, physical activity, and follow-up care. Interview guides were created from 2 conceptual models: Torain's Surgical Disparities Model and Andersen's Behavioral Model of Health Services Use. Study team members derived codes, which were grouped into themes using conventional content analysis., Results: Thirty-four participants were interviewed: 24 patients (12 Roux-en-Y gastric bypass and 12 sleeve gastrectomy), 6 primary care providers, and 4 health psychologists. Patients were predominately female (83%) and White (79%). Providers were predominately female (90%) and White (100%). COVID-19 affected the postoperative bariatric surgery patient experience via 3 mechanisms: (1) it disrupted dietary and physical activity routines due to facility closures and fear of COVID-19 exposure; (2) it required patients to transition their follow-up care to telemedicine delivery; and (3) it increased stress due to financial and psychosocial challenges., Conclusions: COVID-19 has exacerbated patient vulnerability. The pandemic is not over, thus bariatric surgery patients need ongoing support to access mental health professionals, develop new physical activity routines, and counteract increased food insecurity., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Individual characteristics associated with weight loss after bariatric surgery are well established, but the neighborhood characteristics that influence outcomes are unknown., Objectives: The objective of this study was to determine if neighborhood characteristics, including social determinants and lifestyle characteristics, were associated with weight loss after bariatric surgery., Setting: Single university healthcare system, United States., Methods: In this retrospective cohort study, all patients who underwent primary bariatric surgery from 2008 to 2017 and had at least 1 year of follow-up data were included. Patient-level demographics and neighborhood-level social determinants (area deprivation index, urbanicity, and walkability) and lifestyle factors (organic food use, fresh fruit/vegetable consumption, diet to maintain weight, soda consumption, and exercise) were analyzed. Median regression with percent total body weight (%TBW) loss as the outcome was applied to examine factors associated with weight loss after surgery., Results: Of the 647 patients who met inclusion criteria, the average follow-up period was 3.1 years, and the mean %TBW loss at the follow-up was 22%. In adjusted median regression analyses, Roux-en-Y gastric bypass was associated with greater %TBW loss (11.22%, 95% confidence interval [8.96, 13.48]) compared to sleeve, while longer follow-up time (-2.42% TBW loss per year, 95% confidence interval [-4.63, -0.20]) and a preoperative diagnosis of diabetes (-1.00% TBW loss, 95% confidence interval [-1.55, -0.44]) were associated with less. None of the 8 neighborhood level characteristics was associated with weight loss., Conclusions: Patient characteristics rather than neighborhood-level social determinants and lifestyle factors were associated with weight loss after bariatric surgery in our cohort of bariatric surgery patients. Patients from socioeconomically deprived neighborhoods can achieve excellent weight loss after bariatric surgery., (Published by Elsevier Inc.)

Background: Less than 1% adults in the United States who meet body mass index criteria undergo bariatric surgery. Our objective was to identify patient and provider perceptions of individual-level barriers to undergoing bariatric surgery., Methods: Adults with severe obesity and obesity care providers described their experiences with the bariatric surgery care process in semi-structured interviews. Using conventional content analysis, individual-level barriers were identified within Andersen's Behavioral Model of Health Services Use., Results: Of the 73 individuals interviewed, 36 (49%) were female, and 15 (21%) were non-white. Six individual-level barriers were identified: fear of surgery, fear of lifestyle change, perception that weight had not reached its "tipping point," concerns about dietary changes, lack of social support, and patient characteristics influencing referral., Conclusions: Patient and provider education should address patient fears of surgery and the belief that surgery is a "last resort." Bariatric surgery programs should strengthen social support networks for patients., (Published by Elsevier Inc.)

Objective: To characterize system-level barriers to bariatric surgery from the perspectives of Veterans with severe obesity and obesity care providers., Summary of Background Data: Bariatric surgery is the most effective weight loss option for Veterans with severe obesity, but fewer than 0.1% of Veterans with severe obesity undergo it. Addressing low utilization of bariatric surgery and weight management services is a priority for the veterans health administration., Methods: We conducted semi-structured interviews with Veterans with severe obesity who were referred for or underwent bariatric surgery, and providers who delivered care to veterans with severe obesity, including bariatric surgeons, primary care providers, registered dietitians, and health psychologists. We asked study participants to describe their experiences with the bariatric surgery delivery process in the VA system. All interviews were audio-recorded and transcribed. Four coders iteratively developed a codebook and used conventional content analysis to identify relevant systems or "contextual" barriers within Andersen Behavioral Model of Health Services Use., Results: Seventy-three semi-structured interviews with veterans (n = 33) and providers (n = 40) throughout the veterans health administration system were completed. More than three-fourths of Veterans were male, whereas nearly three-fourths of the providers were female. Eight themes were mapped onto Andersen model as barriers to bariatric surgery: poor care coordination, lack of bariatric surgery guidelines, limited primary care providers and referring provider knowledge about bariatric surgery, long travel distances, delayed referrals, limited access to healthy foods, difficulties meetings preoperative requirements, and lack of provider availability and/or time., Conclusions: Addressing system-level barriers by improving coordination of care and standardizing some aspects of bariatric surgery care may improve access to evidence-based severe obesity care within VA., Competing Interests: The authors declare no conflicts of interest related to these funding sources., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Minimizing bariatric surgery care costs is important since more than 250,000 patients undergo bariatric surgery annually in the United States. The study objective was to compare perioperative costs for the two most common bariatric procedures: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). In addition, we sought to identify predictors of high-cost perioperative care. Methods: Adult patients who underwent LSG or LRYGB from 2012 to 2017 were identified using our institutional bariatric surgery database. Perioperative costs, defined as costs incurred from the time of entering the preoperative unit until exiting the postanesthesia care unit, were obtained through billing data. Median perioperative cost components of LSG and LRYGB were compared using Mann-Whitney tests. Multivariable logistic regression was performed to investigate patient-level predictors of high-cost care, defined as the top tercile of perioperative costs. Results: We included 546 bariatric surgery patients with a mean age and body mass index (BMI) of 49.7 years and 45.9 kg/m 2 , respectively. There were no significant differences in median perioperative costs between LSG and LRYGB ($14,942 versus $15,016; P  = .80). Stapler use was the largest cost contributor for both procedures, accounting for 27.7% and 29.2% of costs for LSG and LRYGB, respectively. In multivariable analyses, preoperative patient characteristics, including BMI, were not associated with high-cost perioperative care. Conclusions: Perioperative costs for LSG and LRYGB were similar in our single institution study. Reducing costs outside of the operating room, including those related to ED visits and complications, may be more impactful than focusing on cost reduction directly related to perioperative care.

Purpose: To compare longitudinal hepatic proton density fat fraction (PDFF) changes estimated by magnitude- vs. complex-based chemical-shift-encoded MRI during a weight loss surgery (WLS) program in severely obese adults with biopsy-proven nonalcoholic fatty liver disease (NAFLD)., Methods: This was a secondary analysis of a prospective dual-center longitudinal study of 54 adults (44 women; mean age 52 years; range 27-70 years) with obesity, biopsy-proven NAFLD, and baseline PDFF ≥ 5%, enrolled in a WLS program. PDFF was estimated by confounder-corrected chemical-shift-encoded MRI using magnitude (MRI-M)- and complex (MRI-C)-based techniques at baseline (visit 1), after a 2- to 4-week very low-calorie diet (visit 2), and at 1, 3, and 6 months (visits 3 to 5) after surgery. At each visit, PDFF values estimated by MRI-M and MRI-C were compared by a paired t test. Rates of PDFF change estimated by MRI-M and MRI-C for visits 1 to 3, and for visits 3 to 5 were assessed by Bland-Altman analysis and intraclass correlation coefficients (ICCs)., Results: MRI-M PDFF estimates were lower by 0.5-0.7% compared with those of MRI-C at all visits (p < 0.001). There was high agreement and no difference between PDFF change rates estimated by MRI-M vs. MRI-C for visits 1 to 3 (ICC 0.983, 95% CI 0.971, 0.99; bias = - 0.13%, p = 0.22), or visits 3 to 5 (ICC 0.956, 95% CI 0.919-0.977%; bias = 0.03%, p = 0.36)., Conclusion: Although MRI-M underestimates PDFF compared with MRI-C cross-sectionally, this bias is consistent and MRI-M and MRI-C agree in estimating the rate of hepatic PDFF change longitudinally., Key Points: • MRI-M demonstrates a significant but small and consistent bias (0.5-0.7%; p < 0.001) towards underestimation of PDFF compared with MRI-C at 3 T. • Rates of PDFF change estimated by MRI-M and MRI-C agree closely (ICC 0.96-0.98) in adults with severe obesity and biopsy- proven NAFLD enrolled in a weight loss surgery program. • Our findings support the use of either MRI technique (MRI-M or MRI-C) for clinical care or by individual sites or for multi-center trials that include PDFF change as an endpoint. However, since there is a bias in their measurements, the same technique should be used in any given patient for longitudinal follow-up.

Background: Opioid analgesics are often prescribed to manage pain after bariatric surgery, which may develop into chronic prescription opioid use (CPOU) in opioid-naïve patients. Bariatric surgery may affect opioid use in those with or without presurgical CPOU., Objective: To compare CPOU persistence and incidence in a large multisite cohort of veterans undergoing bariatric surgery (open Roux-en-Y gastric bypass, laparoscopic RYGB, or laparoscopic sleeve gastrectomy) and matched nonsurgical controls., Setting: Veterans Administration hospitals., Methods: In a retrospective cohort study, we matched 1117 surgical patients with baseline CPOU to 9531 nonsurgical controls, and 2822 surgical patients without CPOU at baseline to 26,392 nonsurgical controls using sequential stratification. CPOU persistence in veterans with baseline CPOU was estimated using generalized estimating equations by procedure type. CPOU incidence in veterans without baseline CPOU was estimated in Cox regression models by procedure type because postoperative pain, complications, and absorption may differ by procedure., Results: In veterans with baseline CPOU, postsurgical CPOU declined over time for each surgical procedure; these trends did not differ between surgical patients and nonsurgical controls. In veterans without baseline CPOU, compared with nonsurgical controls, bariatric patients had higher CPOU incidence within 5 years after open Roux-en-Y gastric bypass (hazard ratio = 1.19; 95% confidence interval: 1.06-1.34) or laparoscopic open Roux-en-Y gastric bypass (hazard ratio = 1.22, 95% confidence interval: 1.06-1.41). Veterans undergoing laparoscopic sleeve gastrectomy had higher CPOU incidence 1 to 5 years after surgery (hazard ratio = 1.28; 95% confidence interval: 1.05-1.56) than nonsurgical controls., Conclusions: Bariatric surgery was associated with greater risk of CPOU incidence in patients without baseline CPOU but was not associated with greater CPOU persistence., (Published by Elsevier Inc.)

Objective: This study describes early-phase development of a behavioral intervention to reduce weight regain following bariatric surgery. We utilized the Obesity-Related Behavioral Intervention Trials model to guide intervention development and evaluation. We sought to establish recruitment, retention, and fidelity monitoring procedures; evaluate feasibility of utilizing weight from the electronic medical record (EMR) as an outcome; observe improvement in behavioral risk factors; and evaluate treatment acceptability., Method: The intervention comprised 4 weekly telephone calls addressing behavior change strategies for diet, physical activity, and nutrition supplement adherence and 5 biweekly calls addressing weight loss maintenance constructs. Veterans ( N = 33) who received bariatric surgery 9-15 months prior consented to a 16-week, pre-post study. Self-reported outcomes were obtained by telephone at baseline and 16 weeks. Clinic weights were obtained from the EMR 6 months pre- and postconsent. Qualitative interviews were conducted at 16 weeks to evaluate treatment acceptability. We aimed to achieve a recruitment rate of ≥ 25% and retention rate of ≥ 80%, and have ≥ 50% of participants regain < 3% of their baseline weight., Results: Results supported the feasibility of recruiting (48%) and retaining participants (93% provided survey data; 100% had EMR weight). Pre-post changes in weight (73% with < 3% weight regain) and physical activity (Cohen's ds 0.38 to 0.52) supported the potential for the intervention to yield clinically significant results. Intervention adherence (mean 7.8 calls of 9 received) and positive feedback from interviews supported treatment acceptability., Conclusions: The intervention should be evaluated in an adequately powered randomized controlled trial. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Background: Intraoperative testing of anastomoses and staples lines is commonly performed to minimize the risk of postoperative leaks in bariatric surgery, but its impact is unclear. The aim of this study was to determine the association between leak testing and 30-d postoperative leak, bleed, reoperation, and readmission rates for patients undergoing laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB)., Methods: This is a retrospective observational study utilizing 2015-2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Postoperative outcomes were compared using χ 2 test. Multivariable logistic regression was used to identify factors associated with 30-d outcomes., Results: We included 237,081 patients. Leak testing was performed on 73.0% and 92.1% of LSG and RYGB patients, respectively. LSG was associated with lower rates of leak, bleed, reoperation, and readmission than RYGB. On multivariable analysis, intraoperative leak testing was associated with increased rates of postoperative leak for LSG and RYGB (OR 1.48 and 1.90, respectively) and lower rates of bleed for LSG (OR 0.76). There were no significant associations between leak testing and rates of reoperation or readmission., Conclusions: Use of intraoperative leak testing was not associated with improved outcomes for either LSG or RYGB. A prospective trial investigating leak testing is warranted to better elucidate its impact., (Published by Elsevier Inc.)

Background: Both medical weight management (MWM) and bariatric surgery are significantly underutilized by patients with severe obesity, particularly males. Less than 30% of participants in MWM programs are male, and only 20% of patients undergoing bariatric surgery are men. Objectives: To identify motivations of males who pursue either MWM or bariatric surgery. Setting: Interviews with males with severe obesity (body mass index ≥35 kg/m 2 ), who participated in a Veteran Affairs weight loss program in the Midwest. Materials and Methods: Participants were asked to describe their experiences with MWM and bariatric surgery. Interviews were audio-recorded, transcribed, and uploaded to NVivo for data management and analysis. Five coders iteratively developed a codebook using inductive content analysis to identify relevant themes. We utilized theme matrices organized by type of motivation and treatment pathway to generate higher-level analysis and generate themes. Results: Twenty-five males participated. Participants were 58.7 (standard deviation 8.6) years old on average, and 24% were non-white. Motivations for pursuing MWM or surgery included a desire to improve physical or psychological health and to enhance quality of life. Patients seeking bariatric surgery were motivated by the fear of death and felt that they had exhausted all other weight loss options. MWM patients believed they had more time to pursue other weight loss options. Conclusion: The opportunity to improve health, optimize quality of life, and lengthen lifespan motivates males with severe obesity to pursue weight loss treatments. These factors should be considered when providers educate patients about obesity treatment options and outcomes.

Introduction: Nonalcoholic fatty liver disease (NAFLD) is an epidemic in the obese population. Bariatric surgery is known to reverse multiple metabolic complications of obesity such as diabetes, dyslipidemia, and NAFLD, but the timing of liver changes has not been well described., Materials and Methods: This was an IRB-approved, two-institutional prospective study. Bariatric patients received MRIs at baseline and after a pre-operative liquid diet. Liver biopsies were performed during surgery and if NAFLD positive, the patients received MRIs at 1, 3, and 6 months. Liver volumes and proton-density fat fraction (PDFF) were calculated from offline MRI images. Primary outcomes were changes in weight, body mass index (BMI), percent excess weight loss (EWL%), liver volume, and PDFF. Resolution of steatosis, as defined as PDFF < 6.4% based on previously published cutoffs, was assessed. Secondarily, outcomes were compared between patients who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB)., Results: From October 2010 to June 2015, 124 patients were recruited. 49 patients (39.5%) completed all five scans. EWL% at 6 months was 55.6 ± 19.0%. BMI decreased from 45.3 ± 5.9 to 34.4 ± 5.1 kg/m 2 and mean liver volume decreased from 2464.6 ± 619.4 to 1874.3 ± 387.8 cm 3 with a volume change of 21.4 ± 11.4%. PDFF decreased from 16.6 ± 7.8 to 4.4 ± 3.4%. At 6 months, 83.7% patients had resolution of steatosis. Liver volume plateaued at 1 month, but PDFF and BMI continued to decrease. There were no statistically significant differences in liver volume or PDFF reduction from baseline to 6 months between the LSG versus LRYGB subgroups., Conclusion: Patients with NAFLD undergoing bariatric surgery can expect significant decreases in liver volume and hepatic steatosis at 6 months, with 83.7% of patients achieving resolution of steatosis. Liver volume reduction plateaus 1-month post-bariatric surgery, but PDFF continues to decrease. LSG and LRYGB did not differ in efficacy for inducing regression of hepatosteatosis.

Severe obesity affects nearly 20 million adults in the United States and is associated with significant morbidity and mortality. Bariatric surgery is the most effective treatment for weight loss and resolution of obesity-related co-morbidities. Of adults with severe obesity,<1% undergo bariatric surgery annually. Both contextual (health system, clinicians, and community) and individual factors contribute to the underutilization of bariatric surgery. In this review, we summarize potential barriers to undergoing bariatric surgery within the framework of Andersen's Behavioral Model of Health Services Use., (Published by Elsevier Inc.)

Background: Laparoscopic adjustable gastric banding (LAGB) is an option for the treatment of severe obesity. Few US studies have reported long-term outcomes. We aimed to present long-term outcomes with LAGB., Methods: Retrospective study of patients who underwent LAGB at an academic medical center in the US from 1/2005 to 2/2012. Outcomes included weight loss, complications, re-operations, and LAGB failure., Results: 208 patients underwent LAGB. Mean BMI was 45.4 ± 6.4 kg/m 2 . Mean follow-up was 5.6 (0.5-10.7) years. Complete follow-up was available for 90% at one year (186/207), 80% at five years (136/171), and 71% at ten years (10/14). Percentage of excess weight loss at one, five, and ten years was 29.9, 30, and 16.9, respectively. Forty-eight patients (23.1%) required a reoperation. LAGB failure occurred in 118 (57%) and higher baseline BMI was the only independently associated factor (OR 1.1; 95%CI 1.0-1.1; p = 0.016)., Conclusion: LAGB was associated with poor short and long-term weight loss outcomes and a high failure rate. With the increased safety profile and greater efficacy of other surgical techniques, LAGB utilization should be discouraged., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Bariatric surgery is an effective weight loss and comorbidity treatment among severely obese patients. However, there are limited data describing its impact on patient-reported quality of life (QoL). We examined patient-reported QoL after bariatric surgery and analyzed variables associated with higher postoperative QoL., Methods: Patient demographics, comorbidities, and weight loss data were obtained from our institutional database for patients who underwent bariatric surgery from January 2010 to December 2012. QoL scores were obtained during preoperative and postoperative visits (2, 6, 12, 24, 52, and 104 wk) from the Moorehead-Ardelt Quality of Life Questionnaire II. Multivariable logistic regression was performed to generate odds ratios for variables hypothesized a priori to be associated with higher postoperative QoL., Results: A total of 209 patients were included in the study. Patients lost an average of 59.1% (±19.0) of excess body weight 1 y after surgery. One-year postoperative QoL scores were available for 42% of patients. Mean QoL scores improved from 0.82 preoperatively to 1.66 1 y postoperatively (P = 0.004). Patients scored higher in all individual areas of Moorehead-Ardelt Quality of Life Questionnaire II: self-esteem (0.22 versus 0.36), physical activity (0.11 versus 0.31), social life (0.28 versus 0.36), work ability (0.07 versus 0.22), sexual functioning (0.04 versus 0.16), and approach to food (0.11 versus 0.26; all P values <0.05). On multivariable analysis, higher QoL was associated with private insurance/self-pay versus Medicare (odds ratio 4.20 [95% confidence interval 1.39-12.68])., Conclusions: Bariatric surgery patients experienced significant improvement in QoL 1 y after surgery. Identifying modifiable predictors of high QoL after bariatric surgery requires additional investigation., (Published by Elsevier Inc.)

Background: Understanding what proportion of the eligible population is undergoing bariatric surgery at the state level provides critical insight into characterizing bariatric surgery access. We sought to describe statewide trends in severe obesity demographics and report bariatric surgery volume in Wisconsin from 2011 to 2014., Methods: Self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to calculate prevalence rates of severe obesity (class II and III) in Wisconsin. Bariatric surgery volume data were analyzed from the Wisconsin Hospital Association. A survey was sent to all American Society for Metabolic and Bariatric Surgery member bariatric surgeons in Wisconsin to assess perspectives on bariatric surgery access, insurance coverage, and referral processes., Results: The prevalence of severe obesity in Wisconsin increased by 30% from 2011 to 2014 (10.4%-13.2%; P = .035); the odds of severe obesity nearly doubled for adults age 20-39 (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.3-3.0). During this time, the volume of bariatric surgery declined by 4.2%; (1432 to 1372; P < .001), whereas the rates of bariatric surgery per 1000 persons with severe obesity declined by 25.7% (3.5 to 2.6/1000). A majority (72%) of bariatric surgeon respondents felt bariatric surgery access either worsened or remained the same over the last 4 years., Conclusions: Severe obesity increased significantly in Wisconsin over a 4-year period, whereas bariatric surgery rates among severely obese persons have remained largely unchanged and are substantially below the national average. Combining the state-level obesity survey data and bariatric surgery administrative data may be a useful approach for tracking bariatric surgery access throughout the United States.

Background: Bariatric surgery is the most effective treatment for morbidly obese type II diabetics. However, guidelines for perioperative glucose control are not well established. We examined management of perioperative glucose levels in diabetic patients undergoing bariatric surgery and determined the impact of optimal glucose control as defined by the American Society for Metabolic and Bariatric Surgery (ASMBS) on patient outcomes, including long-term diabetes resolution., Methods: A single-institution, retrospective analysis of 155 morbidly obese diabetic patients who underwent laparoscopic gastric bypass (RYGB) or sleeve gastrectomy (LSG) from 2010 to 2014 was performed. Inpatient finger-stick glucose levels were extracted from the electronic health record and defined as optimal if all values were <180 mg/dl. Ninety-day and one-year outcomes, including diabetes resolution, medication management, mortality and total costs were compared for patients with and without optimal control., Results: 80 % (n = 124) of patients with type II diabetes underwent RYGB, while the remaining patients underwent LSG. Diabetes resolution at 1 year was 70.1 % (73.4 % for RYGB and 53.9 % for LSG, p = 0.191). Preoperatively, 72 % (n = 112) of patients were taking one or more oral antihyperglycemic agents, while only 50.3 % (n = 78) took an oral medication on discharge. 93 % of RYGB and 82 % of LSG patients, respectively, reduced their long-acting insulin dosage by greater than 50 % upon discharge (p = 0.251). Ninety-day and one-year outcomes including total costs were not improved by optimal perioperative glucose control. In total, 96.7 % of optimally controlled patients experienced diabetes resolution at 1 year compared to 53.2 % in the non-optimally controlled group (p < 0.001)., Conclusion: Bariatric surgery leads to significant resolution of type II diabetes and a prompt improvement in glucose tolerance in the perioperative period. Optimal glucose control as defined by the ASMBS was not associated with improved postoperative outcomes in our patient population but was highly predictive of long-term diabetes resolution.

Background: Drivers of high cost care after bariatric operation have not been well described. We sought to compare 1-year costs between patients who underwent laparoscopic vertical sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass and identify predictors of high cost of care., Methods: Morbidly obese patients who underwent laparoscopic vertical sleeve gastrectomy (n = 74) or laparoscopic Roux-en-Y gastric bypass (n = 270) at a single institution from 2010-2014 were identified. Patient demographic characteristics, surgeon age, 90-day and 1-year surgical outcomes, and facility cost data were collected. "High cost" patients were defined as those in the top quartile of costs among all patients. Variables hypothesized a priori to be associated with high total costs were included in a bivariate logistic regression model. Those with a P value < .1 were included in a multivariable logistic regression model with "high cost" as the outcome., Results: Laparoscopic vertical sleeve gastrectomy was associated with slightly greater median total 1-year costs ($18,234 vs $17,151; P = .021) and inpatient costs ($15,026 vs $13,990; P = .019). On multivariable analysis, having Medicaid (odds ratio 2.72; 95% confidence interval, 1.47-5.06) compared with private insurance, being readmitted to the hospital (odds ratio 5.48; 95% confidence interval, 2.45-12.26), and experiencing a postoperative complication (odds ratio 4.12; 95% confidence interval, 1.79-9.48) were associated with high-cost care., Conclusion: Suboptimal operative outcomes seem to be the primary driver of high overall costs after bariatric operation. Improving postoperative outcomes may result in substantial cost savings., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Laparoscopic vertical sleeve gastrectomy (LSG) has replaced laparoscopic Roux-en-Y gastric bypass (LRYGB) as the most commonly performed bariatric surgical procedure in the US for more than the past several years. Identifying which patients will achieve optimal outcomes remains challenging. We compared 90-d and 1-y outcomes between LSG and LRYGB patients and identified predictors of surgery type and excess body weight loss (EBWL)., Methods: Patient demographics, comorbidities, and weight loss were extracted from electronic health records of patients who underwent LRYGB (n = 270) or LSG (n = 74) from January 2010 through March 2014 at a single institution. Variables hypothesized to be associated with surgery type were included in a multivariable model to generate a propensity score for each patient. Propensity score-adjusted multivariable odds ratios (ORs) for characteristics associated with EBWL >50% were calculated., Results: Overall 90-d complication rates were similar between the LRYGB and LSG cohorts. LRYGB patients had more frequent emergency department visits (27.1% versus 14.1%; P = 0.029) but similar rates of readmission (12.3% versus 8.5%; P = 0.53). Female sex, presence of gastroesophageal reflux disease, and surgeon age ≥40 were associated with a greater likelihood of undergoing LRYGB. On propensity score-adjusted multivariable analysis, lower body mass index (OR 3.00 [95% confidence interval (CI) 1.66-5.40]), absence of type 2 diabetes (OR 2.55 [95% CI 1.43-4.54]), and undergoing LRYGB (OR 5.29 [95% CI 2.52-11.09]) were associated with EBWL >50%., Conclusions: Sleeve gastrectomy patients had similar rates of complications compared with gastric bypass patients. Lower body mass index and absence of type 2 diabetes were associated with optimal weight loss. Incorporating these findings into preoperative discussions may help patients set reasonable postoperative goals., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Less than 1% of severely obese US adults undergo bariatric surgery annually. It is critical to understand the factors that contribute to its utilization., Objectives: To understand how primary care physicians (PCPs) make decisions regarding severe obesity treatment and bariatric surgery referral., Setting: Focus groups with PCPs practicing in small, medium, and large cities in Wisconsin., Methods: PCPs were asked to discuss prioritization of treatment for a severely obese patient with multiple co-morbidities and considerations regarding bariatric surgery referral. Focus group sessions were analyzed by using a directed approach to content analysis. A taxonomy of consensus codes was developed. Code summaries were created and representative quotes identified., Results: Sixteen PCPs participated in 3 focus groups. Four treatment prioritization approaches were identified: (1) treat the disease that is easiest to address; (2) treat the disease that is perceived as the most dangerous; (3) let the patient set the agenda; and (4) address obesity first because it is the common denominator underlying other co-morbid conditions. Only the latter approach placed emphasis on obesity treatment. Five factors made PCPs hesitate to refer patients for bariatric surgery: (1) wanting to "do no harm"; (2) questioning the long-term effectiveness of bariatric surgery; (3) limited knowledge about bariatric surgery; (4) not wanting to recommend bariatric surgery too early; and (5) not knowing if insurance would cover bariatric surgery., Conclusion: Decision making by PCPs for severely obese patients seems to underprioritize obesity treatment and overestimate bariatric surgery risks. This could be addressed with PCP education and improvements in communication between PCPs and bariatric surgeons., (Copyright © 2016 American Society for Bariatric Surgery. All rights reserved.)

Background: A higher incidence of gastrojejunal (GJ) anastomotic strictures has been reported following laparoscopic gastric bypass (LRYGB) with the 21 mm compared to 25 mm circular stapler. We hypothesized that the rate of stricture formation is affected by route of anvil insertion and its position relative to the gastric pouch staple line [trans-gastric above staple line (trans-gastric) vs. trans-oral through staple line (trans-oral)] following LRYGB., Methods: Retrospective review of consecutive patients who underwent LRYGB with circular stapled GJ studied in four groups: trans-gastric-21 mm, trans-gastric-25 mm, trans-oral-21 mm, and trans-oral-25 mm. Primary outcome studied was GJ stricture; secondary outcomes were results with endoscopic therapy and weight loss at 12 months. Predictors studied were age, gender, body mass index (BMI), comorbidities, and operative technical factors including anvil size and insertion route. Regression analyses were performed to identify predictors of GJ stricture., Results: Eight hundred seventy-six patients underwent LRYGB. Seventy-six (8.7 %) developed a GJ stricture. The highest stricture rate occurred in the trans-gastric-21 mm group (17 %, p < .01 for all comparisons). Stricture rates were similar for trans-gastric-25 mm (8.4 %), trans-oral-21 mm (5.2 %), and trans-oral-25 mm (1.6 %) groups. Independent predictors of stricture were: trans-gastric-21 mm (OR 10.9, 95%CI 1.4-85.1; p = .022) and age (OR 0.97, 95%CI 0.95-0.99; p = .002). Endoscopic dilation relieved symptoms in all patients. There was no difference in %EWL at 12 months in patients with and without a stricture., Conclusions: We conclude that the trans-oral-21 mm anvil is associated with a low stricture rate. With the advantage of smaller abdominal wall wound, trans-oral-21 mm may be the preferred size and route of anvil insertion.

Purpose: To compare 1-year outcomes and costs between severely obese Medicaid and non-Medicaid patients who underwent laparoscopic Roux-en-Y gastric bypass surgery., Methods: This is a single-institution retrospective review comparing 33 Medicaid patients to 99 randomly selected non-Medicaid patients (1:3 case-control). Ninety-day and 1-year outcomes were extracted from the electronic health record. Costs were obtained from the UW information technology division. Bivariate analyses were used to compare study variables., Results: Emergency department visits (48.2% vs. 27.4%; P=0.06) and readmissions (37.0% vs. 14.7%; P=0.01) were more common for Medicaid patients. Medicaid patients had less excess body weight loss (50.7% vs. 65.6%; P=0.001) but similar comorbidity resolution and complication rates. One-year median costs were similar between Medicaid and non-Medicaid patients ($21,160 vs. $24,215; P=0.92)., Conclusions: One-year comorbidity resolution, complications, and costs following laparoscopic Roux-en-Y gastric bypass were similar between Medicaid and non-Medicaid patients. Focusing on reducing emergency department presentations and readmissions would be a high-impact area for future quality improvement initiatives.

Background: Circular stapled gastrojejunostomy (GJ) is favored by many surgeons during laparoscopic Roux-en-Y gastric bypass (LRYGB). However, it has been associated with higher rates of surgical site infection (SSI)., Objectives: To study the impact of introducing standard technical modifications (intervention) on the incidence of SSI after LRYGB with circular stapled GJ., Setting: Tertiary academic medical center., Methods: Consecutive patients who underwent primary LRYGB between May 2010 and September 2014 were separated into preintervention and postintervention cohorts. The intervention consisted of the use of a stapler cover, wound irrigation, antibiotic application to the wound, and primary wound closure. Predictor variables studied included patient demographic characteristics, the intervention, and other operative and perioperative factors. The primary outcome studied was SSI. Univariate and multivariate analyses were used to determine factors independently associated with SSI., Results: Three hundred thirty patients underwent LRYGB (preintervention n = 200, postintervention n = 130). Patients' characteristics were similar in both groups. A 21-mm stapler and chlorhexidine-based skin preparation were more frequently used in the postintervention group. SSI rate decreased from 15% to 3.8% (P<.01) after the intervention. On multivariate analysis, the intervention (OR .28, 95% CI .09-0.86, P = .026), use of chlorhexidine-based prep (OR .37, 95%CI .15-.93, P = .034), and maintenance of patient temperature (OR .47 95%CI .26-0.85, P = .012) were independently associated with reduced SSI rates., Conclusion: Use of a stapler cover, wound irrigation, wound antibiotic application, and primary wound closure were associated with a significantly lower wound infection rate after LRYGB with the circular stapled GJ. The observed SSI rates after our intervention are similar to those reported after hand-sewn and linear stapled techniques. In addition, other factors associated with decreasing the likelihood of developing SSI were use of chlorhexidine-based prep and maintaining intraoperative normothermia., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Although bariatric surgery is the most cost-effective treatment for severe obesity, less than 1% of severely obese patients undergo it. Reasons for this low use are unclear., Objectives: To identify patient and referring practitioner characteristics associated with the likelihood of undergoing bariatric surgery., Evidence Review: The PubMed, PsycINFO, CINAHL, and Cochrane databases were searched for articles published from January 1, 1998, through December 31, 2014. Studies were eligible if they presented descriptive data regarding facilitators or barriers to bariatric surgery or if they reported statistical associations between patient or practitioner characteristics and referral to or receipt of bariatric surgery. Frequency effect sizes were calculated as the proportion of studies reporting a finding., Findings: Of the 7212 records identified in the initial search, 53 were included in full-text review. Nine studies met our inclusion criteria and were included in analyses. Of those, 4 included descriptive findings, 6 reported statistical associations, and 1 included both. One study included practitioners as participants, whereas 8 included patients. Four of 9 studies identified an association between female sex and a greater willingness to undergo bariatric surgery. Lack of knowledge about bariatric surgery was a barrier in 2 studies. Five of 9 cited patient concerns about the outcomes and safety of bariatric surgery as a barrier to undergoing it. Patients were more likely to pursue bariatric surgery when it was recommended by referring practitioners. Practitioners who believed that obesity treatment should be covered by insurance were more likely to recommend bariatric surgery., Conclusions and Relevance: Limited patient and referring practitioner knowledge about the safety and effectiveness of bariatric surgery are important barriers to bariatric surgery use. Future efforts focused on improving knowledge and identification of the critical determinants of obesity treatment decision making from the practitioner and patient perspectives would have an important effect on public health.

Background: Identifying severely obese patients who will succeed after bariatric surgery remains challenging. Although numerous studies have attempted to identify preoperative patient characteristics associated with weight loss, the roles of many dietary and psychological characteristics are unclear. The purpose of this study was to examine preoperative dietary and psychological predictors of successful weight loss after bariatric surgery., Materials and Methods: This retrospective cohort study included all patients who underwent laparoscopic Roux-en-Y gastric bypass from September 2011-June 2013 at a single institution (n = 124). Patient demographics, comorbidities, dietary and psychological factors, and weight loss outcomes were extracted from the electronic medical record. Bivariate associations between these factors and successful weight loss (≥50% excess body weight) were examined. Factors significant at P ≤ 0.1 were included in a multivariate logistic regression model., Results: On bivariate analysis, absence of either type 2 diabetes or hypertension, preoperative weight <270 lbs, no intentional past weight loss >50 lbs, no previous purging or family history of obesity, and no soda consumption preoperatively were associated with successful weight loss (P < 0.1). On multivariate analysis, successful weight loss was inversely associated with the presence of type 2 diabetes (odds ratio [OR], 0.22, 95% confidence interval [CI], 0.06-0.73), maximum intentional past weight loss >50 lbs (OR, 0.12 [95% CI, 0.04-0.43]), and decreasing soda consumption by >50% (OR, 0.27 [95% CI, 0.08-0.99])., Conclusions: Patients with type 2 diabetes mellitus, significant previous weight loss, and poor soda consumption habits are more likely to experience suboptimal weight loss after bariatric surgery. Additional preoperative counseling and close postoperative follow-up is warranted for these patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Millions of patients will be added to Medicaid programs throughout the country due to expansion driven by the Affordable Care Act. Since 90 % of state Medicaid programs cover bariatric surgery, the outcomes of Medicaid patients will be important to study. We performed a retrospective analysis to compare outcomes between Medicaid and non-Medicaid bariatric surgery patients over a two-year period., Methods: All patients who underwent a laparoscopic Roux-en-Y gastric bypass at The Ohio State University Medical Center from January 2008-April 2011 were identified. Of these 609 patients, 30 Medicaid patients were identified and compared to 90 randomly selected non-Medicaid patients (1:3 case-control). Preoperative data and postoperative outcome data (weight loss, comorbidity resolution, complications, and mortality) were obtained from electronic medical records. Descriptive statistical analyses were performed to compare categorical and continuous variables., Results: Medicaid patients had a significantly higher average BMI (58.4 vs. 49.5; p < 0.001) and higher rates of comorbidities. Over a 90-day postoperative period, Medicaid patients experienced a higher wound complication rate (20.0 vs. 5.6 %; p = 0.03) and visited the ER more frequently (33.3 vs. 10.0 %; p = 0.007) but had similar rates of medical complications compared to non-Medicaid patients. The Medicaid cohort lost 52.1 % of its excess body weight vs. 64.6 % for the non-Medicaid cohort (p = 0.02) over a two-year period. There were no significant differences in comorbidity resolution, anastomotic complications, or mortality after 2 years of follow-up., Conclusion: Despite being a higher risk cohort, Medicaid patients undergoing laparoscopic Roux-en-Y gastric bypass had similar long-term outcomes compared to non-Medicaid patients.