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OBJECTIVE The aim of this study was to compare the safety of single- versus two-stage conversion of adjustable gastric band (AGB) to gastric bypass (RYGB) or sleeve gastrectomy (SG). SUMMARY BACKGROUND DATA AGB patients often present for conversion to RYGB or SG. The impact of single- or two-stage approach of such conversion remains unclear. METHODS A statewide database was used to identify all patients who underwent AGB removal and concurrent (single-stage) or interval (two-stage) RYGB or SG. Propensity score matching schemes were constructed to account for differences in baseline comorbidities and demographics, allowing for matched pairs available for comparisons. RESULTS A total of 4330 patients underwent AGB conversion. Complications, readmissions, and ED visits were noted in 394 (9.1%), 278 (6.42%), and 589 (13.6%) patients, respectively. Three hundred sixty-seven matched pairs underwent RYGB; single-stage patients experienced shorter length of stay (LOS) (median difference -1 d, P < 0.0001), less complications [risk difference (RD): -8.4%, 95% confidence interval (CI), -13.4% to -3.5%], readmissions (RD: -5.2%, 95% CI, -9.6% to -0.8%), and ED visits (RD: -5.7%, 95% CI, -11.3% to -0.2%). Eight hundred seventy-five matched pairs underwent SG; single-stage patients experienced improved outcomes in all measures examined. For single-stage procedures (809 pairs), RYGB was associated with longer LOS, and more complications (RD: 3.3%, 95% CI, 0.9%-5.8%), with similar readmissions, and ED visits. CONCLUSIONS AGB conversion procedures have low morbidity. Single-stage conversion is associated with lower morbidity compared with the two-stage approach. Conversion to SG seems to be safer than RYGB.

Acupressure therapy is associated with favourable efficacies on postoperative nausea, pain and sleep disturbance, although the quality of the evidence is generally low. No randomised clinical trial has yet assessed the effect of acupressure on postoperative quality of recovery (QoR).The objective was to study acupressure efficacy on patient-reported postoperative recovery.We conducted a single centre, three-group, blind, randomised controlled, pragmatic trial assessing acupressure therapy on the PC6, LI4 and HT7 acupoints.Postoperative patients expected to stay in hospital at least 2 days after surgery.In the acupressure group, pressure was applied for 6 min (2 min per acupoint), three times a day after surgery for a maximum of 2 postoperative days during the hospital stay. In the sham group, extremely light touch was applied to the acupoints. The third group did not receive any touch.The primary outcome was the change in the QoR, using the QoR-15 questionnaire, between postoperative days 1 and 3. Key secondary outcomes included patients' satisfaction, postoperative nausea and vomiting, pain score and opioid (morphine equivalent) consumption. Assessors for the primary and secondary endpoints were blind to the group allocation.Overall, 163 patients were randomised (acupressure n=55, sham n=53, no intervention n=55). The mean (SD) postoperative change in QoR-15 did not differ statistically (P = 0.27) between the acupressure, sham and no intervention groups: 15.2 (17.8), 14.2 (21.9), 9.2 (21.7), respectively. Patient satisfaction (on a 0 to 10 scale) was statistically different (P = 0.01) among these three groups: 9.1 (1.5), 8.4 (1.6) and 8.2 (2.2), respectively. Changes in pain score and morphine equivalent consumption were not significantly different between the groups.Two days of postoperative acupressure therapy (up to six treatments) did not significantly improve patient QoR, postoperative nausea and vomiting, pain score or opioid consumption. Acupressure, however, was associated with improved patient satisfaction.ClinicalTrials.gov, identifier: NCT02762435.

SAGES is responsible for defining educational content for Advanced GI/MIS fellowships administered through the fellowship council (FC). In Fall 2016, to better define core content contained in these fellowships, SAGES proposed new case log criteria including minimum volumes within six defined categories. To test feasibility of these criteria, SAGES conducted a pilot study during the 2017–2018 academic year. Advanced GI/MIS fellowship programs directors (PD’s) who also held leadership roles in SAGES were invited to participate in the pilot. Fourteen programs including 17 fellows volunteered. To assess generalizability, 2016–2017 case log data for the volunteered pilot programs were compared to all other advanced GI/MIS programs (n = 92). To assess feasibility of the new criteria, pilot programs’ 2017–2018 case logs were compared to 3 years of historical fellows’ case logs (n = 326). Fisher’s exact test was used for comparisons with p

Although bariatric center procedural volume has been associated with early perioperative safety, data on the effect of such volume and long-term outcomes after sleeve gastrectomy (SG) are limited. This study aims to examine the relationship between annual bariatric center SG volume and the incidence of revisions or conversions (RC) after SG. The New York Statewide Planning and Research Cooperative System database was used to identify all patients who underwent SG between 2006 and 2012. Subsequent RC events were captured up to 2016. Bariatric centers having annual SG volume less than 45, between 45 and 65, and greater than 65 were defined as low (LV), medium (MV), and high volume (HV), respectively. Multivariable Cox proportional hazard regression analysis was performed to compare the risk of having RC among centers with different yearly sleeve volumes. We identified 8389 patients who underwent SG. The overall estimated cumulative incidence of RC was 0.5% (95% CI 0.3–0.6%) at 1 year, 6.2% (95% CI 5.4–7.0%) at 5 years, and 15.3% (95% CI 12.6–18.0%) at 8 years after SG. The estimated cumulative incidence of RC for LV, MV, and HV at 8 years after SG was 16.7% (95% CI 11.1–22.3%), 15.5% (95% CI 11.2–19.8%), and 13.7% (95% CI 9.4–17.9%), respectively. HV centers have lower risk of RC compared to LV (hazard ratio 0.65; 95% CI 0.48–0.88) and MV (hazard ratio 0.75; 95% CI 0.57–0.98). LV and MV centers have comparable risk of RC (hazard ratio 1.15; 95% CI 0.87–1.51). Patients having the initial SG performed in LV were the least likely to have RC in the same institution (46.1% of LV, 13.2% of MV and 22.3% of HV; p

There is limited data examining specific annual surgeon procedural volumes associated with improvement of postoperative outcomes following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).Effect of surgeon volume on procedural outcomes.Using the SPARCS Administrative database, patients undergoing laparoscopic RYGB or SG between 2010-2014 were analyzed. Multivariable generalized linear mixed regression models were first used to analyze the influences of 3 yearly mean volumes (combined, RYGB and SG mean volumes) on each of three surgical outcomes: 30-day readmission, peri-operative complications, and extended length of stay (LOS), while accounting for patient specific variables.A total of 46,511 laparoscopic bariatric procedures were included in the study. Risk for any complication and 30-day readmissions following RYGB decreased with increasing RYGB volume up to a specific volume and stayed similar afterward (OR 0.97, 95% CI 0.96-0.98 while volume 247.9 cases/year and OR 0.99, 95% CI 0.98-0.99 while volume 354.1 cases/year, respectively) while risk for extended LOS decreased with increasing combined bariatric mean volume up to a specific volume and stayed similar afterward (OR 0.9, 95% CI 0.85-0.95 while volume 62.1 cases/year). Similar patterns were found for extended LOS and complications following SG (OR 0.82, 95% CI 0.72-0.93 while SG volume 26.3 cases/year and OR 0.94, 95% CI 0.91-0.98 while combined volume 62.1 cases/year, respectively), while 30-day readmission following SG significantly increased when combined bariatric volume being more than 138 cases/year (OR 1.10, 95% CI 1.00-1.21 while combined volume 138 cases/year)).Bariatric procedure peri-operative outcomes are affected by procedure-specific annual surgeons' volume.

The incidence of massive ventral hernias among the elderly will increase as the population ages. Advanced age is often viewed as a contraindication to elective hernia repair. A relationship between age and complications of component separation procedures for ventral hernias is not well established. This study evaluated the effect of age on the peri-operative safety of AWR. The 2005–2013 ACS-NSQIP participant use data were reviewed to compare surgical site infection (SSI), overall morbidity, and serious morbidity in non-emergent component separation procedures among all age groups. All patients were stratified into four age quartiles and evaluated. Baseline characteristics included age, body mass index (BMI) and ASA 3 or 4 criteria. Statistical analysis was performed using SPSS. Odds ratios (OR) and 95% confidence intervals were reported as appropriate. 4485 patients were identified. Majority of the cases were clean (76.8%). Patients were divided into the following quartiles based on age. The older quartile had a mean age of 72.7 ± 4.87 years. There were baseline differences in BMI and chronic comorbidity severity (measured by incidence of ASA score of 3 or 4) between the age groups, with the oldest group having lower BMI but higher rate of ASA 3 or 4 (p

Although the number of weight loss procedures is increasing, bariatric surgery is not used equitably in the United States. As obesity is more prevalent in minorities, higher priorities are placed toward improvement of access to care for these groups.To evaluate whether patient insurance status has any effect on use of bariatric surgery for patients in New York State.Administrative statewide database.The Statewide Planning and Research Cooperative System administrative database was used to identify all patients undergoing primary bariatric procedures between 2005 and 2016. Revision procedures were excluded from analysis. Multivariable logistic regression models were used to compare outcomes among patients with different payor status after controlling for confounding factors.After the application of inclusion and exclusion criteria, there were 125,666 bariatric records from 2005 to 2016. Most patients had commercial insurance (n = 106,148, 84.5%), followed by Medicare (n = 9355, 7.4%), Medicaid (n = 7939, 6.3%), and other/unknown (n = 2224, 1.8%). The percentage of Medicaid was estimated to be increase by 12%/yr and the percentage of Medicare was estimated to be increase by 5%/yr during 2005 to 2016. Univariate analysis showed that patients with different insurance types were significantly different in terms of age, sex, race, region, subtype of surgeries, most co-morbidities, overall complication, 30-day readmission/emergency department visits, and length of stay (P values.0001). After adjusting for other confounding factors, patients with Medicare insurance had significantly higher risk of having overall complications, 30-day readmissions/emergency department visits, and longer length of stay.The majority of patients undergoing bariatric surgery are insured by private insurance, whereas only 13.7% of bariatric surgeries are performed on patients with public insurance.

Innovation is important in medicine and surgery, as new technologies and techniques have immensely improved patient care. However, innovation has required collaboration between physicians, industry, engineers, investors, and entrepreneurs, among others. Because of these relations, ethical conflicts can exist. The following chapter will review the ethical challenges that surgeons face today when confronted to innovative procedures or developments.

Medical errors are inevitable and common in the US healthcare system, which require medical providers to be adept at discussing errors and other complications with their patients. The process of error disclosure in obesity surgery begins with the initial patient encounter when reviewing proposed interventions and procedures. Patients expect full disclosure when medical errors occur; in fact, full disclosure may now be considered the standard of care. There are psychosocial factors that act as barriers preventing full disclosure and creating a gap between patient expectations, clinical guidelines/recommendations, and the current practice as it relates to discussion of medical errors. Many states and countries have instituted apology laws to encourage physicians to speak openly about errors and complications with their patients in an attempt to bridge this gap. Early disclosure programs have been implemented to improve patient satisfaction and minimize the financial burden of medical errors on healthcare institutions. This chapter details the concept of and barriers to full disclosure of medical errors, the approach to patient disclosure conversations, the legal protection (or lack thereof) provided by apology laws, and discusses the effectiveness of early disclosure programs.

The diaphragm is an anatomically complex organ composed of muscular and tendinous portions with a rich neurovascular network. An intact and functioning diaphragm is critical for respiration, and it serves as a barrier between the chest and abdominal cavities. Diaphragmatic hernias not located at the esophageal hiatus can either be congenital (Morgagni or Bochdalek hernias) or traumatic (either accidental or postoperative) in nature. Abdominal organs may be pulled into the thoracic cavity through any diaphragmatic defect, encouraged by the pressure differential between the chest and abdomen. In general, in patients with reasonable operative risk, any diaphragmatic hernia should be repaired when diagnosed. Surgical repair of non-hiatal diaphragmatic defects can be either transabdominal or transthoracic and may incorporate minimally invasive techniques. Repair often includes primary tissue apposition, due to the redundancy of diaphragmatic muscular tissue. When mesh is required, most surgeons prefer a nonporous mesh material. Postoperatively, the diet can be restarted immediately. Long-term recurrence is unusual following repair.

Autologus augmentation of wound remodeling with platelet concentrate is a burgeoning field with promising results. We hypothesized that the addition of filtered platelet concentrate (fPC) to an acellular biologic graft would improve crural healing and tissue integrity in hiatal hernia repair. Sixteen healthy Yorkshire female pigs were divided into three groups: hiatus repair (HR) (n = 7), HR with biologic graft (HRM; n = 8, and HR with biologic graft and fPC (fPC; n = 9). Surgeries were performed by a single surgeon. Animals were euthanized at 8 weeks, and the distal esophagus with hiatus was harvested en-block. Tissue was graded by a histopathologist on collagen deposition, vascularization, and inflammation at the graft–hiatal interface. Tensile strength testing was performed using the Teststar IIs (MTS), coupled with a strain extensometer (Epsilon). Samples of equal dimensions were preloaded to 1 N and deformed at a constant rate of 0.2 mm/s. Statistical analysis was performed via Kruskal–Wallis one-way analysis of variance. Aspirate analysis revealed a mean platelet count of 3 million platelets/1 mL of aspirate. Animals in the fPC group had significantly increased mean chronic inflammation (3.1 ± 1.1 vs. 1.8 ± 1.6, 1.2 ± 1.2, p = 0.04) compared to HR alone and HR + biologic graft. Vascular deposition did not differ between groups (p = 0.8). A trend toward increased collagen deposition was demonstrated for the fPC group (1.4 ± 1.1 vs. 2.0 ± 0.6 in HR group and 3.0 ± 1.2 in HRM group, p = 0.06). There was a statistically significant increase in tensile strength, yield force, and Young’s modulus in the fPC group compared with HR and HR + biologic mesh (p

Conservative management trends in diverticulitis may lead to increased hospitalizations secondary to repeated attacks. The study aimed to characterize trends in management and risk-assess patients with diverticulitis that required multiple admissions to identify high utilizers. A total of 265,724 patients with diverticulitis were identified from 1995 to 2014 from the New York SPARCS database. Patients with ≥2 hospital admissions were stratified across demographics, comorbidities, insurance status, and surgical intervention. In total, 42,850 patients had ≥2 hospital admissions. Risk factors for ≥2 admissions included younger age, White race, obesity, hypertension, pulmonary disease, hypothyroidism, rheumatoid arthritis, and depression. Fifty-two percent of these patients went on to have surgery. The percentage of elective cases increased from 59 to 70 %, while emergent cases conversely decreased from 41 to 30 %. One in five patients admitted with diverticulitis required two or more admissions. Numerous patient factors were correlated with increased risk of readmission. These factors may be used to guide treatment decisions and help reduce economic burden in frequent utilizers. Trends in surgery rates for these patients could reflect improved treatment options and/or changing clinical practice patterns.

Since the introduction of laparoscopic cholecystectomy (LC), there has been continued evolution in technique, instrumentation and postoperative management. With increased experience, LC has migrated to the outpatient setting. We asked whether increased availability and experience has impacted incidence of and indications for LC.The New York (NY) State Planning and Research Cooperative System longitudinal administrative database was utilized to identify patients who underwent cholecystectomy between 1995 and 2013. ICD-9 and CPT procedure codes were extracted corresponding to laparoscopic and open cholecystectomy and the associated primary diagnostic codes. Data were analyzed as relative change in incidence (normalized to 1000 LC patients) for respective diagnoses.From 1995 to 2013, 711,406 cholecystectomies were performed in NY State: 637,308 (89.58 %) laparoscopic. The overall frequency of cholecystectomy did not increase (1.23 % increase with a commensurate population increase of 6.32 %). Indications for LC during this time were: 72.81 % for calculous cholecystitis (n = 464,032), 4.88 % for biliary colic (n = 31,124), 8.98 % for acalculous cholecystitis (n = 57,205), 3.01 % for gallstone pancreatitis (n = 19,193), and 1.59 % for biliary dyskinesia (n = 10,110). The incidence of calculous cholecystitis declined (-20.09 %, p 0.0001) between 1995 and 2013; meanwhile, other diagnoses increased in incidence: biliary colic (+54.96 %, p = 0.0013), acalculous cholecystitis (+94.24 %, p 0.0001), gallstone pancreatitis (+107.48 %, p 0.0001), and biliary dyskinesia (+331.74 %, p 0.0001). Outpatient LC incidence catapulted to 48.59 % in 2013, from 0.15 % in 1995, increasing320-fold. Analysis of LC through 2014 revealed increasing rates of digestive, infectious, respiratory, and renal complications, with overall cholecystectomy complication rates of 9.29 %.A shifting distribution of operative indications and increasing rates of complications should prompt careful consideration prior to surgery for benign biliary disease. For what is a common procedure, LC carries substantial risk of complications, thus requiring the patient to be an active participant and to share in the decision-making process.

There is an increased need for surgical trainees to acquire advanced laparoscopic skills as laparoscopy becomes the standard of care in many areas of general surgery. Since the introduction of minimally invasive surgery (MIS) fellowships, there has been a continuing debate as to whether these fellowships adversely affect general surgery resident exposure to laparoscopic cases. The aim of our study was to examine whether the introduction of an MIS fellowship negatively impacts general surgery residents’ experience at a single academic center. We describe the changes following establishment of MIS fellowship at an academic center. Resident case log system from the Accreditation Council for Graduate Medical Education was queried to obtain all PGY 1–5 resident operative case logs. Two-year time period preceding and following the institution of an MIS fellowship at our institution in 2012 was compared. P values less than 0.05 were considered statistically significant. Following initiation of the MIS fellowship, an MIS service was established. The service comprised of a fellow, midlevel resident, and intern. Operative experience was examined. From 2010–2012 to 2012–2014, residents logged a total of 272 and 585 complex laparoscopic cases, respectively. There were 43 residents from 2010 to 2013 and 44 residents from 2013 to 2014. When the two time periods were compared, a trend of increased numbers for all procedures was noted, except laparoscopic GYN/genito-urinary procedures. Average percent increase in complex general surgery procedures was 249 ± 179.8 %. Following establishment of a MIS fellowship, reported cases by residents were higher or similar to those reported nationally for laparoscopic procedures. Institution of an MIS fellowship had a favorable effect on general surgery resident operative education at a single academic training center. Residents may benefit from the presence of a fellowship at an academic center because they are able to participate in an increased number of complex laparoscopic cases.

Common bile duct (CBD) injury is a serious and dreaded complication of cholecystectomy. A paucity of data assessing long-term outcomes exists. This study aimed to determine long-term mortality and liver transplantation rates following CBD injury requiring operative intervention. Patients were identified via the New York State (NYS) Planning and Research Cooperative System longitudinal administrative database which captures patient-level data from every inpatient and outpatient hospital discharge in NYS. In total, 125 patients with CBD injuries were identified following 156,958 laparoscopic cholecystectomies for cholelithiasis performed in NYS from 2005 to 2010. Patients were then tracked by unique identifier to obtain rate of liver transplantation. Follow-up ranged from 4 to 9 years from surgery. There were 125 patients with CBD injuries detected. No mortalities occurred within 30 days. All-cause mortality was 20.8 % (n = 26) with mean time to death 1.64 ± 1.08 years. One patient who underwent hepaticoenterostomy required a liver transplant 4.3 years after surgery. Significant factors predictive of all-cause mortality included: age >61, Medicare insurance, male gender, White race, diabetes, hypertension and pulmonary complications following surgery. Overall 30-day morbidity, timing to and type of operative intervention did not influence mortality. Considerable long-term mortality, 20.8 %, is associated with common bile duct injury requiring operative intervention. This was an increase of 8.8 % above the cohort’s expected age-adjusted rate of death. The mortality rate is appreciably higher than quoted previously. No difference was demonstrated by type of repair required. Liver transplant rate was 0.8 %. These data have significant implications for patient and family counseling both prior to cholecystectomy and following CBD injury.

Obesity is associated with the development of gastroesophageal reflux disease (GERD) and hiatal hernia (HH). This study aimed to assess practice patterns regarding concomitant HH repair (HHR) during laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). The incidence of concomitant HHR with LSG or LRYGB was analyzed using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. One hundred thirty thousand, seven hundred seventy-two patients underwent RYGB (30.5%) and LSG (69.5%). Concomitant HHR was more common, despite less GERD, in SG patients compared to RYGB (21.0% vs 10.8%, p

The purpose of our study was to evaluate the rate of ventral hernia repair (VHR) after open abdominal aortic anneurysm in New York State compared with the rate of VHR after open abdominal aortic bypass procedures. The Statewide Planning and Research Cooperative System database was queried for all abdominal aortic aneurysm (AAA) and bypass procedures performed between 2000 and 2010. Social security death index was used to identify patients who died. The cause-specific Cox proportional hazard model was applied to compare the risk of having follow-up VHR between patients with AAA and bypass with death as a competing risk event. A multivariable model was used to explore independent relationship with the risk of having follow-up ventral hernia after adjusting for other factors. There were 9314 patients who underwent open AAA repair, 739 (7.93%) of which had subsequent VHR. Comparatively, 8280 patients underwent aortofemoral or aortoiliac bypass procedures, with 480 (5.8%) undergoing subsequent VHR. The observed one-year, five-year, and 10-year VHR rates for AAA versus bypass were 2.8 versus 1.8 per cent, 10.0 versus 8.0 per cent, 10.7 versus 9.38 per cent, respectively. After controlling for all other factors, patients undergoing AAA repair were more likely and elderly patients were less likely to undergo VHR (P0.0001). Patients with serious comorbid conditions such as valvular disease, diabetes mellitus, and neurologic disorders were less likely to undergo subsequent VHR controlling for other factors. VHR after AAA procedures is more common compared with bypass procedures for occlusive disease. Because this patient population has significant comorbidity, prophylactic mesh placement may play a role in preventing necessity for future procedures.

Background Publicly reported hospital scores are used by patients to make health care–related decisions; however, their relationship to clinical outcomes is unknown. Methods Through the use of the New York Statewide Planning and Research Cooperative System database, the association between two commonly used scores (Healthgrades and Centers for Medicare & Medicaid Services Hospital Compare) and four clinical outcomes was evaluated in several surgical fields (general, colorectal, hepatobiliary, foregut, and bariatric). Results After adjusting for patient-level factors, patients from facilities with greater Healthgrades scores were less likely to develop any complication after general surgery operations (P = .0013). Also, greater Healthgrades scores were associated with less 30-day readmissions and emergency department visits for general surgery operations only (P = .0061 and P = .0013, respectively). In addition, greater Healthgrades scores were significantly associated with a lesser hospital length of stay for colorectal, foregut, and general surgery operations. Greater Centers for Medicare & Medicaid Services Hospital Compare scores were significantly associated with less 30-day readmissions and lesser hospital length of stay for specific operative groups. Conclusion Although some specialties demonstrated a correlation, there was no consistent relationship between publicly reported hospital scores and surgical outcomes that contributed to clinically meaningful use for patients or operations.

In the United States the percentage of adolescents with obesity has reached an alarming level of 21%. Bariatric surgery has emerged as a successful intervention in the weight loss for adolescents.To compare bariatric procedures performed in adolescent and adult populations.University Hospital, United States.Using the Statewide Planning and Research Cooperative System (SPARCS) database, records from the adolescent (age 12-21years) and adult populations undergoing bariatric surgery during 2005-2014 were examined. Patients' demographics, surgery type (Roux-en-Y gastric bypass (RYGB), Sleeve Gastrectomy (SG), Laparoscopic Adjustable Gastric Banding (LAGB), length of stay (LOS), complications and comorbidities were analyzed.The annual adolescent bariatric cases increased from 150 in 2005 to 406 in 2014. In the adolescent population, increasing utilization trends were noted in the Hispanic population (RR=1.08, p-value0.0001), use of Public (Medicaid or Medicare) insurance (RR=1.10, p-value=0.0003) and SG procedures (RR= 1.56, p-value0.0001). Decreasing trends were noted in the Caucasian population (RR=0.95, p-value0.0001), RYGB (RR=0.92, p-value0.0001) and LAGB (RR= 0.84, p-value=0.0001). Adolescents undergoing bariatric surgery had fewer comorbidities (55.4% vs 81.1%, p-value0.0001), experienced fewer complications (3.3% vs 4.9%, p-value0.0001) and 30-day readmissions (3.8% vs 5.0%, p-value=0.0029). Length of stay was also found to be significantly shorter for the adolescent population (1.73 vs 2.00 days, p-value0.0001). After adjusting for other confounding factors, adolescent patients still had significantly lower complication risk (p-value=0.01) and shorter length of stay (p-value=0.0005) than adults.Bariatric surgery procedure rates have increased in the adolescent population with increasing trend of using LSG. The data from our study supports that bariatric surgery is safe in adolescents with significantly lower complication risk and shorter length of stay as compared to the adult population.

This study assesses the cumulative incidence of anastomotic ulceration at 1, 2, 5, and 8 years postsurgery in patients who underwent Roux-en-Y gastric bypass.

Little is known of the natural history of fundoplication or paraesophageal hernia (PEH) repair in terms of reoperation or the incidence treatment of postsurgical gastroparesis (PSG) in large series. Repeat fundoplications or PEH repairs, as well as pyloroplasty/pyloromyotomy operations, have proven to be effective in the context of PSG or recurrence. In this study, we analyzed the incidences of PSG and risk factors for these revisional surgeries following fundoplication and PEH repair procedures in the state of New York. The New York State Planning and Research Cooperative System (NY SPARCS) database was utilized to examine all adult patients who underwent fundoplication or PEH repair for the treatment of GERD between 2005 and 2010. The primary outcome was the incidence of each type of reoperation and the timing of the follow-up procedure/diagnosis of gastroparesis. Generalized linear mixed models were used to examine the risk factors for follow-up procedures/diagnosis. A total of 5656 patients were analyzed, as 3512 (62.1%) patients underwent a primary fundoplication procedure and 2144 (37.9%) patients underwent a primary PEH repair. The majority of subsequent procedures (n = 254, 65.5%) were revisional procedures (revisional fundoplication or PEH repair) following a primary fundoplication. A total of 134 (3.8%) patients who underwent a primary fundoplication later had a diagnosis of gastroparesis or a follow-up procedure to treat gastroparesis, while 95 (4.4%) patients who underwent a primary PEH repair were later diagnosed with gastroparesis or underwent surgical treatment of gastroparesis. The results revealed low reoperation rates following both fundoplication and PEH repairs, with no significant difference between the two groups. Additionally, PEH repair patients tended to be older and were more likely to have a comorbidity compared to fundoplication patients, particularly in the setting of hypertension, obesity, and fluid and electrolyte disorders. Further research is warranted to better understand these findings.

The annual volume of bariatric surgery is growing, giving rise to an increase in complications requiring complex management, including revision. Bariatric revision procedures are also becoming increasingly necessary for weight-loss recidivism and patients at the extreme of obesity. This chapter outlines clinical management pathways used to address secondary bariatric surgery. It summarizes reasons for, and outcomes with, revision of a laparoscopic gastric band, vertical banded gastroplasty, sleeve gastrectomy, or Roux-en-Y gastric bypass. Surgical techniques used to manage weight regain or failed weight loss after bariatric surgery are also discussed. Finally, surgical solutions for bariatric surgery-induced malnutrition are described, particularly in the setting of biliopancreatic diversion, duodenal switch, or jejunoileal bypass. Overall, the chapter concludes that standardization of revisional procedures can have a significant patient impact, and guidelines must be evidence-based in order to ensure patient safety and success.

Laparoscopic sleeve gastrectomy (LSG) has emerged as a popular procedure for treatment of morbid obesity, with weight loss comparable to that with other procedures and with a relatively low number of postoperative complications. The benefits of LSG include its technical simplicity and its proven efficacy for reversal of obesity-related comorbidities. The association between gastroesophageal reflux disease (GERD) and LSG has been controversial. After LSG, GERD is described as either de novo GERD or an exacerbation of previous symptoms. This chapter reviews the current literature on reflux, esophagitis, and chronic nausea after LSG, as well as the proposed mechanisms responsible for exacerbating or improving GERD after LSG and techniques to minimize reflux after LSG.

Roux-en-Y-gastric bypass (RYGB) and sleeve gastrectomy (SG) are commonly performed bariatric procedures that are associated with a significant learning curve. The effect of surgeon experience on perioperative outcomes and safety is established, but the effect of trainee participation remains unclear. The purpose of this study was to assess the impact of trainees on early perioperative safety of bariatric surgery. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for 2015 was used to identify non-revisional laparoscopic and robotic RYGB and SG procedures. Comparisons were made based on assistant level. Multivariable logistic and linear regression methodology was used to compare clinical outcomes. There were 35,354 laparoscopic RYGB, 2896 robotic RYGB, 79,717 laparoscopic SG, and 5449 robotic SG procedures examined. 21,257 (17%) and 11,322 (9%) of all procedures were performed with a resident or fellow, respectively. Fellow presence was independently associated with the development of complications for all procedure types except robotic SG when compared to non-trainee [odds ratio (OR) 1.31, 2.20, 1.28 for laparoscopic RYGB, robotic RYGB, and laparoscopic SG, respectively]. The most common events were urinary tract and superficial surgical site infections. This negative impact of fellow on overall complications was eliminated after accounting for operative duration. In laparoscopic SG, resident participation was associated with higher leak rate (OR 1.61), readmission (OR 1.18), re-intervention (OR 1.4), and complication rate (OR 1.32) compared to non-trainee, even after accounting for procedural duration. In robotic SG, there was no impact of trainee on outcomes. Although fellow training is associated with higher overall complication rate, there is no such impact on major safety benchmarks, including leak rate and re-operation. In contrast, the impact of resident trainees on SG outcomes is substantial. Operative involvement of trainees in bariatric surgery leads to different outcomes based on trainee level and should be judiciously considered during the programmatic design of bariatric educational curricula.

BACKGROUND The incidence of infection due to Clostridium difficile infection (CDI) and subsequent economic burden are substantial. GOALS The impact of changing practice patterns on demographics at risk and utilization of health care resources for recurrence of CDI remains unclear. STUDY A total of 291,163 patients hospitalized for CDI were identified from 1995 to 2014 from the New York SPARCS database. The χ test, the Welch t test, and multivariable logistic regression analysis were performed to evaluate factors related to readmission. RESULTS Hospital admissions and readmissions for CDI peaked in 2008 at 20,487 and 13,795, respectively, and have since decreased (linear trend, 0.9706 and 0.9464, respectively; P

Pathways for enhanced recovery after surgery (ERAS) have been shown to improve length-of-stay (LOS) and post-operative complications across various surgical fields, however there is a lack of evidence-based studies in bariatric surgery. Specifically, the value of early feeding within an ERAS program in bariatric surgery is unclear. The objective of the current study was to determine the effect of early feeding on LOS for patients who underwent primary or revisional laparoscopic sleeve gastrectomy (LSG) and Roux-en-y gastric bypass (RYGB). Retrospective single institution study of implementation of a new diet protocol in which initiation of oral intake changed from post-operative day 1 to day 0. LOS and 30-day events were compared. Patients were excluded if they were planned for 23-h stay, had significant intra-operative complications, or required reoperation within the same admission. Mann–Whitney U tests were done to compare LOS and chi-squared tests to compare 30-day events pre- and post-intervention. A total of 244 patients were included; 84.4% were primary cases. 50.8% of cases occurred prior to early feeding implementation. Median age was 43.5 years (IQR 33–53) and majority of patients were female (78.7%). Median LOS was 32.6 (IQR 30.0–50.6). Median LOS across the whole sample was shorter in the early feeding group (36.2 vs. 31.0 h; p

Early readmissions (30 days) have been used as a measure of health care quality. The purpose of our study was to evaluate patterns of readmission for a longer period (up to 2 years) following Hepatopancreatobiliary (HPB) surgery in the state of New York. The State Planning and Research Cooperative System database was utilized to identify patients undergoing complex HPB procedures between 2010 and 2012. Patients were followed for 2 years following surgery to identify all-cause readmissions. Factors for readmissions included patient demographics, comorbidities, perioperative complications, surgery type, and academic status. Multivariable generalized linear mixed models were performed to evaluate risk factors for readmissions. There were 6207 complex HPB procedures with 1272 (20.49%) unplanned 30-day readmissions, 816 (13.15%) unplanned 31–90-day readmissions, 1678 (27.03%) unplanned 91-day to 1-year readmissions, and 1404 (22.62%) 1–2-year readmissions. After adjusting for other possible confounding factors, risk factors for 30-day readmissions include surgery type, as pancreatectomy and gallbladder patients are more likely to have a 30-day readmission than hepatectomy patients, facility type, as academic centers are more likely to have a readmission, male gender, presence of any comorbidity, and peri-operative complications. Risk factors for 31–90-day readmissions include race, insurance group, any comorbidity or any peri-operative complication, and 30-day readmissions. Risk factors for 91-day to 1-year readmissions include male gender, race, any comorbidity, 30-day readmissions, and 31–90 days’ readmissions. Risk factors for 1–2-year readmissions include presence of any comorbidity, and previous 91-day to 1-year readmissions. The 30-day readmission window is an inadequate, but predictive, measure of total readmission following complex HPB procedures.

Obesity in pediatric patients is rising with nearly one third of children in the USA classified as overweight and up to 16-18% of the adolescent population obese with at least one comorbid condition. Consequently, bariatric procedures in this population have increased without consistent recommendations for follow-up and transition to adult providers. This review describes the known and potential long-term consequences of bariatric surgery in pediatric patients, reviews the current literature on transitions of care for adolescent patients with chronic illnesses. Additionally, this review summarizes recommendations from the literature for developing a standardized program for transitioning care for post-bariatric surgical patients and offers useful tools and guidelines for doing so.

Perioperative malnutrition has proven to be challenging to define, diagnose, and treat. Despite these challenges, it is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Although perioperative caregivers consistently express recognition of the importance of nutrition screening and optimization in the perioperative period, implementation of evidence-based perioperative nutrition guidelines and pathways in the United States has been quite limited and needs to be addressed in surgery-focused recommendations. The second Perioperative Quality Initiative brought together a group of international experts with the objective of providing consensus recommendations on this important topic with the goal of (1) developing guidelines for screening of nutritional status to identify patients at risk for adverse outcomes due to malnutrition; (2) address optimal methods of providing nutritional support and optimizing nutrition status preoperatively; and (3) identifying when and how to optimize nutrition delivery in the postoperative period. Discussion led to strong recommendations for implementation of routine preoperative nutrition screening to identify patients in need of preoperative nutrition optimization. Postoperatively, nutrition delivery should be restarted immediately after surgery. The key role of oral nutrition supplements, enteral nutrition, and parenteral nutrition (implemented in that order) in most perioperative patients was advocated for with protein delivery being more important than total calorie delivery. Finally, the role of often-inadequate nutrition intake in the posthospital setting was discussed, and the role of postdischarge oral nutrition supplements was emphasized.

To quantify the impact of body mass index (BMI) on surgical site infection (SSI) following abdominal wall reconstruction (AWR) using component separation techniques and attempt to identify obesity-related targets, such as BMI, that can be potentially used to guide preoperative patient optimization. Though AWR has established perioperative outcomes for hernia repair, the applicability in the obese population is not well established.The 2005-2013 ACS-NSQIP participant use file was reviewed to compare SSI, severe, and overall morbidity in non-emergent AWR patients based on BMI. Multivariable logistic regression was used to control for patient demographics and comorbidities. Odds ratios (OR) with 95% confidence intervals were reported.We identified 4488 patients. The average BMI was 32.76 ± 7.70 kg/mThere is a significant increase in SSI and other perioperative complications in patients with a BMI ≥ 35 kg/m

Studies examining utilization and impact of venous thromboembolism (VTE) chemoprophylaxis for patients undergoing bariatric surgery are limited. Determination of the optimal prophylactic regimen to minimize complications is crucial. The Cerner Health Facts database from 2003 to 2013 was queried using ICD-9 codes to identify patients undergoing laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB). VTE chemoprophylaxis regimens were divided into pre-operative alone (PreP), post-operative alone (PostP), both pre-operative and post-operative (PPP), or no prophylaxis (NP). Specific chemoprophylaxis agents were compared. Comparisons in inpatient clinical outcomes were based on univariate analysis and multivariable logistic regression when appropriate. We identified 11,860 patients who underwent LSG and RYGB. 634 (5.35%) had PreP, 4593 (38.73%) had PostP, 2646 (22.31%) had PPP, and 3987 (33.62%) had NP. The overall rates of transfusion, DVT, and PE were 2.48, 0.27, and 0.18%, respectively. Patients without chemoprophylaxis had higher rate of DVT compared to any chemoprophylaxis (0.58 vs 0.11%, p

The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendations on this important topic with the goal to (1) develop a rational definition for POGD that can serve as a framework for clinical and research efforts; (2) critically review the evidence behind current prevention strategies and provide consensus recommendations; and (3) develop rational treatment strategies that take into account the wide spectrum of impaired GI function in the postoperative period.

Patient-reported outcomes (PROs) are measures of health status that come directly from the patient. PROs are an underutilized tool in the perioperative setting. Enhanced recovery pathways (ERPs) have primarily focused on traditional measures of health care quality such as complications and hospital length of stay. These measures do not capture postdischarge outcomes that are meaningful to patients such as function or freedom from disability. PROs can be used to facilitate shared decisions between patients and providers before surgery and establish benchmark recovery goals after surgery. PROs can also be utilized in quality improvement initiatives and clinical research studies. An expert panel, the Perioperative Quality Initiative (POQI) workgroup, conducted an extensive literature review to determine best practices for the incorporation of PROs in an ERP. This international group of experienced clinicians from North America and Europe met at Stony Brook, NY, on December 2-3, 2016, to review the evidence supporting the use of PROs in the context of surgical recovery. A modified Delphi method was used to capture the collective expertise of a diverse group to answer clinical questions. During 3 plenary sessions, the POQI PRO subgroup presented clinical questions based on a literature review, presented evidenced-based answers to those questions, and developed recommendations which represented a consensus opinion regarding the use of PROs in the context of an ERP. The POQI workgroup identified key criteria to evaluate patient-reported outcome measures (PROMs) for their incorporation in an ERP. The POQI workgroup agreed on the following recommendations: (1) PROMs in the perioperative setting should be collected in the framework of physical, mental, and social domains. (2) These data should be collected preoperatively at baseline, during the immediate postoperative time period, and after hospital discharge. (3) In the immediate postoperative setting, we recommend using the Quality of Recovery-15 score. After discharge at 30 and 90 days, we recommend the use of the World Health Organization Disability Assessment Scale 2.0, or a tailored use of the Patient-Reported Outcomes Measurement Information System. (4) Future study that consistently applies PROMs in an ERP will define the role these measures will have evaluating quality and guiding clinical care. Consensus guidelines regarding the incorporation of PRO measures in an ERP were created by the POQI workgroup. The inclusion of PROMs with traditional measures of health care quality after surgery provides an opportunity to improve clinical care.

There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent increase in number of weight reduction surgeries, in these individuals. Thus, pregnancy following weight loss surgery is increasingly encountered in clinical practice. A multidisciplinary team is needed to address these patients as they pose specific surgical, medical, and obstetric challenges. This chapter describes common considerations relating to pregnant bariatric surgical patients.

Bariatric surgery is the most effective treatment for morbid obesity. A minority of patients will suffer from inadequate weight loss or weight regain. The reasons for this are multifactorial, including anatomic, physiologic, behavioral, and psychosocial factors. A thorough assessment begins with a history and physical examination in order to identify any contributors to poor weight loss outcomes. Common reasons for weight recidivism include maladaptive eating habits, psychosocial stressors, and decreased energy expenditure and physical activity. Anatomic and surgical factors, such as infrequent band adjustments or large pouch size, play a role as well. Management includes in-depth counseling regarding nutrition and behavior modification and, depending on the patient, may include revision or conversion surgery.

Controversy exists regarding the relevance of Center of Excellence accreditation to bariatric surgery outcomes. The objective of this study was to evaluate the impact of national hospital accreditation on perioperative and long-term outcomes following bariatric surgery.Retrospective, longitudinal study using 2004-2010 data from the New York Statewide Planning and Research Cooperative longitudinal administrative database (n = 47,342). Multivariable logistic regression analyzed outcomes following laparoscopic bariatric surgery. Accredited hospitals and accreditation year were identified from the Centers for Medicaid and Medicare website. Outcomes were analyzed with and without temporal correlation to accreditation year.30-day mortality was determined from social security death records.Risk of perioperative morbidity OR 1.4 (range 1.2-1.6, P.001), mortality OR 2.6 (range 1.3-5.4, P = .01) and all-cause long-term mortality OR 1.4 (range 1.2-1.7, P = .0002) were significantly increased in unaccredited versus accredited hospitals on univariate analysis. In accredited hospitals, significant changes in payor and patient mix, operation, perioperative, and long-term outcomes were demonstrated following accreditation. A significant decrease in operations performed on black patients, Hispanic patients, and Medicare patients was also identified. Controlling for patient demographics, co-morbidity, insurance, and operative procedure, multivariable logistic regression demonstrated accreditation as independently associated with fewer major complications versus unaccredited hospitals OR 0.72 (range .63-.83, P.001) and within the same hospital following accreditation OR .86 (range 0.77-0.96, P = .01). Following multiple cox proportional hazard model analysis, long-term mortality differences were not significant.In New York State, bariatric hospital accreditation improved patient outcomes as compared to unaccredited hospitals and within the same hospital compared to preaccreditation. Significant changes were identified for some underserved at-risk populations. Measures to ensure equitable health care for at-risk populations following institutional accreditation are imperative.

Background There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent increase in number of weight reduction surgeries in these individuals. As a result, special attention needs to be paid to potential postsurgical complications during pregnancy, particularly after Roux-en-Y gastric bypass (RYGB). We are presenting our small case series and our suggestions for management for the pregnant bariatric patient. The aim of this study is to review our institutional experience and present our algorithm to approach pregnant women presenting with abdominal pain and/or emesis after RYGB. Methods After Institutional Review Board approval, a retrospective chart review was performed at a single center institution between 2010 and 2013. Data regarding clinical presentation, physical exam findings, laboratory values, radiographic studies, intraoperative findings, and clinical outcomes of both mother and fetus were collected and reviewed for pregnant patients with history of RYGB and abdominal distress. Results Five patients were identified. Patient age ranged from 22–34 years (mean 28.4). Gestational age ranged from 9–31 months (mean 19.2). Average body mass index at presentation was 30.3 kg/m 2 . Of the 5 patients, 4 presented with abdominal pain and one with intractable emesis. Four patients were taken to the operating room. One was successfully discharged. Two of the patients had an obstruction from adhesions, and the other 2 were found to have internal hernia. There was no mortality for either fetus or mother. One patient required premature delivery at 28 weeks. Conclusions Pregnant women with history of RYGB who present with abdominal pain should be evaluated urgently for internal hernia or obstruction. A systematic approach is needed to ensure prompt diagnosis.

Background Many new techniques and bariatric endoluminal procedures are being developed and used for the treatment of obesity. Clear guidelines or opinions of the new techniques are not readily available. The aim of this study was to gauge the level of interest and opinions of bariatric surgeons regarding these new techniques, using online and real poll surveys. Methods The American Society for Metabolic and Bariatric Surgery (ASMBS) Emerging Technologies committee developed a questionnaire that was distributed among the membership and conducted a live poll of attendees at Obesity Week 2013. Opinions of new technologies and techniques by practitioners were assessed. Results A total of 134 responses to the questionnaire were returned. Most responses (79%) expressed the belief that new bariatric techniques are needed to improve the practice of bariatric and metabolic surgery. The responses describing the effects of new procedures and technology as beneficial were (1) increased interest from patients or referring physicians (94%), (2) expanded indications for intervention (93%), and (3) lower risk intervention (96%). Nearly all respondents (90.2%) identified value in informational guidelines on new technologies and procedures, and most (88.7%) agreed that the ASMBS should coordinate clinical trials or registries to evaluate these therapies. Conclusion Although most bariatric and metabolic surgeons agree that new endoluminal surgical techniques are beneficial, most also are unable to offer the procedures to their patients without more clinical evidence and clear guidelines from the society.

Background With the rise of obesity in adolescents, there is an exponential increase in bariatric procedures in this patient population. Objectives The purpose of our study was to examine perioperative outcomes after bariatric surgery in this cohort. Setting University hospital, involving a large database in New York State. Methods The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file was queried to identify all adolescent patients (age Results We identified 1072 patients who underwent Roux-en-Y gastric bypass (n = 279) or SG (n = 793). The majority were Caucasian (n = 790) and female (n = 857) with mean body mass index and age of 47.9 ± 8.1 kg/m 2 and 18.2 ± 1 years, respectively, preoperative hypertension, type 2 diabetes, and obstructive sleep apnea were present in 90 (8.4%), 139 (13%), and 165 (15.4%) of patients, respectively. There was significant difference in preoperative gastroesophageal reflux disease (18.6% versus 13.4%, P = .033), obstructive sleep apnea (19.7% versus 13.9%, P = .02), and body mass index (48.6 ± 7.9 versus 47.6 ± 8.2 kg/m 2 , P = .03) between patients undergoing Roux-en-Y gastric bypass and SG, respectively. Thirty-day reoperation, readmission, and reintervention were reported in 1.5%, 3.3%, and 1.6% of the adolescent cohort, respectively. Four patients (.4%) developed a staple line/anastomotic leak, and 1 patient (.09%) died within 30 days; 93.9% of all adolescent patients experienced an uneventful 30-day recovery. Uneventful recovery was significantly more likely for patients undergoing SG (95.3% versus 90%, P = .001; adjusted odds ratio 2.2, 95% confidence interval 1.31–3.69). Conclusion Perioperative safety of bariatric surgery in adolescents in accredited centers is safer than previously reported with low rate of 30-day events. SG is a safer procedure in this patient population.

The American health care system faces deficits in quality and quantity of surgeons. SAGES is a major stakeholder in surgical fellowship training and is responsible for defining the curriculum for the Advanced GI/MIS fellowship. SAGES leadership is actively adapting this curriculum. The process of reform began in 2014 through a series of iterative meetings and discussions. A working group within the Resident and Fellow Training Committee reviewed case log data from 2012 to 2015. These data were used to propose new criteria designed to provide adequate exposure to core content. The working group also proposed using video assessment of an MIS case to provide objective assessment of competency. Case log data were available for 326 fellows with a total of 85,154 cases logged (median 227 per fellow). The working group proposed new criteria starting with minimum case volumes for five defined categories including foregut (20), bariatrics (25), inguinal hernia (10), ventral hernia (10), and solid organ/colon/thoracic (10). Fellows are expected to perform an additional 75 complex MIS cases of any category for a total of 150 required cases overall. The proposal also included a minimum volume of flexible endoscopy (50) and submission of an MIS foregut case for video assessment. The new criteria more clearly defined which surgeon roles count for major credit within individual categories. Fourteen fellowships volunteered to pilot these new criteria for the 2017–2018 academic year. The new SAGES Advanced GI/MIS fellowship has been crafted to better define the core content that should be contained in these fellowships, while still allowing sufficient heterogeneity so that individual learners can tailor their training to specific areas of interest. The criteria also introduce innovative, evidence-based methods for assessing competency. Pending the results of the pilot program, SAGES will consider broad implementation of the new fellowship criteria.

Although multiple studies demonstrate that routine postoperative contrast studies have a low yield in diagnosing patients with early gastrointestinal (GI) leak after bariatric surgery, the practice pattern is unknown. Additionally, routine imaging may hinder procedural pathways that lead to accelerated postoperative discharge.To report on the nationwide use of routine upper GI studies (UGI) and evaluate the effect on hospital resource utilization.Nationwide analysis of accredited centers.The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file for 2015 was used to identify patients who underwent routine UGI after nonrevisional Roux-en-Y gastric bypass or sleeve gastrectomy. Multivariable logistic regression models were developed to identify risk factors for early hospital discharge.Bariatric surgery was performed on 130,686 patients. Routine UGI was performed in 30.9% of Roux-en-Y gastric bypass and 43% of sleeve gastrectomy patients (P.0001). Patients undergoing routine UGI were less likely to be discharged by postoperative day 1 (odds ratio .7, 95%; confidence interval .69-0.72). There was no difference in postoperative leak rate between the routine UGI versus nonroutine UGI group (.7% versus .8%, P = .208). Among patients who developed a GI leak, there was no significant difference in the rate of reoperation, readmission, and reintervention between the 2 groups. The time interval between index operation and any further management for the leak was longer in the routine UGI group.Routine UGI evaluation after bariatric surgery remains a common practice in accredited centers. This practice is associated with prolonged hospital length of stay, with no effect on the diagnosis of leak rate.

Background A primary measure of the success of a procedure is the whether or not additional surgery may be necessary. Multi-institutional studies regarding the need for reoperation after bariatric surgery are scarce. Objectives The purpose of this study is to evaluate the rate of revisions/conversions (RC) after 3 common bariatric procedures over 10 years in the state of New York. Setting University Hospital, involving a large database in New York State. Methods The Statewide Planning and Research Cooperative System database was used to identify all patients undergoing laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB) between 2004 and 2010. Patients were followed for RC to other bariatric procedures for at least 4 years (up to 2014). Multivariable cox proportional hazard regression analysis was performed to identify risk factors for additional surgery after each common bariatric procedure. Multivariable logistic regression was used to check the factors associated with having ≥2 follow-up procedures. Results There were 40,994 bariatric procedures with 16,444 LAGB, 22,769 RYGB, and 1781 SG. Rate of RC was 26.0% for LAGB, 9.8% for SG, and 4.9% for RYGB. Multiple RC ( = />2) were more common for LAGB (5.7% for LAGB, .5% for RYGB, and .2% for LSG). Band revision/replacements required further procedures compared with patients who underwent conversion to RYGB/SG (939 compared with 48 procedures). Majority of RC were not performed at initial institution (68.2% of LAGB patients, 75.9% for RYGB, 63.7% of SG). Risk factors for multiple procedures included surgery type, as LAGB was more likely to have multiple RC. Conclusions Reoperation was common for LAGB, but less common for RYGB (4.9%) and SG (9.8%). RC rate are almost twice after SG than after RYGB. LAGB had the highest rate (5.7%) of multiple reoperations. Conversion was the procedure of choice after a failed LAGB.

Leaks following bariatric surgery occur in 1.6–4.8% of Roux-en-Y gastric bypass (RYGB) procedures and in 1.7–2.4% of laparoscopic sleeve gastrectomy (LSG) cases. Surgical re-exploration for bariatric leaks carries an increased morbidity (15–50%) and mortality (2–10%). Endoscopically placed self-expandable stents offer a noninvasive means of managing bariatric leaks. This chapter focuses on the indications, deployment techniques, and complications of placing endoluminal stents for the treatment of leak following bariatric surgery.

The purpose of our study was to investigate surgical outcomes following advanced colorectal procedures at academic versus community institutions. The SPARCS database was used to identify patients undergoing Abdominoperineal resection (APR) and Low Anterior Resection between 2009 and 2014. Linear mixed models and generalized linear mixed models were used to compare outcomes. Laparoscopic versus open procedures, surgery type, volume status, and stoma formation between academic and community facilities were compared. Higher percentages of laparoscopic surgeries (58.68 vs. 41.32%, p value

Background As the number of obese patients in the United States continues to grow, there is a parallel increase in the number of bariatric surgery patients. A quarter of these patients will return to the Emergency Department (ED) within the first two years of the index procedure. Objective An understanding of the most common bariatric procedures and their related complications will greatly aide the Emergency Medicine physician in the care of these patients. Discussion Abdominal pain is the most common reason for bariatric patients to present to the ED and can represent a diagnostic challenge to EM physicians. It is important that EM physicians have a good understanding of bariatric procedures. We describe the three most common bariatric procedures: 1) the Laparoscopic Adjustable Gastric Banding (LAGB); 2) the Laparoscopic Sleeve Gastrectomy (LSG); 3) and the Roux-en-Y Gastric Bypass (RYGB). Due to the unique altered anatomy following the procedures there are specific complications related to each individual procedure. We will describe the most common presentations of abdominal pain in the post bariatric surgery patient. Finally, we will review new endoscopic procedures and the associated complications that may cause patients to present to the ED. Conclusion Certain complications in bariatric surgery patients can have a high rate of morbidity and mortality. An improved understanding of bariatric procedures and their complications will allow for improved vigilance and management.