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Financial incentives to promote recommended behaviors have been applied in many healthcare settings, but to our knowledge, have never been tested as a strategy to improve patient follow-up after bariatric surgery. Given that females make up majority of bariatric surgery patients, our goal was to explore female patient perceptions on the effects of a financial incentive program designed to increase follow-up after bariatric surgery.This was an exploratory qualitative study of patient participants in a pilot program investigating financial incentives. We performed qualitative interviews with female patients to include personal experiences with bariatric surgery, progress toward goals, and concerns related to post-surgical behaviors. The data was analyzed iteratively through inductive thematic analysis.Twenty-one female patients who had undergone bariatric surgery and enrolled in the financial incentive program participated in this study. Participants had generally positive impressions of the financial incentive program. Participants described the utility of the program in helping to pay for expenses associated with bariatric surgery; feeling that participation was their way of demonstrating that they were compliant with post-surgical recommendations; and that it provided additional motivation. All patients stated that even without the financial incentive they would have continued to follow-up.While financial incentives can provide additional motivation for patients following bariatric surgery, they are not the primary reason that patients choose to follow-up. Understanding the motivation of patients who choose to follow-up (or not) may better inform investigations intended to improve follow-up rates after bariatric surgery.

Background Patient-reported outcomes (PRO) obtained from follow-up survey data are essential to understanding the longitudinal effects of bariatric surgery. However, capturing data among patients who are well beyond the recovery period of surgery remains a challenge, and little is known about what factors may influence follow-up rates for PRO. Objectives To assess the effect of hospital practices and surgical outcomes on patient survey completion rates at 1 year after bariatric surgery. Setting Prospective, statewide, bariatric-specific clinical registry. Methods Patients at hospitals participating in the Michigan Bariatric Surgery Collaborative are surveyed annually to obtain information on weight loss, medication use, satisfaction, body image, and quality of life following bariatric surgery. Hospital program coordinators were surveyed in June 2017 about their practices for ensuring survey completion among their patients. Hospitals were ranked based on 1-year patient survey completion rates between 2011 and 2015. Multivariable regression analyses were used to identify associations between hospital practices, as well as 30-day outcomes, on hospital survey completion rankings. Results Overall, patient survey completion rates at 1 year improved from 2011 (33.9% ± 14.5%) to 2015 (51.0% ± 13.0%), although there was wide variability between hospitals (21.1% versus 77.3% in 2015). Hospitals in the bottom quartile for survey completion rates had higher adjusted rates of 30-day severe complications (2.6% versus 1.7%, respectively; P = .0481), readmissions (5.0% versus 3.9%, respectively; P = .0157), and reoperations (1.5% versus .7%, respectively; P = .0216) than those in the top quartile. While most hospital practices did not significantly impact survey completion at 1 year, physically handing out surveys during clinic visits was independently associated with higher completion rates (odds ratio, 13.60; 95% confidence interval, 1.99−93.03; P =.0078). Conclusions Hospitals vary considerably in completion rates of patient surveys at 1 year after bariatric surgery, and lower rates were associated with hospitals that had higher complication rates. Hospitals with the highest completion rates were more likely to physically hand surveys to patients during clinic visits. Given the value of PRO on longitudinal outcomes of bariatric surgery, improving data collection across multiple hospital systems is imperative.

Opioid prescribing following bariatric surgery has been a focus due to its association with new persistent opioid use (NPOU) and worse outcomes. Guidelines have led to a reduction in opioids prescribed, but there remains variation in prescribing practices.We conducted interviews with 20 bariatric surgeons across Michigan. Transcripts were analyzed using descriptive content analysis.At the patient level, surgeons described the role of surgical history and pain tolerance. At the provider level, surgeons discussed patient dissatisfaction, reputation, and workload. At the institution level, surgeons discussed colleagues, resources, and administration. At a collaborative level, surgeons described the role of evidence and performance measures. There was lack of consensus on whether NPOU is a problem facing patients undergoing bariatric surgery.Despite efforts aimed at addressing opioid prescribing, variability exists in prescribing practices. Understanding determinants that impact stakeholder alignment is critical to increasing adherence to guideline-concordant care.

Enhanced Recovery After Surgery (ERAS) Protocols are well-established in fields such as colorectal surgery but within bariatric surgery have not been uniformly adopted by all programs.Qualitative study with focus groups at five hospitals participating in a statewide bariatric surgery quality improvement collaborative. Members of the clinical care team at each pilot site participated. Participants described barriers to implementation, and strategies to address these.Participants expressed satisfaction with the implementation process. Barriers included a lack of buy-in from team members, availability of specific resources, staffing turnover, and interruption to implementation. Increased communication at all phases and a specific point-person to guide implementation would improve success.These findings will be integrated into our work as we continue to implement this protocol at all hospitals participating within the collaborative. Future work will focus on the impact of the protocol on clinical outcomes and patient satisfaction following surgery.

The most common cause of mortality following bariatric surgery is venous thromboembolism. Our study aimed to (1) determine the practice patterns of venous thromboembolism (VTE) chemoprophylaxis among bariatric surgeons participating in a large statewide quality collaborative and (2) compare the results of surgeon self-reported chemoprophylaxis practices to actual practices from abstracted chart data. We administered a 13-question survey to 66 surgeons across a statewide collaborative aimed at revealing VTE practice patterns such as medication type, dosage, timing, duration, and level of trainee involvement (response rate 93%). We conducted on-site data audits to examine the charts of all patients that had developed VTE during the study period and 15 other randomly selected patient charts per site. We then evaluated both the ordered perioperative chemoprophylaxis and the actual administered chemoprophylaxis from nursing and electronic records. There was 31% overall discordance between self-reported and abstracted chart data for pre-operative VTE dosing regimens. Among patients who had a VTE, 39% of administered chemoprophylaxis did not match surgeon responses. Conversely, among patients who did not have a VTE, only 29% were discordant (p = 0.03). In contrast, for post-operative VTE dosing, there was no significant difference in the rate of discordance in patients with and without a VTE (47% discordance vs 38%, p = 0.0552, respectively). Greater discordance between surgeon self-reported and actual perioperative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the system characteristics associated with these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis.

To determine the accuracy of postoperative patient-reported comorbidity assessment, as it may be an important mechanism for long-term follow-up in surgical patients.Less than 1% of patients who qualify actually undergo bariatric surgery which may be due to concerns surrounding long-term efficacy. Longitudinal follow-up of patients' comorbidities remains a challenge.Retrospective, cross-sectional study of bariatric surgery patients from 38 sites within a state-wide collaborative from 2017 to 2018. A minimum of 10 and maximum of 20 responses to a 1-year postoperative questionnaire from each site were randomly sampled. We examined percent agreement between patient-reported and medical chart audit comorbidity assessment and further evaluated agreement by intraclass correlation or κ statistic. Postoperative comorbidities assessed include weight, hyperlipidemia, hypertension, diabetes, depression, obstructive sleep apnea, gastroesophageal reflux disease (GERD), anxiety, and pain.Five hundred eighty-five patients completed postoperative questionnaires after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass. The response rate was 64% during the study period. Patients reported weight with a mean difference of 2.7 lbs from chart weight (intraclass correlation = 0.964). Agreement between patient report and audit for all comorbidities was above 80% except for GERD (71%). κ statistics were greater than 0.6 (good agreement) for hyperlipidemia, hypertension, diabetes, and depression. Anxiety ( κ = 0.45) and obstructive sleep apnea ( κ = 0.53) had moderate agreement. Concordance for GERD and pain were fair (both κ = 0.38).Patient-reported comorbidity assessment has high levels of agreement with medical chart audit for many comorbidities and can improve understanding of long-term outcomes. This will better inform patients and providers with hopes of 1 day moving beyond the 1%.

Objective This study sought to explore the relationship of bariatric surgeon age and patient outcomes. Background Regulators, policy makers, and patient advocacy groups have recently been pushing to establish clear guidelines for physician retirement in the United States. Although it is often assumed that increasing physician age leads to worse patient outcomes, the relationship is lacking robust evidence, and is still unclear. Methods We conducted a study analyzing all bariatric surgeons in Michigan who participated in a statewide collaborative quality improvement program (n = 71) who performed primary laparoscopic Roux-en-Y Gastric Bypass, or sleeve gastrectomy operations, and data on their patients (n = 60430) over the past 10 years. Our primary outcomes were 30-day postoperative complications. Odds ratios for overall complications and serious complications were calculated for each age group, and surgery type. Results Late career surgeons had more bariatric surgery experience and had a higher average annual case volume than early career surgeons. Considering all cases in the past 10 years, older surgeons performed more Roux-en-Y Gastric Bypass (40%) and less sleeve gastrectomy (38.8%) than younger surgeons (34.7% and 51.5%). When adjusting for patient and surgeon characteristics, there were no statistically significant differences in overall or serious complication rates for either procedure among surgeon age groups. Conclusions When evaluating bariatric surgeons in the State of Michigan, we found no statistically significant association between surgeon age and patient outcomes. Our findings do not provide evidence for age-specific retirement cut-offs, but support the development of guidelines which are holistic, and focus on evaluating and improving physician outcomes at all career levels.

OBJECTIVE The aim of this study was to explore the efficacy of current bariatric perioperative measures at reducing emergency department (ED) visits following bariatric surgery in the state of Michigan. SUMMARY OF BACKGROUND DATA Many ED visits following bariatric surgery do not result in readmission and may be preventable. Little research exists evaluating the efficacy of perioperative measures aimed at reducing ED visits in this population. Therefore, understanding the driving factors behind these preventable ED visits may be a fruitful approach to prevention. Furthermore, evaluating the efficacy of current perioperative measures may shed light on how to achieve meaningful reductions in ED visits. METHODS We studied 48,035 eligible bariatric surgery patients across 37 Michigan Bariatric Surgical Collaborative (MBSC) sites between January 2012 and October 2015. Hospitals were ranked according to their risk- and reliability-adjusted ED visit rates. For hospitals in each ED visit rate tercile, several patient, surgery, and hospital summary characteristics were compared. We then studied whether a hospital's compliance with specific perioperative measures was significantly associated with reduced ED visit rates. RESULTS Only 3 of the 30 surgery, hospital, and patient summary characteristics studied were significant predictors of a hospital's ED visit rate: rate of sleeve gastrectomies, rate of readmissions, and rate of venous thromboembolism complications (P = 0.04, P = 0.0065, and P = 0.0047, respectively). Also, a hospital's compliance with the perioperative measures evaluated was not a significant predictor of ED visit rates (P = 0.12). CONCLUSIONS Current practices aimed at reducing ED visits appear to be ineffective. Due to heterogeneity in patient populations and local infrastructure, a more tailored approach to ED visit reduction may be more successful.

Physician-nurse communication skills are critical for incoming residents; however, standardized training and feedback targeting these skills are not well-described. We used a qualitative approach to determine types of feedback standardized registered nurses (SRN) can provide to students pre-residency. Senior medical students enrolled in an elective one-month specialty-specific Residency Preparation Course in 2018 participated in a simulated paging curriculum where they responded to urgent pages from SRNs about mock patients. The SRNs followed a script and assessed students using a rubric, then provided immediate verbal feedback on the students’ clinical management and communication skills. We recorded, de-identified, transcribed, and coded feedback, then determined themes. Seventy-six students participated and 162 encounters were recorded. We developed nine codes and identified two themes: positive reinforcement and authentic clinical feedback. The SRNs connected the cases to real-life experiences, reflecting upon mistakes or interactions they have made, to emphasize learning points for the student. This non-scripted, authentic clinical feedback reinforced the feedback provided on specific domains including information gathering, communication, and clinical management. This study highlights the value of utilizing SRNs to provide interprofessional feedback to medical students just prior to residency.

The most common cause of mortality following bariatric surgery is venous thromboembolism. Our study aimed to (1) determine the practice patterns of venous thromboembolism (VTE) chemoprophylaxis among bariatric surgeons participating in a large statewide quality collaborative and (2) compare the results of surgeon self-reported chemoprophylaxis practices to actual practices from abstracted chart data.We administered a 13-question survey to 66 surgeons across a statewide collaborative aimed at revealing VTE practice patterns such as medication type, dosage, timing, duration, and level of trainee involvement (response rate 93%). We conducted on-site data audits to examine the charts of all patients that had developed VTE during the study period and 15 other randomly selected patient charts per site. We then evaluated both the ordered perioperative chemoprophylaxis and the actual administered chemoprophylaxis from nursing and electronic records.There was 31% overall discordance between self-reported and abstracted chart data for pre-operative VTE dosing regimens. Among patients who had a VTE, 39% of administered chemoprophylaxis did not match surgeon responses. Conversely, among patients who did not have a VTE, only 29% were discordant (p = 0.03). In contrast, for post-operative VTE dosing, there was no significant difference in the rate of discordance in patients with and without a VTE (47% discordance vs 38%, p = 0.0552, respectively).Greater discordance between surgeon self-reported and actual perioperative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the system characteristics associated with these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis.

Individual weight loss outcomes after bariatric surgery can vary considerably. As a result, identifying and assisting patients who are not on track to reach their weight loss goals can be challenging. Using a bariatric surgery outcomes calculator, which was formulated using a state-wide bariatric-specific data registry, predicted weight loss at 1 year after surgery was calculated on 658 patients who underwent bariatric surgery at 35 different bariatric surgery programs between 2015 and 2017. Patient characteristics, postoperative complications, and weight loss trajectories were compared between patients who met or exceeded their predicted weight loss calculation to those who did not based on observed to expected weight loss ratio (O:E) at 1 year after surgery. Patients who did not meet their predicted weight loss at 1 year (n = 237, 36%) had a mean O:E of 0.71, while patients who met or exceeded their prediction (n = 421, 63%) had a mean O:E = 1.14. At 6 months, there was a significant difference in the percent of the total amount of predicted weight loss between the groups (88% of total predicted weight loss for those that met their 1-year prediction vs 66% for those who did not, p < 0.0001). Age, gender, procedure type, and risk-adjusted complication rates were similar between groups. Using a bariatric outcomes calculator can help set appropriate weight-loss expectations after surgery and also identify patients who may benefit from additional therapy prior to reaching their weight loss nadir.

Background Bariatric surgery leads to changes in mental health, quality of life and social functioning, yet these outcomes differ among individuals. In this study, we explore patients’ psychosocial experiences following bariatric surgery and elucidate the individual-level factors that may drive variation in psychosocial outcomes. Methods Eleven semi-structured focus groups with Michigan Bariatric Surgery Collaborative (MBSC) patients (n = 77). Interviews were audio recorded, transcribed verbatim, and analyzed using a grounded theory approach. Data on participant demographic characteristics were abstracted from the MBSC clinical registry. Results Most focus group participants were female (89%), white (64%), and married (65%). We identified three major themes: (1) change in self-perception; (2) change in perception by others; and (3) change in relationships. Each theme includes 3 sub-themes, demonstrating a range of positive and negative psychosocial experiences. For example, weight loss led to increased self-confidence among many participants while others described a loss of self-identity. Some noted improved relationships with family or friends while others experienced worsening or even loss of relationships due to perceived jealousy. Conclusion Weight loss following bariatric surgery leads to complex changes in self-perception and inter-personal relationships, which may be proximal mediators of commonly assessed mental health outcomes such as depression. Individuals considering bariatric surgery may benefit from anticipatory guidance about these diverse experiences, and post-surgical longitudinal monitoring should include evaluation for adverse psychosocial events.

Background Bariatric surgery is underutilized. Objectives To identify factors associated with eligible patient dropout from bariatric surgery. Setting University hospital, United States. Methods Eligible candidates were identified after a multidisciplinary review committee (MRC) of all patients (n = 484) who attended a bariatric surgery informational session (BIS) at a single-center academic institution in 2015. We compared patients who underwent surgery within 2 years of BIS with those who did not (i.e., dropped out) by evaluating patient, insurance, and program-specific variables. Univariate analyses and multivariable regressions were performed to identify factors associated with patient dropout among eligible candidates. Results We identified 307 (63%) patients who underwent MRC. Thirty-three (11%) patients were deemed poor candidates and surgery was not recommended. Among eligible candidates, 82 (30%) dropped out from the program. Factors independently associated with eligible patient dropout included coronary artery disease (odds ratio [OR] .13 [.02–.66]; P = .014), hypertension (OR .46 [.24–.87]; P = .017), time from BIS to MRC (OR .99 [.99–.99]; P = .002), 3 months of medically supervised weight loss documentation (OR .09 [.02–.51]; P = .007), endocrinology clearance (OR .26 [.09–.76]; P = .014), hematology clearance (OR .37 [.14–.95]; P = .039), urine drug screen testing (OR .31 [.13–.72]; P = .006), additional psychological evaluation (OR .43 [.20–.93]; P = .031), and required extra sessions with the dietician (OR .39 [.17–.92]; P = .032). Thirty-three (6.8%) patients underwent surgery at another institution, and 42% of these patients lived more than 50 miles from attended BIS site. Conclusions Twenty-seven percent of patients did not undergo bariatric surgery at their initial site of evaluation despite being considered eligible candidates after MRC. Dropout was independently associated with patient, insurance, and program-specific variables that may represent barriers to care amenable to improvement.

Background Reducing avoidable emergency department (ED) visits is an increasingly important target of quality improvement and cost containment efforts in bariatric surgery. Administrative and clinical registry data provide an incomplete picture of the factors contributing to postoperative ED utilization. Patient-centered interviews can help identify intervention opportunities. Objectives We sought to understand the circumstances surrounding patient self-referral to the ED after elective, primary bariatric surgery. Setting A quality improvement collaborative in Michigan. Methods A prospective review of clinically abstracted data and patient interviews was completed across 40 hospitals participating in a statewide quality improvement collaborative. Trained nurses collected data on the circumstances surrounding patients' 30-day postoperative ED visits using a previously validated interview tool. Over a year, 201 of 633 total ED visits met the inclusion criteria, with 78% of those patients being interviewed. Results The most common reported chief complaints were abdominal pain and nausea/vomiting. Patients reported high compliance with provider-driven perioperative measures to reduce ED visits. One third of patients stated urgency as the reason for not contacting their surgeon prior to their visit. A majority of patients believed their ED visit was both necessary and unavoidable. Conclusions Most patients experienced non-life-threatening symptoms but believed their concerns required immediate medical attention in an ED. Patients did not seek lower acuity alternatives despite the increasing availability of these lower cost options. Urgent care centers are one practical alternative for patients who need expeditious professional evaluation. Focused, patient-centered education and promotion of appropriate lower acuity options may decrease nonurgent ED utilization among postoperative bariatric patients.

Video assessment is an emerging tool for understanding variation in surgical technique.Representative videos of laparoscopic sleeve gastrectomy (LSG) were voluntarily submitted by 20 surgeons who participated in a statewide quality improvement collaborative. The amount of time required to complete the salient steps of the operation was measured and variations in the tasks performed during each step were captured.Twenty-two videos of LSG were submitted and 11 videos included concurrent hiatal hernia repair. Data obtained from video analysis identified variation in time to complete each step of the procedure: prestapling dissection of stomach (5-25 minutes), gastric stapling (8-20 minutes), and management of the staple line (1-25 minutes). Time required to perform a hiatal hernia repair also varied (1-26 minutes), as did the type of repair: 55% were performed with a posterior cruropexy, 27% were performed with an anterior cruropexy, and 18% were performed with both. Ten different permutations of staple heights and buttressing material were used during division of the stomach with a gastric stapler. Management of the staple line included use of buttressing (64%), fibrin sealant (36%), oversewing (9%), surgical clips (18%), imbrication of the staple line (36%), and omentoplasty (55%).LSG technique is not uniform. Video analysis identified variation in (1) time to complete each step of the procedure, (2) hiatal hernia repair technique, (3) stapling technique, and (4) post-transection staple line management. Future efforts linking video analysis with clinical outcomes can provide objective evidence to support best practices.

To assess the effect of operative technique on staple line leaks after laparoscopic sleeve gastrectomy (LSG).Staple-line leaks after LSG are a major source of morbidity and mortality. Variations in operative technique exist; however, their effect on leaks is poorly understood.We analyzed data from the Michigan Bariatric Surgery Collaborative (MBSC) to perform a case-control study comparing patients who had a clinically significant leak after undergoing a primary LSG to those who did not. A total of 45 patients with leaks were identified between January 2007 and December 2013. The leak group was matched 1:2 to a control group based on procedure type, age, body mass index, sex, and year the procedure was performed. Technique-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. Conditional logistic regression was used to identify techniques associated with leaks. To increase the power of our analysis, we used a significance level of .10.Leak rates with LSG have decreased over the past 5 years (1.18% to .36%) as annual case volume has increased (846 cases/yr to 4435 cases/yr). Surgeons who performed 43 or more cases per year had a leak rate1%. Leaks were more common among cases requiring a blood transfusion (26.2% versus 1.08%, P = .0031) and when cases were converted to open surgery (7.14% versus 0%, P = .0741). However, there was no significant difference in operative time between cases involving a leak and their matched controls (95.4 min versus 87.1 min, P = .1197). Oversewing of the staple line was the only technique associated with less leaks after controlling for confounding factors (OR .397 CI .174, .909, P = .0665). Notably, surgeons who oversewed routinely were also found to have higher case volume (307 versus 140, P = .0216) and less overall complication rates (4.81% versus 7.95%, P = .0027). Furthermore, oversewing technique varied widely as only 22.6% of cases involved oversewing of the entire staple line.Despite considerable variation in operative technique, leak rates with laparoscopic sleeve gastrectomy have decreased over time as operative volume has increased. Oversewing of the staple line was associated with fewer leaks, but specific suturing technique was not uniform and oversewing was performed routinely by more experienced surgeons with higher case volumes and less complication rates overall. Before standardizing surgical technique one must take into account variations in surgeon skill and experience.

Objective To assess the relationship between technique and surgical devices on anastomotic and staple-line leaks after laparoscopic Roux-en-Y gastric bypass. Background Leaks after bariatric surgery remain a major source of morbidity and mortality. The association of surgical technique and devices with leaks after gastric bypass is poorly understood. Setting Multi-centered study that included teaching and non-teaching hospitals that participate in a statewide consortium for quality improvement using a payer-funded outcome registry. Methods We analyzed data from the Michigan Bariatric Surgery Collaborative and performed a case-control study comparing patients who sustained a leak with those who did not after primary laparoscopic Roux-en-Y gastric bypass. A total of 71 (.44%) patients with leaks were identified between January 2007 and December 2011. The leak group was matched 1:2 to a control group (nonleak) based on procedure type, age, body mass index, sex, and the year in which the procedure was performed. Technique-specific case characteristics and device-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. Results The rate of leak decreased during the study period, and there was a significant downward trend (slope estimate: –.19961%, P = .0372). After performing multivariate analysis, the type of anastomosis (circular stapler, hand-sewn, or linear stapler) and stapler manufacturer were not associated with leaks. The use of buttressing material was associated with a higher rate of leaks (odds ratio: 8.79 [95% confidence interval: 2.49–31.01], P = .0007), whereas the use of fibrin sealant was associated with a lower rate of leaks (odds ratio .11 [95% confidence interval: .03–.41], P = .0013). These findings could not be explained by differences in measures of surgeon performance. Conclusion Leak rates after laparoscopic gastric bypass have fallen in Michigan despite variations in technique and device utilization. Although the type of anastomosis and stapler manufacturer do not appear to be significantly associated with leaks, it appears that the use of buttressing material was more common in cases in which leaks occurred, whereas the use of fibrin sealant was not. Given the complex interplay of multiple variables that affect surgical outcomes, future studies justifying the benefits of operative devices should be evaluated prospectively in the context of surgeon technique and skill.

accessed, fluid removed, and immediately replaced with no net change. Patients and assessors were blinded to condition, and deflation/sham-deflation days were counterbalanced. On both days, patients completed a form indicating their estimate (deflation/ sham), followed by a food cue paradigm in the scanner where they viewed pictures of unhealthy, healthy, and shuffled food images. BOLD activation to unhealthy versus shuffled images was analyzed using SPM8. Contiguous clusters with kZ10 were deemed significant at po.005 corrected, determined by 10,000 MonteCarlo simulations (Cox, 1996). Results: In the deflate versus sham condition, patients showed significantly greater activation in thalamus, lingual gyrus, putamen (reward-related regions), superior and inferior frontal gyri, cingulate gyrus (inhibitory and emotional control), and parahippocampal gyrus (reward/ hunger/memory) to unhealthy food images versus shuffled images. Patients correctly identified the procedure as a deflation 66.7% of the time and as sham 75% of the time. Conclusions: Our findings are consistent in identifying brain regions found in other studies regarding obesity and food cues. Because band deflation increased responses in reward-related regions, band inflation may work at a neuronal level by controlling reward responses to food, making regulation of food intake and consequently, weight loss easier to achieve. The increased activation in regions associated with inhibitory and emotional control during band deflation suggests that patients may need to engage cognitive control regions to restrain their food choices. This could be due to the lack of physical gastric restriction and therefore fear of loss of control. This is the first study to demonstrate that deflation of LAGB leads to brain changes related to reward and emotional control.

quate fundus reduction were treated with stapled revision. Esophagrams that showed mild pouch and/or anastomotic dilatation were selected to undergo a revision in which a LAGB would be placed. We collected information on age, weights, follow-up times, and any complications, including removal of the band. Finally, we performed a phone interview with any patient that had not been seen in the office within the past year to inquire about their current condition. Results: We reviewed 2094 LAGB cases performed since 2001. A total of 139 LAGBs were placed around a RYGB. All bands were placed laparoscopically with no conversions to open or peri-operative complications. 31 patients had previous open bypasses and 108 patients had laparoscopic bypasses. Patients have been followed for a mean of 2.5 years, with 16 patients having been followed for greater than 5 years, the longest being 10 years. The average pre-RYGB BMI was 54.4 (SE 1⁄4 0.90), which decreased to 32.1 (0.62) post RYGB. At the time of band, the pre-BaB BMI was 42.2 (0.63), which decreased to 35.7 (0.68) at the present time (p o 0.05). Patients who have been followed for more than 5 years (16) have an average BMI of 31.4, and more than 10 years (2) an average BMI of 31.3. Of the 139 bands, 11 (7.9%) have been removed: four due to erosion (2.9%), four due to clinical intolerance (2.9%), two due to slippage (1.4%), and one due to an unrelated illness. Complications requiring removal occurred on average of 2.25 years after band placement (SE 1⁄4 0.41). There were no records of any additional nutritional deficiencies after band placement. Conclusion: This study shows that LAGB is not only a safe alternative to complex revisional surgery in patients failing gastric bypass, but also one that yields long-term weight loss success. It can be performed safely, often as a same day procedure. Longterm follow-up demonstrates that the band removal rate is in the lower-end of the literature reported rates for primary LAGB. Because of its safety profile and weight loss result, LAGB around prior RYGB should be considered a long-term solution for patients who have continued to struggle with their weights after a RYGB. A141