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Objective: To examine the renoprotective effects of metabolic surgery in patients with established chronic kidney disease (CKD)., Background: The impact of metabolic surgery compared with glucagon-like peptide-1 receptor agonists (GLP-1RA) in patients with established CKD has not been fully characterized., Methods: Patients with obesity (body mass index ≥30 kg/m 2 ), type 2 diabetes, and baseline estimated glomerular filtration rate (eGFR) 20-60 mL/min/1.73 m² who underwent metabolic bariatric surgery at a large US health system (2010-2017) were compared with nonsurgical patients who continuously received GLP-1RA. The primary end point was CKD progression, defined as a decline of eGFR by ≥50% or to <15 mL/min/1.73 m 2 , initiation of dialysis, or kidney transplant. The secondary end point was the incident kidney failure (eGFR <15 mL/min/1.73 m 2 , dialysis, or kidney transplant) or all-cause mortality., Results: 425 patients, including 183 patients in the metabolic surgery group and 242 patients in the GLP-1RA group, with a median follow-up of 5.8 years (IQR, 4.4-7.6), were analyzed. The cumulative incidence of the primary end point at 8 years was 21.7% (95% CI: 12.2-30.6) in the surgical group and 45.1% (95% CI: 27.7 to 58.4) in the nonsurgical group, with an adjusted hazard ratio of 0.40 (95% CI: 0.21 to 0.76), P =0.006. The cumulative incidence of the secondary composite end point at 8 years was 24.0% (95% CI: 14.1 to 33.2) in the surgical group and 43.8% (95% CI: 28.1 to 56.1) in the nonsurgical group, with an adjusted HR of 0.56 (95% CI: 0.31 to 0.99), P =0.048., Conclusions: Among patients with type 2 diabetes, obesity, and established CKD, metabolic surgery, compared with GLP-1RA, was significantly associated with a 60% lower risk of progression of kidney impairment and a 44% lower risk of kidney failure or death. Metabolic surgery should be considered as a therapeutic option for patients with CKD and obesity., Competing Interests: A.A. reported receiving grants and personal fees from Medtronic, Eli Lilly, and Ethicon. P.R.S. reported receiving grants from Medtronic and Ethicon, and personal fees from GI Dynamics, Persona, Mediflix, Metabolic Health Institute, Eli Lilly, SE Healthcare, lder, Novo Nordisk, and Heron Advisory Board. R.J.R. reported receiving personal fee from Medtronic, Diagnostic Green, mediCAD simulation GmbH, and Dendrite Imaging and serving as the interim CEO of Dendrite Imaging. S.E.N. reported receiving grants to perform clinical trials from AbbVie, AstraZeneca, Amgen, Bristol Myers Squibb, Eli Lilly, Esperion Therapeutics Inc, Medtronic, MyoKardia, New Amsterdam Pharmaceuticals, Novartis, and Silence Therapeutics. M.B.R. has a consulting relationship with the Blue Cross Blue Shield Association. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Historically, the American Board of Surgery required surgeons to pass the qualifying examination (QE) before taking the certifying examination (CE). However, in the 2020-2021 academic year, with mitigating circumstances related to COVID-19, the ABS removed this sequencing requirement to facilitate the certification process for those candidates who were negatively impacted by a QE delivery failure. This decoupling of the traditional order of exam delivery has provided a natural comparator to the traditional route and an analysis of the impact of examination sequencing on candidate performance., Methods: All candidates who applied for the canceled July 2020 QE were allowed to take the CE before passing the QE. The sample was then reduced to include only first-time candidates to ensure comparable groups for performance outcomes. Logistic regression was used to analyze the relationship between the order of taking the QE and the CE, controlling for other examination performance, international medical graduate status, and gender., Results: Only first-time candidates who took both examinations were compared (n=947). Examination sequence was not a significant predictor of QE pass/fail outcomes, OR=0.54; 95% CI, 0.19-1.61, P =0.26. However, examination sequence was a significant predictor of CE pass/fail outcomes, OR=2.54; 95% CI, 1.46-4.68, P =0.002., Conclusions: This important study suggests that preparation for the QE increases the probability of passing the CE and provides evidence that knowledge may be foundational for clinical judgment. The ABS will consider these findings for examination sequencing moving forward., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Commonly cited studies have reported substantial improvements (defined as >20%) in process measure compliance after implementation of colorectal enhanced recovery programs (ERPs). However, hospitals have anecdotally reported difficulties in achieving similar improvement gains. This study evaluates improvement uniformity among 151 hospitals exposed to an 18-month implementation protocol for 6 colorectal ERP process measures (oral antibiotics, mechanical bowel preparation, multimodal pain control, early mobilization, early liquid intake, and early solid intake)., Study Design: One hundred fifty-one hospitals implemented a colorectal ERP with pathway, educational and supporting materials, and data capture protocols; 906 opportunities existed for process compliance improvement across the cohort (151 hospitals × 6 process measures). However, 240 opportunities were excluded due to high starting compliance rates (ie compliance >80%) and 3 opportunities were excluded because compliance rates were recorded for fewer than 2 cases. Thus, 663 opportunities for improvement across 151 hospitals were studied., Results: Of 663 opportunities, minimal improvement (0% to 20% increase in compliance) occurred in 52% of opportunities, substantial improvement (>20% increase in compliance) in 20%, and worsening compliance occurred in 28%. Of the 6 processes, multimodal pain control and use of oral antibiotics improved the most., Conclusions: Contrary to published ERP literature, the majority of study hospitals had difficulty improving process compliance with 80% of the opportunities not achieving substantial improvement. This discordance between ERP implementation success rates reported in the literature and what is observed in a large sample could reflect differences in hospitals' culture or characteristics, or a publication bias. Attention needs to be directed toward improving ERP adoption across the spectrum of hospital types., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Bariatric surgery has demonstrated sustained improvements in quality. Malpractice closed claims have been offered as a means of assessing quality. Few studies have investigated malpractice closed claims and opportunities for improvement in bariatric surgery., Objectives: To examine the prevalence and causes of malpractice claims with examination of prospects for quality improvement., Setting: University hospital, United States; private practice., Methods: Four national malpractice insurers participated in the closed-claims registry. Data regarding patients, staff, procedures, and hospital status were gathered from closed-claims files. Following data collection, a clinical summary of each closed claim was collected and later assessed by an expert panel on the basis of the following: contributing diagnosis and treatment events; whether complications were potentially preventable by the surgeon; the role of language, fatigue, distraction, workload, or teaching hospital/trainee supervision; communication concerns; and final care determination., Results: A total of 175 closed claims were collected from index bariatric surgeries within the period from 2006-2014. Of these, 75.9% of surgeons were board certified and 43.3% of the hospitals were accredited for bariatric surgery. Most clinical complications after bariatric surgery that led to malpractice lawsuits were mortality (35.1%) and leaks (17.5%). While they were not the common cause for malpractice suits, bleeding (5.3%), retained foreign body (5.3%), and vascular injury (4.4%) occurred at higher rates than national averages., Conclusion: Prevalence of malpractice claims regarding bariatric surgery is low. Failure to diagnose, delay in treatment, postoperative care, and communication domain responses indicate future opportunities for improvement., (Copyright © 2022 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Obesity increases the incidence and mortality from some types of cancer, but it remains uncertain whether intentional weight loss can decrease this risk., Objective: To investigate whether bariatric surgery is associated with lower cancer risk and mortality in patients with obesity., Design, Setting, and Participants: In the SPLENDID (Surgical Procedures and Long-term Effectiveness in Neoplastic Disease Incidence and Death) matched cohort study, adult patients with a body mass index of 35 or greater who underwent bariatric surgery at a US health system between 2004 and 2017 were included. Patients who underwent bariatric surgery were matched 1:5 to patients who did not undergo surgery for their obesity, resulting in a total of 30 318 patients. Follow-up ended in February 2021., Exposures: Bariatric surgery (n = 5053), including Roux-en-Y gastric bypass and sleeve gastrectomy, vs nonsurgical care (n = 25 265)., Main Outcomes and Measures: Multivariable Cox regression analysis estimated time to incident obesity-associated cancer (a composite of 13 cancer types as the primary end point) and cancer-related mortality., Results: The study included 30 318 patients (median age, 46 years; median body mass index, 45; 77% female; and 73% White) with a median follow-up of 6.1 years (IQR, 3.8-8.9 years). The mean between-group difference in body weight at 10 years was 24.8 kg (95% CI, 24.6-25.1 kg) or a 19.2% (95% CI, 19.1%-19.4%) greater weight loss in the bariatric surgery group. During follow-up, 96 patients in the bariatric surgery group and 780 patients in the nonsurgical control group had an incident obesity-associated cancer (incidence rate of 3.0 events vs 4.6 events, respectively, per 1000 person-years). The cumulative incidence of the primary end point at 10 years was 2.9% (95% CI, 2.2%-3.6%) in the bariatric surgery group and 4.9% (95% CI, 4.5%-5.3%) in the nonsurgical control group (absolute risk difference, 2.0% [95% CI, 1.2%-2.7%]; adjusted hazard ratio, 0.68 [95% CI, 0.53-0.87], P = .002). Cancer-related mortality occurred in 21 patients in the bariatric surgery group and 205 patients in the nonsurgical control group (incidence rate of 0.6 events vs 1.2 events, respectively, per 1000 person-years). The cumulative incidence of cancer-related mortality at 10 years was 0.8% (95% CI, 0.4%-1.2%) in the bariatric surgery group and 1.4% (95% CI, 1.1%-1.6%) in the nonsurgical control group (absolute risk difference, 0.6% [95% CI, 0.1%-1.0%]; adjusted hazard ratio, 0.52 [95% CI, 0.31-0.88], P = .01)., Conclusions and Relevance: Among adults with obesity, bariatric surgery compared with no surgery was associated with a significantly lower incidence of obesity-associated cancer and cancer-related mortality.

Purpose: Clinically severe obesity (SO) is a known risk factor for worsened outcomes and recurrence of acute diverticulitis. Paucity of data exist on outcomes of diverticulitis after bariatric surgery., Methods: The Nationwide Readmissions Database was queried for diverticulitis hospitalizations between the years 2010 and 2014. We restricted analysis to patients with SO and those who had bariatric surgery (BRS). Outcomes of mortality, surgical events, and recurrent diverticulitis admissions were compared using multivariable analysis and one-to-one propensity score matching., Results: Among 52,274 diverticulitis admissions, 91.2% (47,694) patients had SO and 8.8% (4580) had prior BRS. Patients with SO had higher odds of suffering mortality on index diverticulitis admission when compared to those with prior BRS [adjusted odds ratio (aOR): 10.55; 95%CI 1.45,76.75]. Patients with SO were also more likely to undergo emergency surgery (aOR: 1.71; 95%CI 1.25,2.34) and colectomy (aOR: 1.45; 95%CI 1.26,1.68). Rates of recurrent diverticulitis readmissions within 30 days and 6 months were also higher in patients with SO compared to BRS patients (aOR: 7.94; 95%CI 1.09,57.83 and aOR: 1.98; 95%CI 1.14,3.43, respectively). Propensity score matching confirmed our findings of increased rates of mortality (OR: 17.28; 95%CI 2.02,147.6), recurrent diverticulitis, and worsened surgical outcomes within 30 days in patients with SO compared to BRS., Conclusion: This study is first to show improved outcomes and less recurrent hospitalizations for diverticulitis after bariatric surgery compared to patients with clinically severe obesity. Further studies are needed to understand mechanisms leading to this improvement and the role of weight loss in prevention of severe diverticulitis., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Importance: No therapy has been shown to reduce the risk of serious adverse outcomes in patients with nonalcoholic steatohepatitis (NASH)., Objective: To investigate the long-term relationship between bariatric surgery and incident major adverse liver outcomes and major adverse cardiovascular events (MACE) in patients with obesity and biopsy-proven fibrotic NASH without cirrhosis., Design, Setting, and Participants: In the SPLENDOR (Surgical Procedures and Long-term Effectiveness in NASH Disease and Obesity Risk) study, of 25 828 liver biopsies performed at a US health system between 2004 and 2016, 1158 adult patients with obesity were identified who fulfilled enrollment criteria, including confirmed histological diagnosis of NASH and presence of liver fibrosis (histological stages 1-3). Baseline clinical characteristics, histological disease activity, and fibrosis stage of patients who underwent simultaneous liver biopsy at the time of bariatric surgery were balanced with a nonsurgical control group using overlap weighting methods. Follow-up ended in March 2021., Exposures: Bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy) vs nonsurgical care., Main Outcomes and Measures: The primary outcomes were the incidence of major adverse liver outcomes (progression to clinical or histological cirrhosis, development of hepatocellular carcinoma, liver transplantation, or liver-related mortality) and MACE (a composite of coronary artery events, cerebrovascular events, heart failure, or cardiovascular death), estimated using the Firth penalized method in a multivariable-adjusted Cox regression analysis framework., Results: A total of 1158 patients (740 [63.9%] women; median age, 49.8 years [IQR, 40.9-57.9 years], median body mass index, 44.1 [IQR, 39.4-51.4]), including 650 patients who underwent bariatric surgery and 508 patients in the nonsurgical control group, with a median follow-up of 7 years (IQR, 4-10 years) were analyzed. Distribution of baseline covariates, including histological severity of liver injury, was well-balanced after overlap weighting. At the end of the study period in the unweighted data set, 5 patients in the bariatric surgery group and 40 patients in the nonsurgical control group experienced major adverse liver outcomes, and 39 patients in the bariatric surgery group and 60 patients in the nonsurgical group experienced MACE. Among the patients analyzed with overlap weighting methods, the cumulative incidence of major adverse liver outcomes at 10 years was 2.3% (95% CI, 0%-4.6%) in the bariatric surgery group and 9.6% (95% CI, 6.1%-12.9%) in the nonsurgical group (adjusted absolute risk difference, 12.4% [95% CI, 5.7%-19.7%]; adjusted hazard ratio, 0.12 [95% CI, 0.02-0.63]; P = .01). The cumulative incidence of MACE at 10 years was 8.5% (95% CI, 5.5%-11.4%) in the bariatric surgery group and 15.7% (95% CI, 11.3%-19.8%) in the nonsurgical group (adjusted absolute risk difference, 13.9% [95% CI, 5.9%-21.9%]; adjusted hazard ratio, 0.30 [95% CI, 0.12-0.72]; P = .007). Within the first year after bariatric surgery, 4 patients (0.6%) died from surgical complications, including gastrointestinal leak (n = 2) and respiratory failure (n = 2)., Conclusions and Relevance: Among patients with NASH and obesity, bariatric surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident major adverse liver outcomes and MACE.

Objective: To determine which one of the two most common metabolic surgical procedures is associated with greater reduction in risk of major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus (T2DM) and obesity., Research Design and Methods: A total of 13,490 patients including 1,362 Roux-en-Y gastric bypass (RYGB), 693 sleeve gastrectomy (SG), and 11,435 matched nonsurgical patients with T2DM and obesity who received their care at the Cleveland Clinic (1998-2017) were analyzed, with follow-up through December 2018. With multivariable Cox regression analysis we estimated time to incident extended MACE, defined as first occurrence of coronary artery events, cerebrovascular events, heart failure, nephropathy, atrial fibrillation, and all-cause mortality., Results: The cumulative incidence of the primary end point at 5 years was 13.7% (95% CI 11.4-15.9) in the RYGB groups and 24.7% (95% CI 19.0-30.0) in the SG group, with an adjusted hazard ratio (HR) of 0.77 (95% CI 0.60-0.98, P = 0.04). Of the six individual end points, RYGB was associated with a significantly lower cumulative incidence of nephropathy at 5 years compared with SG (2.8% vs. 8.3%, respectively; HR 0.47 [95% CI 0.28-0.79], P = 0.005). Furthermore, RYGB was associated with a greater reduction in body weight, glycated hemoglobin, and use of medications to treat diabetes and cardiovascular diseases. Five years after RYGB, patients required more upper endoscopy (45.8% vs. 35.6%, P < 0.001) and abdominal surgical procedures (10.8% vs. 5.4%, P = 0.001) compared with SG., Conclusions: In patients with obesity and T2DM, RYGB may be associated with greater weight loss, better diabetes control, and lower risk of MACE and nephropathy compared with SG., (© 2021 by the American Diabetes Association.)

Introduction: Patients with type 2 diabetes experience resolution of hyperglycemia within days after Roux-en-Y gastric bypass (RYGB) surgery. This is attributed, in part, to enhanced secretion of hindgut factors following exclusion of the gastric remnant and proximal intestine during surgery. However, evidence of the mechanisms of remission remain limited due to the challenges of metabolic evaluation during the early postoperative period. The purpose of this investigation was to determine the role of foregut exclusion in the resolution of type 2 diabetes after RYGB., Methods: Patients with type 2 diabetes (n = 15) undergoing RYGB had a gastrostomy tube (G-tube) placed in their gastric remnant at time of surgery. Patients were randomized to receive a mixed meal tolerance test via oral or G-tube feeding immediately prior to and 2 weeks after surgery in a repeated measures crossover design. Plasma glucose, insulin, C-peptide, incretin responses, and indices of meal-stimulated insulin secretion and sensitivity were determined., Results: Body weight, fat mass, fasting glucose and insulin, and circulating lipids were significantly decreased 2 weeks after surgery. The glycemic response to feeding was reduced as a function of total area under the curve but not after adjustment for the reduction in fasting glucose. Oral feeding significantly enhanced insulin and incretin secretion after RYGB, which was entirely ablated by G-tube feeding., Conclusion: Foregut exclusion accounts for the rise in incretin and insulin secretion but may not fully explain the early improvements in glucose metabolism after RYGB surgery., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The aim of this study was to investigate the long-term effects of medical and surgical treatments of type 2 diabetes mellitus (T2DM) on patient-reported outcomes (PROs)., Background: Robust data on PROs from randomized trials comparing medical and surgical treatments for T2DM are lacking., Methods: The Surgical Treatment And Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial showed that 5 years after randomization, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were superior to intensive medical therapy (IMT) alone in achieving glycemic control in patients with T2DM and obesity. A subset of 104 patients participating in the STAMPEDE trial were administered two generic health-related quality of life (QoL) questionnaires (RAND-36 and EQ-5D-3L) and a diabetes-specific instrument at baseline, and then on an annual basis up to 5 years after randomization., Results: On longitudinal analysis, RYGB and SG significantly improved the domains of physical functioning, general health perception, energy/fatigue, and diabetes-related QoL compared with IMT group. In the IMT group, none of the QoL components in the generic questionnaires improved significantly from baseline. No significant long-term differences were observed among the study groups in measures of psychological and social aspects of QoL. On multivariable analysis, independent factors associated with improved general health perception at long-term included baseline general health (P < 0.001), insulin independence at 5 years (P = 0.005), RYGB versus IMT (P = 0.005), and SG versus IMT (P = 0.034). Favorable changes following RYGB and SG were comparable., Conclusions: In patients with T2DM, metabolic surgery is associated with long-term favorable changes in certain PROs compared with IMT, mainly on physical health and diabetes-related domains. Psychosocial well-being warrants greater attention after metabolic surgery., Competing Interests: The authors report no direct conflicts of interests., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Metabolic surgery has beneficial metabolic effects, including remission of type 2 diabetes. We hypothesized that duodenojejunal bypass (DJB) surgery can protect against development of type 1 diabetes (T1D) by enhancing regulation of cellular and molecular pathways that control glucose homeostasis., Methods: BBDP/Wor rats, which are prone to develop spontaneous autoimmune T1D, underwent loop DJB (n = 15) or sham (n = 15) surgery at a median age of 41 days, before development of diabetes. At T1D diagnosis, a subcutaneous insulin pellet was implanted, oral glucose tolerance test was performed 21 days later, and tissues were collected 25 days after onset of T1D. Pancreas and liver tissues were assessed by histology and RT-qPCR. Fecal microbiota composition was analyzed by 16S V4 sequencing., Results: Postoperatively, DJB rats weighed less than sham rats (287.8 vs 329.9 g, P = 0.04). In both groups, 14 of 15 rats developed T1D, at similar age of onset (87 days in DJB vs 81 days in sham, P = 0.17). There was no difference in oral glucose tolerance, fasting and stimulated plasma insulin and c-peptide levels, and immunohistochemical analysis of insulin-positive cells in the pancreas. DJB rats needed 1.3 ± 0.4 insulin implants vs 1.9 ± 0.5 in sham rats (P = 0.002). Fasting and glucose stimulated glucagon-like peptide 1 (GLP-1) secretion was elevated after DJB surgery. DJB rats had reduced markers of metabolic stress in liver. After DJB, the fecal microbiome changed significantly, including increases in Akkermansia and Ruminococcus, while the changes were minimal in sham rats., Conclusion: DJB does not protect against autoimmune T1D in BBDP/Wor rats, but reduces the need for exogenous insulin and facilitates other metabolic benefits including weight loss, increased GLP-1 secretion, reduced hepatic stress, and altered gut microbiome.

Reductions in β-cell number and function contribute to the onset type 2 diabetes (T2D). Roux-en-Y gastric bypass (RYGB) surgery can resolve T2D within days of operation, indicating a weight-independent mechanism of glycemic control. We hypothesized that RYGB normalizes glucose homeostasis by restoring β-cell structure and function. Male Zucker Diabetic Fatty (fa/fa; ZDF) rats were randomized to sham surgery ( n = 16), RYGB surgery ( n = 16), or pair feeding ( n = 16). Age-matched lean (fa/+) rats ( n = 8) were included as a secondary control. Postprandial metabolism was assessed by oral glucose tolerance testing before and 27 days after surgery. Fasting and postprandial plasma GLP-1 was determined by mixed meal tolerance testing. Fasting plasma glucagon was also measured. β-cell function was determined in isolated islets by a glucose-stimulated insulin secretion assay. Insulin and glucagon positive areas were evaluated in pancreatic sections by immunohistochemistry. RYGB reduced body weight ( P < 0.05) and improved glucose tolerance ( P < 0.05) compared with sham surgery. RYGB reduced fasting glucose compared with both sham ( P < 0.01) and pair-fed controls ( P < 0.01). Postprandial GLP-1 ( P < 0.05) was elevated after RYGB compared with sham surgery. RYGB islets stimulated with 20 mM glucose had higher insulin secretion than both sham and pair-fed controls ( P < 0.01) and did not differ from lean controls. Insulin content was greater after RYGB compared with the sham ( P < 0.05) and pair-fed ( P < 0.05) controls. RYGB improves insulin secretion and pancreatic islet function, which may contribute to the remission of type 2 diabetes following bariatric surgery. NEW & NOTEWORTHY The onset and progression of type 2 diabetes (T2D) results from failure to secrete sufficient amounts of insulin to overcome peripheral insulin resistance. Here, we demonstrate that Roux-en-Y gastric bypass (RYGB) restores islet function and morphology compared to sham and pair-fed controls in ZDF rats. The improvements in islet function were largely attributable to enhanced insulin content and secretory function in response to glucose stimulation.

Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria.

Background: Despite thromboprophylaxis, postoperative deep vein thrombosis and pulmonary embolism occur after bariatric surgery, perhaps because of failure to achieve optimal prophylactic levels in the obese population., Objectives: The aim of this study was to evaluate the adequacy of prophylactic dosing of enoxaparin in patients with severe obesity by performing an antifactor Xa (AFXa) assay., Setting: An academic medical center METHODS: In this observational study, all bariatric surgery cases at an academic center between December 2016 and April 2017 who empirically received prophylactic enoxaparin (adjusted by body mass index [BMI] threshold of 50 kg/m 2 ) were studied. The AFXa was measured 3-5 hours after the second dose of enoxaparin., Results: A total of 105 patients were included; 85% were female with a median age of 47 years. In total, 16 patients (15.2%) had AFXa levels outside the prophylactic range: 4 (3.8%) cases were in the subprophylactic and 12 (11.4%) cases were in the supraprophylactic range. Seventy patients had a BMI <50 kg/m 2 and empirically received enoxaparin 40 mg every 12 hours; AFXa was subprophylactic in 4 (5.7%) and supraprophylactic in 6 (8.6%) of these patients. Of the 35 patients with a BMI ≥50 who empirically received enoxaparin 60 mg q12h, no AFXa was subprophylactic and 6 (17.1%) were supraprophylactic. Five patients (4.8%) had major bleeding complications. One patient developed pulmonary embolism on postoperative day 35., Conclusion: BMI-based thromboprophylactic dosing of enoxaparin after bariatric surgery could be suboptimal in 15% of patients with obesity. Overdosing of prophylactic enoxaparin can occur more commonly than underdosing. AFXa testing can be a practical way to measure adequacy of pharmacologic thromboprophylaxis, especially in patients who are at higher risk for venous thromboembolism or bleeding., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine the minimum amount of weight loss required to see a reduction in major adverse cardiovascular events (MACE)., Background: Although obesity is an established risk factor for morbidity and mortality, the minimum amount of weight loss to have a meaningful impact on cardiovascular health and survival is unknown., Methods: Patients with obesity (body mass index ≥30 kg/m) and type 2 diabetes who underwent metabolic surgery in an academic center (1998-2017) were propensity-matched 1:5 to nonsurgical patients who received usual care. The adjusted linear and nonlinear effects of weight loss (achieved in the first 18 months after the index date) were studied to identify cut-offs for the minimum weight loss to achieve decreased risk of all-cause mortality and MACE (composite of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation)., Results: A total of 7201 patients (1223 surgical and 5978 nonsurgical) with a median follow-up time of 4.9 years (interquartile range, 3.5-7) were included. The positive effect of metabolic surgery was still present after adjusting for weight loss amounts, suggesting that there are weight loss-independent factors contributing to a reduction in risk of MACE and all-cause mortality in the surgical cohort. After considering the weighted estimates from a diverse set of models, the risk of MACE decreases after approximately 10% of weight is lost in the surgical group and approximately 20% in the nonsurgical group. For all-cause mortality, the threshold for benefit appeared to be approximately 5% weight loss after metabolic surgery and 20% in the nonsurgical group., Conclusions: This large matched-cohort study identified the minimum weight loss thresholds for reduction in risk of MACE and all-cause mortality in patients with obesity and diabetes. Furthermore, in our analysis, the effect of surgery was still present after accounting for weight loss, which may suggest the presence of weight-independent beneficial effects of metabolic surgery on MACE and survival.

Background: Diabetic nephropathy is the leading cause of chronic kidney disease. Observational studies suggest Roux-en-Y gastric bypass (RYGB) reduces progression of diabetic nephropathy., Objectives: To unravel the mechanisms by which RYGB is beneficial and protective for diabetic nephropathy., Setting: Academic laboratories., Methods: Forty-eight Zucker diabetic fatty rats were randomized to RYGB, sham surgery (SHAM), or pair-fed (PF) groups. An oral glucose tolerance test was performed at 25 days post intervention and kidneys were harvested at 30 days. Primary outcome measures included expression of key genes and proteins in the glucose transport, oxidative stress, inflammation, and fibrosis pathways., Results: Thirty days post intervention, RYGB rats weighed 349 ± 8 g, which was lower than SHAM (436 ± 14 g, P < .001), but not PF (374 ± 18 g) rats. RYGB rats had lower fasting glucose than PF animals and improved homeostatic model assessment of insulin resistance compared with PF and SHAM groups. These enhanced metabolic outcomes were accompanied by reduced sodium-glucose co-transporter 1 (Sglt1) gene expression (-23% versus PF, P = .01) in the kidney of RYGB rats. Expression of Sglt2, Glut1, or Glut2 mRNA, or oxidative stress and inflammation markers did not differ significantly. However, RYGB surgery induced a 19% lower expression of transforming growth factor (Tgfβ) mRNA (P = .004) compared with SHAM treated animals. Notably, adenosine monophosphate-activated protein kinase phosphorylation was increased (P = .04) in kidneys of the RYGB surgery animals., Conclusions: Improvement of hyperglycemia after RYGB may reduce the glucose load on the kidney leading to a downregulation of specific glucose transporters. RYGB surgery may also attenuate kidney fibrosis through the adenosine monophosphate-activated protein kinase/TGFβ pathway., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: COVID-19 has created an urgent need for reorganization and surge planning among departments of surgery across the USA., Methods: Review of the COVID-19 planning process and work products in preparation for a patient surge. Organizational and process changes, workflow redesign, and communication plans are presented., Results: The planning process included widespread collaboration among leadership from many disciplines. The department of surgery played a leading role in establishing clinical protocols, guidelines, and policies in preparation for a surge of COVID-19 patients. A multidisciplinary approach with input from clinical and nonclinical stakeholders is critical to successful crisis planning. A clear communication plan should be implemented early and input from trainees, staff, and faculty should be solicited., Conclusion: Major departmental and health system reorganization is required to adapt academic surgical practices to a widespread crisis. Surgical leadership, innovation, and flexibility are critical to successful planning and implementation.

Background: Non-alcoholic fatty liver disease (NAFLD)/steatohepatitis (NASH) is the hepatic manifestation of metabolic syndrome. Our aim was to study the long-term effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on NAFLD/NASH., Methods: Between 2008 and 2015, 3813 patients had an intraoperative liver biopsy performed at the time of primary RYGB and SG at a single academic center. Utilizing strict inclusion criteria, 487 patients with biopsy-proven NAFLD who had abnormal alanine aminotransferase (ALT) or aspartate aminotransferase (AST) values (≥ 40 IU/L) at baseline were identified. Matching of SG to RYGB patients (1:4) was performed via logistic regression and propensity scores adjusting for clinical and liver histological characteristics. Changes in liver function tests (LFTs) at least 1 year after surgery were compared to baseline values and between the surgical groups., Results: A total of 310 (weighted) patients (SG n = 62, and RYGB n = 248) with a median follow-up time of 4 years (range, 1-10) were included in the analysis. The distribution of covariates was well-balanced after propensity matching. In 84% of patients, LFT values normalized after bariatric surgery at the last follow-up time. The proportions of patients having normalized LFT values did not differ significantly between the SG and RYGB groups (82% vs. 84%, p = 0.66). The AST decreased from (SG: 49.1 ± 21.5 vs. RYGB: 49.3 ± 22.0, p = 0.93) at baseline to (SG: 28.0 ± 16.5 vs. RYGB: 26.5 ± 15.5, p = 0.33) at the last follow-up. Similarly, a significant reduction in ALT values from (SG: 61.7 ± 30.0 vs. RYGB 59.4 ± 24.9, p = 0.75) at baseline to (SG: 27.2 ± 21.5 vs. RYGB: 26.1 ± 19.2, p = 0.52) at the last follow-up was observed., Conclusions: In patients with biopsy-proven NAFLD/NASH, abnormal LFTs are normalized in most SG and RYGB patients by the end of the first postoperative year and remain normal until the last follow-up. This study also suggests that both bariatric procedures are similarly effective in improving liver function.

Background: Metabolic and bariatric surgery, despite being the only effective durable treatment for obesity, remains underused as approximately 1% of all patients who qualify undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate therapy., Objectives: The objective of this study was to provide the best estimated number of metabolic and bariatric procedure performed in the United States in 2018., Setting: United States., Methods: We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and outpatient centers were used to estimate outpatient center activity. Data from 2018 were compared mainly with data from the previous 2 years., Results: Compared with 2017, the total number of metabolic and bariatric procedures performed in 2018 increased from approximately 228,000 to 252,000. The sleeve gastrectomy continues to be the most common procedure. The gastric bypass procedure trend remained relatively stable and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Finally, intragastric balloons placement continues as a significant contributor to the cumulative total number of procedures performed but declined from the previous year., Conclusions: There was a 10.8% increase in the number of metabolic and bariatric procedures performed in 2018, compared with 2017, with an overall increase of approximately 60% since 2011. When taking into account primary procedures only, approximately 1.1% of patients who qualified for metabolic and bariatric surgery were treated with surgery in 2018., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To construct and internally validate prediction models to estimate the risk of long-term end-organ complications and mortality in patients with type 2 diabetes and obesity that can be used to inform treatment decisions for patients and practitioners who are considering metabolic surgery., Research Design and Methods: A total of 2,287 patients with type 2 diabetes who underwent metabolic surgery between 1998 and 2017 in the Cleveland Clinic Health System were propensity-matched 1:5 to 11,435 nonsurgical patients with BMI ≥30 kg/m 2 and type 2 diabetes who received usual care with follow-up through December 2018. Multivariable time-to-event regression and random forest machine learning models were built and internally validated using fivefold cross-validation to predict the 10-year risk for four outcomes of interest. The prediction models were programmed to construct user-friendly web-based and smartphone applications of Individualized Diabetes Complications (IDC) Risk Scores for clinical use., Results: The prediction tools demonstrated the following discrimination ability based on the area under the receiver operating characteristic curve (1 = perfect discrimination and 0.5 = chance) at 10 years in the surgical and nonsurgical groups, respectively: all-cause mortality (0.79 and 0.81), coronary artery events (0.66 and 0.67), heart failure (0.73 and 0.75), and nephropathy (0.73 and 0.76). When a patient's data are entered into the IDC application, it estimates the individualized 10-year morbidity and mortality risks with and without undergoing metabolic surgery., Conclusions: The IDC Risk Scores can provide personalized evidence-based risk information for patients with type 2 diabetes and obesity about future cardiovascular outcomes and mortality with and without metabolic surgery based on their current status of obesity, diabetes, and related cardiometabolic conditions., (© 2020 by the American Diabetes Association.)

Objective: To characterize the status of cardiometabolic risk factors after late relapse of type 2 diabetes mellitus (T2DM) and to identify factors predicting relapse after initial diabetes remission following bariatric surgery to construct prediction models for clinical practice., Research Design and Methods: Outcomes of 736 patients with T2DM who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at an academic center (2004-2012) and had ≥5 years' glycemic follow-up were assessed. Of 736 patients, 425 (58%) experienced diabetes remission (HbA 1c <6.5% [48 mmol/mol] with patients off medications) in the 1st year after surgery. These 425 patients were followed for a median of 8 years (range 5-14) to characterize late relapse of diabetes., Results: In 136 (32%) patients who experienced late relapse, a statistically significant improvement in glycemic control, number of diabetes medications including insulin use, blood pressure, and lipid profile was still observed at long-term. Independent baseline predictors of late relapse were preoperative number of diabetes medications, duration of T2DM before surgery, and SG versus RYGB. Furthermore, patients who relapsed lost less weight during the 1st year after surgery and regained more weight afterward. Prediction models were constructed and externally validated., Conclusions: While late relapse of T2DM is a real phenomenon (one-third of our cohort), it should not be considered a failure, as the trajectory of the disease and its related cardiometabolic risk factors is changed favorably after bariatric surgery. Earlier surgical intervention, RYGB (compared with SG) and more weight loss (less late weight regain) are associated with less diabetes relapse in the long-term., (© 2020 by the American Diabetes Association.)

Background: To date, there have been no large-scale enhanced recovery projects in bariatric surgery in the United States., Objective: The aim of this project was to implement an enhanced recovery protocol for selected Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program centers and determine its impact on length of stay, bleeding, readmissions, and reoperation rates., Setting: University and private practice programs, United States., Methods: Participating sites were identified based on historical extended length of stay (ELOS, ≥4 d). A 6-month run-up period was used to allow implementation of the protocol. Primary bariatric procedures were included in the analysis, which compared ELOS from historic data (2016) with outcomes during the Employing Enhanced Recovery Goals in Bariatric Surgery (ENERGY) project. Relationships between adherence to the 26 process measures and ELOS were analyzed. Specific adverse 30-day outcomes were monitored., Results: Thirty-six centers participated in the project. The final analytic sample consisted of 18,048 cases total over a 24-month period, including 8946 from the 2016 calendar year and 9102 from the ENERGY period. The overall rates of ELOS for pre- and postintervention were 8.1% and 4.5%, respectively, without increasing readmission rates, reoperation rates, or overall morbidity. Bleeding rates increased from .8% preintervention to 1.1% during ENERGY (adjusted P = .06). There was a significant association between increased adherence score and decreased odds of ELOS (P < .01)., Conclusion: Implementation of a large-scale enhanced recovery project is feasible and results in decreased ELOS without increasing overall adverse events or readmissions. Increased adherence to the protocol was closely associated with decreased ELOS. The ENERGY protocol or similar enhanced recovery pathways should be implemented on a larger scale to further improve the care and outcomes of bariatric surgery patients., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Although metabolic surgery (defined as procedures that influence metabolism by inducing weight loss and altering gastrointestinal physiology) significantly improves cardiometabolic risk factors, the effect on cardiovascular outcomes has been less well characterized., Objective: To investigate the relationship between metabolic surgery and incident major adverse cardiovascular events (MACE) in patients with type 2 diabetes and obesity., Design, Setting, and Participants: Of 287 438 adult patients with diabetes in the Cleveland Clinic Health System in the United States between 1998 and 2017, 2287 patients underwent metabolic surgery. In this retrospective cohort study, these patients were matched 1:5 to nonsurgical patients with diabetes and obesity (body mass index [BMI] ≥30), resulting in 11 435 control patients, with follow-up through December 2018., Exposures: Metabolic gastrointestinal surgical procedures vs usual care for type 2 diabetes and obesity., Main Outcomes and Measures: The primary outcome was the incidence of extended MACE (composite of 6 outcomes), defined as first occurrence of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation. Secondary end points included 3-component MACE (myocardial infarction, ischemic stroke, and mortality) and the 6 individual components of the primary end point., Results: Among the 13 722 study participants, the distribution of baseline covariates was balanced between the surgical group and the nonsurgical group, including female sex (65.5% vs 64.2%), median age (52.5 vs 54.8 years), BMI (45.1 vs 42.6), and glycated hemoglobin level (7.1% vs 7.1%). The overall median follow-up duration was 3.9 years (interquartile range, 1.9-6.1 years). At the end of the study period, 385 patients in the surgical group and 3243 patients in the nonsurgical group experienced a primary end point (cumulative incidence at 8-years, 30.8% [95% CI, 27.6%-34.0%] in the surgical group and 47.7% [95% CI, 46.1%-49.2%] in the nonsurgical group [P < .001]; absolute 8-year risk difference [ARD], 16.9% [95% CI, 13.1%-20.4%]; adjusted hazard ratio [HR], 0.61 [95% CI, 0.55-0.69]). All 7 prespecified secondary outcomes showed statistically significant differences in favor of metabolic surgery, including mortality. All-cause mortality occurred in 112 patients in the metabolic surgery group and 1111 patients in the nonsurgical group (cumulative incidence at 8 years, 10.0% [95% CI, 7.8%-12.2%] and 17.8% [95% CI, 16.6%-19.0%]; ARD, 7.8% [95% CI, 5.1%-10.2%]; adjusted HR, 0.59 [95% CI, 0.48-0.72])., Conclusions and Relevance: Among patients with type 2 diabetes and obesity, metabolic surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident MACE. The findings from this observational study must be confirmed in randomized clinical trials., Trial Registration: ClinicalTrials.gov Identifier: NCT03955952.

Aim: To assess the potential protective effect of bariatric surgery on mortality after myocardial infarction (MI) or cerebrovascular accident (CVA)., Materials and Methods: Using the National Inpatient Sample (2007-2014), 2218 patients with a principal discharge diagnosis of acute MI and 2168 patients with ischaemic CVA who also had history of prior bariatric surgery were identified. Utilizing propensity scores, these patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Control group-1 included participants with obesity (BMI ≥ 35 kg/m 2 ) only and participants in control group-2 were matched according to post-surgery BMI with the bariatric surgery group. The primary and secondary endpoints were in-hospital all-cause mortality and length of hospital stay, respectively. Outcomes after MI and CVA were separately compared among groups in multivariate regression models., Results: A total of 48 300 (weighted) participants were included in the analysis. The distribution of covariates was well balanced after propensity matching. Mortality rates after MI were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.85% vs 3.03%; odds ratio (OR), 0.61; 95% confidence interval (CI), 0.44-0.86; P = 0.004) and with control group-2 (2.00% vs 3.26%; OR, 0.62; 95% CI, 0.44-0.88; P = 0.008). Similarly, in-hospital mortality rates after CVA were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.43% vs 2.74%; OR, 0.54; 95% CI, 0.37-0.79; P = 0.001) and with control group-2 (1.54% vs 2.59%; OR, 0.61; 95% CI, 0.41-0.91; P = 0.015). Furthermore, length of stay was significantly shorter in the bariatric surgery group for all comparisons (P < 0.001)., Conclusion: Prior bariatric surgery is associated with significant protective effect on survival after MI and CVA., (© 2019 John Wiley & Sons Ltd.)

Introduction: Bariatric and metabolic surgery significantly improves type 2 diabetes mellitus (T2DM). However, a small percentage of patients after bariatric surgery either have persistent hyperglycemia or relapse of their T2DM. These patients are usually medically managed. The aim of this study was to evaluate the effect of revisional surgery on the glycemic status of patients with T2DM who either failed to remit or relapsed after an initial remission following bariatric surgery., Methods: Metabolic parameters and clinical outcomes of 81 patients with persistent or relapsed T2DM after revisional bariatric surgery at an academic center between 2008 and 2017 were studied., Results: The most common types of revisional surgery were pouch and/or stoma revision of Roux-en-Y gastric bypass (RYGB) (n = 22, 27.2%), conversion of vertical banded gastroplasty (VBG) to RYGB (n = 20, 24.7%), conversion of adjustable gastric banding (AGB) to RYGB (n = 14, 17.3%), and conversion of sleeve gastrectomy (SG) to RYGB (n = 13, 16%). Revision of pouch/stoma after RYGB yielded improvement of T2DM in 50% of patients and remission in 22.7%. Conversion to RYGB yielded improvement of T2DM in 55%, 35.7%, and 30.8% of patients who previously had VBG, AGB, or SG, respectively. Furthermore, conversion of VBG, AGB, and SG to RYGB was associated with diabetes remission rates of 35%, 35.7%, and 23.1%, respectively., Conclusion: Findings of this study, which is the largest series to date, indicate that revisional surgery in patients with persistent or relapsed T2DM after bariatric surgery can significantly improve glucose control and use of diabetes medications. Further clinical and mechanistic studies are needed to better demonstrate the role of revisional bariatric surgery in patients with residual T2DM.

Purpose: Roux-en-Y gastric bypass (RYGB) is associated with remission of type 2 diabetes. However, the cellular and molecular mechanisms remain unknown. We hypothesized that RYGB would increase peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α), sirtuin-1 (SIRT1), AMPK/pAMPK, and citrate synthase (CS) protein expression and decrease insulin resistance and these changes would be mediated by sphingolipids, including ceramides and the sphingolipid metabolite sphingosine-1 phosphate (S1P)., Materials and Methods: Male ZDF rats were randomized to RYGB (n = 7) or sham surgery (n = 7) and harvested after 28 days. Total tissue ceramide, ceramide subspecies (C14:0, C16:0, C18:0, C18:1, C20:0, C24:0, and C24:1), and S1P were quantified in the white gastrocnemius muscle using LC-ESI-MS/MS after separation with HPLC. Total SIRT1, AMPK, PGC-1α, and CS protein expression were measured by Western blot., Results: Body weight, fasting glucose, insulin, and HOMA-IR decreased significantly after RYGB compared with sham control. These changes were paralleled by lower total ceramide (483.7 ± 32.3 vs. 280.1 ± 38.8 nmol/g wwt), C18:0 ceramide subspecies (P < 0.05), higher S1P (0.83 ± 0.05 vs. 1.54 ± 0.21 nmol/g wwt, P < 0.05), and a lower ceramide/S1P ratio (P < 0.05) in the RYGB versus sham group. AMPK, pAMPK, SIRT1, PGC-1α, and CS protein expression was also higher after RYGB (P < 0.05). The ceramide/S1P ratio correlated with weight loss (r = 0.48, P = 0.08), insulin resistance (r = 0.61, P = 0.02), PGC-1α (r = - 0.51, P < 0.06), CS (r = - 0.63, P = 0.01), and SIRT1 (r = - 0.54, P < 0.04)., Conclusion: Our data demonstrate that sphingolipid balance, and increased AMPK, SIRT1, PGC-1α, and CS protein expression are part of the mechanism that contributes to the remission of diabetes after RYGB surgery.

Background: The impact of bariatric surgery on discrete cardiovascular events has not been well characterized., Objectives: To assess the impact of prior bariatric surgery on mortality associated with heart failure (HF) admission., Setting: A retrospective analysis of 2007-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample., Methods: Participants including 2810 patients with a principal discharge diagnosis of HF who also had a history of prior bariatric surgery were identified. These patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Propensity scores, balanced on baseline characteristics, were used to assemble 2 control groups. Control group-1 included patients with obesity (body mass index [BMI] ≥35 kg/m 2 ) only. In control group-2, the BMI was considered as one of the matching criteria in propensity matching. Multivariate regression models were utilized to calculate the odds ratio (OR) and 95% confidence interval (CI) of mortality and length of stay (LOS)., Results: With well-balanced matching, 33,720 (weighted) patients were included in the analysis. In-hospital mortality rates after HF admission were significantly lower in patients with a history of bariatric surgery compared with control group-1 (0.96% versus 1.86%, OR .52, 95% CI .35-0.77, P = .0013) and control group-2 (0.96% versus 1.86%, OR .52, 95% CI .35-0.77, P = .0011). Furthermore, LOS was shorter in the bariatric surgery group compared with control group-1 (4.8 ± 4.4 versus 5.7 ± 5.7 d, P < .001) and control group-2 (4.8 ± 4.4 versus 5.4 ± 6.3 d, P < .001)., Conclusions: Our data suggest that prior bariatric surgery is associated with almost 50% reduction in in-hospital mortality and shorter LOS in patients with HF admission., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Perioperative pulmonary complications are frequent in patients with interstitial lung diseases (ILD). Limited literature exists regarding the safety of bariatric procedures in patients with ILD. This study aims to assess the safety, feasibility, and outcomes of patients with ILD who underwent bariatric surgery at our institution., Methods: After IRB approval, all patients with preoperative diagnosis of ILD who had bariatric surgery at an academic center between 2004 and 2014 were retrospectively reviewed., Results: A total of 25 patients with ILD underwent bariatric surgery: Roux-en-Y gastric bypass (n = 17, 68%), sleeve gastrectomy (n = 7, 28%), and adjustable gastric banding (n = 1, 4%). Twenty-one patients (84%) were females. The median age and preoperative body mass index (BMI) were 53 (IQR 42-58) years and 39 (IQR 37-44) kg/m 2 , respectively. The median operative time and length of stay was 137 (IQR 110-187) min and 3 (IQR 2-5) days, respectively. The 30-day complications were reported in four patients (16%) but there was no pulmonary complication or unplanned admission to the intensive care unit. At 1-year follow-up (85%), the median BMI and excess weight loss were 30 (IQR 25-36) kg/m 2 and 67% (IQR 45-100), respectively. Compared to preoperative values, there was significant improvement in the pulmonary function test (PFT) variables at 1 year with respect to forced vital capacity (62% vs 74%; n = 13, p = 0.003), and diffusing capacity of the lungs for carbon monoxide (53% vs 66%; n = 10, p = 0.003). Six out of the seven potential lung transplant candidates became eligible for transplantation after weight loss, and one of them had successful lung transplant at 88 months after bariatric surgery., Conclusion: In our experience, bariatric patients with ILD achieved significant weight loss and improvement in PFT. Bariatric surgery in these higher risk ILD patients appears relatively safe with acceptable perioperative morbidity and improved candidacy for lung transplantation.

Background: Bariatric surgery has been shown to improve and resolve diabetes. However, limited literature about its impact on end-organ complications of diabetes is available. The aim of this study was to examine the long-term effect of bariatric surgery on albuminuria., Methods: We studied 101 patients with pre-operative diabetes and albuminuria [defined as urine albumin:creatinine ratio (uACR) > 30 mg/g] who underwent bariatric surgery at an academic center from 2005 to 2014., Results: Fifty-seven patients (56%) were female with a mean age of 53 (± 11) years. The mean pre-operative BMI and glycated hemoglobin (HbA1c) were 43.1 (± 7.6) kg/m 2 and 8.4 (± 1.8)%, respectively. The median pre-operative uACR was 80.0 (45.0-231.0) mg/g. Bariatric procedures included Roux-en-Y gastric bypass (n = 75, 74%) and sleeve gastrectomy (n = 26, 26%). The mean follow-up period was 61 (± 29) months. At last follow-up, the mean BMI was 33.8 (± 8.3) kg/m 2 . The overall glycemic control improved after bariatric surgery. At last follow-up, 73% had good glycemic control (HbA1c < 7%) and 27% met diabetes remission criteria. The mean HbA1c at last follow-up was 6.7 (± 1.0)% and the median uACR was 30 (IQR 7-94) mg/g. Albuminuria improved in 77% and resolved in 51% of patients at long-term., Conclusions: Bariatric surgery has a significantly positive impact on albuminuria in patients with obesity and type 2 diabetes. Our data showed almost an 80% improvement in albuminuria at the short- and long-term period after bariatric surgery.

Background: Bariatric surgery is remarkably effective in achieving weight loss and improving obesity-related co-morbidities; however, efforts still continue to improve its long-term outcomes. Particularly, banded Roux-en-Y gastric bypass (RYGB) has been scrutinized in comparison to standard (nonbanded) RYGB in terms of benefits and postoperative complications., Objectives: This study aims to compare the safety and efficacy of banded versus nonbanded RYGB., Setting: Meta-analysis of randomized controlled trials (RCTs)., Methods: A meta-analysis of high-quality studies that compared banded and nonbanded RYGB was conducted through February 2019 by systematically searching multiple electronic databases. Published RCTs comparing these 2 procedures were included to pool the data on excess weight loss, food tolerability, and postoperative complications., Results: Three RCTs were eligible to be included in this meta-analysis, comprising a total of 494 patients (247 in each group). Two of the RCTs provided 2-year postoperative data, and 1 study reported 5-year outcome. Age ranged from 21 to 50 years, and body mass index ranged from 42 to 65 kg/m 2 . Percentage of excess weight loss was significantly greater with banded RYGB than with nonbanded RYGB (mean difference 5.63%; 95% CI 3.26-8.00; P < .05). Postoperative food intolerance, emesis, and dysphagia were more common after banded RYGB (odds ratio 3.76; 95% CI 2.27-6.24; P < .001). Nevertheless, major postoperative complications did not significantly differ between the 2 groups., Conclusion: Findings of this meta-analysis of RCTs indicate that in a medium-term follow-up, excess weight loss with banded RYGB would be 5% greater than that with the nonbanded RYGB (about 1 point difference in body mass index) at the expense of more food intolerance and postoperative vomiting; however, the frequency of postoperative complications would not be significantly different., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There is limited data in the literature evaluating outcomes of bariatric surgery in severely obese patients with left ventricular assist device (LVAD) as a bridge to make them acceptable candidates for heart transplantation. This study aims to assess the safety and effectiveness of laparoscopic sleeve gastrectomy (LSG) in patients with previously implanted LVAD at our institution., Methods: All the patients with end-stage heart failure (ESHF) and implanted LVAD who underwent LSG from2013 to January 2017 were studied., Results: Seven patients with end stage heart failure (ESHF) and implanted LVAD were included. The median age and median preoperative BMI were 39 years (range: 26-62) and 43.6 kg/m 2 (range 36.7-56.7), respectively. The median interval between LVAD implantation and LSG was 38 months (range 15-48). The median length of hospital stay was 9 days (rang: 6-23) out of which 4 patients had planned postoperative ICU admission. Thirty-day complications were noted in 5 patients (3 major and 2 minor) without any perioperative mortality. The median duration of follow-up was 24 months (range 2-30). At the last available follow-up, the median BMI, %EWL, and %TWL were 37 kg/m 2 , 47%, and 16%, respectively. The median LVEF before LSG and at the last follow-up point (before heart transplant) was 19% (range 15-20) and 22% (range, 16-35), respectively. In addition, the median NYHA class improved from 3 to 2 after LSG. Three patients underwent successful heart transplantations., Conclusion: Patients with morbid obesity, ESHF, and implanted LVAD constitute a high-risk cohort. Our results with 7 patients and result from other studies (19 patients) suggested that bariatric surgery may be a reasonable option for LVAD patients with severe obesity. Bariatric surgery appears to provide significant weight loss in these patients and may improve candidacy for heart transplantation.

Background: The safety profile of bariatric surgery in patients with class I obesity, or body mass index ≥30 and <35 kg/m 2 , is a matter of concern among patients and physicians., Objective: To assess the safety profile of bariatric surgery in patients with class I obesity., Setting: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data set., Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2016 data sets were queried for class I obesity patients who underwent primary bariatric procedures. The 30-day postoperative safety profile, predictors of adverse events, and comparison between Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG) were studied., Results: A total of 8628 cases with a mean preoperative body mass index of 33.7 ± 1.1 kg/m 2 were analyzed: 1838 (21.3%) underwent RYGB, 6243 (72.4%) underwent SG, 530 (6.1%) underwent gastric banding, and 17 (.2%) underwent duodenal switch; 33.9% had diabetes and 75% had hypertension. The composite morbidity rate (defined as presence of any of 24 postoperative adverse events) for the entire cohort was 3.8%, and the serious morbidity rate (presence of any of 9 serious complications) was .7%. The 30-day mortality rate was .05% (4 cases). Presence of chronic kidney disease was found to be associated with higher composite and serious morbidity (composite morbidity: odds ratio 5.1, 95% confidence interval 2.22-11.71; serious morbidity: odds ratio 5.66, 95% confidence interval 1.52-21.14). SG patients had significantly better short-term safety outcomes than RYGB patients., Conclusion: Findings from this study, the largest series to date, indicate that bariatric surgery is safe in patients with class I obesity, with very low risk of morbidity and mortality., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Enhanced recovery after surgery has led to early recovery and shorter hospital stay after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). This study aims to assess feasibility and outcomes of postoperative day (POD) 1 discharge after LRYGB and LSG from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset., Methods: Patients who underwent elective LRYGB and LSG and were discharged on POD 1 and 2 were extracted from the MBSAQIP dataset. A 1:1 propensity score matching was performed between cases with POD 1 vs POD 2 discharge, and the 30-day outcomes of the cohorts were compared., Results: A total of 80,464 patients met the study criteria: 8862 LRYGB and 31,370 LSG cases, which were discharged on POD 1, and matched 1:1 with those discharged on POD 2. Within the LRYGB cohort, patients discharged on POD 2 had higher all-cause morbidity (7.5% vs 6.1%; p < 0.001) and 30-day re-intervention (2.0% vs 1.5%; p = 0.004) in comparison with patients discharged on POD 1. There were no statistical differences with respect to serious morbidity (0.5% vs 0.4%; p = 0.15), 30-day readmission (4.9% vs 4.5%; p = 0.2), and 30-day reoperation (1.3% vs 1.2%; p = 0.7). Within the LSG cohort, patients discharged on POD 2 had higher all-cause morbidity (4.2% vs 3.4%; p < 0.001), serious morbidity (0.4% vs 0.3%; p < 0.001), 30-day re-intervention (1.0% vs 0.6%; p < 0.001), and 30-day readmission (2.9% vs 2.5%; p = 0.002) in comparison with patients discharged on POD 1., Conclusions: Early discharge on POD 1 may be safe in a selective group of bariatric patients without significant comorbidities.

Introduction: Studies on bariatric patients with cirrhosis and portal hypertension are limited. The aim of this study was to review our experience in cirrhotic patients with portal hypertension who had bariatric surgery., Method: All cirrhotic patients with portal hypertension who underwent laparoscopic bariatric surgery, from 2007 to 2017, were retrospectively reviewed., Results: Thirteen patients were included; eight (62%) were female. The median age was 54 years (interquartile range, IQR 49-60) and median BMI was 48 kg/m 2 (IQR 43-55). Portal hypertension was diagnosed based on endoscopy (n = 5), imaging studies (n = 3), intraoperative increased collateral circulation (n = 2), and endoscopy and imaging studies (n = 3). The bariatric procedures included sleeve gastrectomy (n = 10, 77%) and Roux-en-Y gastric bypass (n = 3, 23%). The median length of hospital stay was 3 days (IQR 2-4). Three 30-day complications occurred including wound infection (n = 1), intra-abdominal hematoma (n = 1), and subcutaneous hematoma (n = 1). No intraoperative or 30-day mortalities. There were 11 patients (85%) at 1-year follow-up and 9 patients (69%) at 2-year follow-up. At 2 years, the median percentage of excess weight loss (EWL) and total weight loss (TWL) were 49 and 25%, respectively. There was significant improvement in diabetes (100%), dyslipidemia (100%), and hypertension (50%) at 2 years after surgery., Conclusion: Bariatric surgery in selected cirrhotic patients with portal hypertension is relatively safe and effective.

Background: Uncontrolled hyperglycemia in patients undergoing surgery has been shown to be a risk factor for postoperative complications., Objective: To assess the clinical significance of perioperative hyperglycemia on infectious complications and clinical outcomes in patients undergoing bariatric surgery., Setting: Single academic center., Methods: Retrospective chart review of all patients who underwent primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between 2013 and 2016 was performed. The association between any elevated perioperative glucose value (hyperglycemia: ≥126 mg/dL) and level of elevation (≥126 or ≥200 mg/dL) with 30-day infectious complications, reoperation, length of hospital stay, and readmission was assessed. Patients who developed early complications (within 3 d of surgery), which could potentially lead to immediate postoperative hyperglycemia, were not included in the analysis. Outcomes of patients with and without diabetes were separately analyzed., Results: A cohort of 1981 patients was studied, including Roux-en-Y gastric bypass (n = 1171, 59%) and sleeve gastrectomy (n = 810, 41%) patients. In patients with diabetes (n = 751, 38%), perioperative hyperglycemia was independently associated with higher composite infectious complications (defined as presence of any of 6 infectious complications; odds ratio [OR] 3.1, 95% confidence interval [CI] 1.2-8.2, P = .018) and higher readmission rate (OR 2.2, 95% CI 1.1-4.6, P = .027). In patients without diabetes (n = 1230, 62%), 19.2% had perioperative hyperglycemia (≥126 mg/dL). Perioperative hyperglycemia in patients without diabetes was associated with higher composite infectious complications (OR 2.6, 95% CI 1.1-5.5, P = .018) and prolonged length of stay (OR 3.0, 95% CI 1.5-5.9, P = .001)., Conclusions: An elevated perioperative glucose value is adversely associated with infectious complications and key clinical outcomes after bariatric surgery. The increased risk is correlated with the extent of glucose elevation (dose-response relationship). Our findings highlight the importance of glucose control during the perioperative period in bariatric surgical patients., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric surgery can improve renal dysfunction associated with obesity and diabetes. However, acute kidney injury (AKI) can complicate the early postoperative course after bariatric surgery. The long-term consequences of early postoperative AKI on renal function are unknown., Methods: Patient undergoing bariatric surgery from 2008 to 2015 who developed AKI within 60 days after surgery were studied. Patients on dialysis before surgery were excluded., Results: Out of 4722 patients, 42 patients (0.9%) developed early postoperative AKI after bariatric surgery of whom five had chronic kidney disease (CKD) preoperatively including CKD stage 3 (n = 2), stage 4 (n = 2), and stage 5 (n = 1). Etiologies of AKI included prerenal in 37 and renal in 5 patients. Nine patients (21%) underwent hemodialysis in early postoperative period for AKI. The median duration of follow-up was 28 months (interquartile range, 4-59). Of the 40 patients eligible for follow-up, 36 patients (90%) returned to their baseline renal function. However, four patients (10%) had worsening of renal function at follow-up., Conclusions: The incidence of early postoperative AKI after bariatric surgery is about 1%. The most common causes of AKI after bariatric surgery are dehydration and infectious complications. In our series, 10% of patients who developed AKI in early postoperative period had worsening of renal function in long-term follow-up. In the absence of severe sepsis and severe underlying kidney dysfunction (CKD stages 4 and 5), full recovery is expected after postoperative AKI.

Background: Data regarding the outcomes of bariatric surgery in patients with pulmonary hypertension (PH) is limited. The aim of this study was to review our experience on bariatric surgery in patients with PH., Setting: An academic medical center., Methods: Patients with PH who underwent either a primary or revisional bariatric surgery between 2005 and 2015 and had a preoperative right ventricle systolic pressure (RVSP) ≥35 mm Hg were included., Results: Sixty-one patients met the inclusion criteria. Fifty (82%) were female with the median age of 58 years (interquartile range [IQR] 49-63). The median body mass index was 49 kg/m 2 (IQR 43-54). Procedures performed included the following: Roux-en-Y gastric bypass (n = 33, 54%), sleeve gastrectomy (n = 24, 39%), adjustable gastric banding (n = 3, 5%), and banded gastric plication (n = 1, 2%). Four patients (7%) underwent revisional bariatric procedures. Median operative time and length of stay was 130 minutes (IQR 110-186) and 3 days (IQR 2-5), respectively. The 30-day complication rate was 16% (n = 10) with pulmonary complications noted in 4 patients. There was no 30-day mortality. One-year follow-up was available in 93% patients (n = 57). At 1 year, median body mass index and excess weight loss were 36 kg/m 2 (IQR 33-41) and 51% (IQR 33-68), respectively. There was significant improvement in the RVSP after bariatric surgery at a median follow-up of 22 months (IQR 10-41). The median RVSP decreased from 44 (IQR 38-53) to 40 mm Hg (IQR 28-54) (P = .03)., Conclusion: Bariatric surgery can be performed without prohibitive complication rates in patients with PH. In our experience, bariatric patients with PH achieved significant weight loss and improvement in RVSP., (Copyright © 2018. Published by Elsevier Inc.)

Background: During the 2004 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on best practices in bariatric surgery. The rapid evolution of endoluminal technologies, surgical indications, and training in bariatric surgery since 2004 has led to new questions and concerns about optimal treatment algorithms, patient selection, and the preparation of our current and future bariatric workforce., Methods: An expert panel was convened at the SAGES 2017 annual meeting to provide a summative update on current practice patterns, techniques, and training in bariatric surgery in order to review and establish best practices. This was a joint effort by SAGES, International Society for the Perioperative Care of the Obese Patient, and the American Society for Metabolic and Bariatric Surgery., Results: On March 23, 2017, seven expert faculty convened to address current areas of controversy in bariatric surgery and provide updated guidelines and practice recommendations. Areas addressed included the expanded indications for use of metabolic surgery in the treatment of diabetes, the safety and efficacy of new and investigational endoluminal procedures, updates on new guidelines for the management of airway and sleep apnea in the obese patient, the development of clinical pathways to reduce variation in the management of the bariatric patient, and new guidelines for training, credentialing, and bariatric program accreditation. The following article is a summary of this panel., Conclusion: Bariatric surgery is a field that continues to evolve. A timely, systematic approach, such as described here, that coalesces data and establishes best practices on the current body of available evidence is imperative for optimal patient care and to inform provider, insurer, and policy decisions.

Background: Literature directly looking at post-bariatric surgery hypoglycemia consists mostly of small case series. The rate, severity, and outcomes of treatment in a large bariatric population are less characterized., Objective: To determine the rate of post-bariatric surgery hypoglycemia, its clinical features and management outcomes over a 13-year period at our institution., Setting: An academic center in the United States., Methods: Patients who underwent bariatric surgery at a single academic center between 2002 and 2015 and had a postdischarge glucose level of ≤70 mg/dL were studied., Results: Of 6024 patients who underwent bariatric procedure, 118 patients (2.0%) had a postoperative glucose level ≤70 mg/dL. Eighty-three patients (1.4%) had symptomatic hypoglycemia. The known underlying causes of symptomatic hypoglycemia included postprandial hyperinsulinemic hypoglycemia (n = 32, 38%), infection (n = 8, 10%), diabetic medications (n = 8, 10%), and poor oral intake (n = 8, 10%). Overall, 9 patients required intervention for nutritional supplementation including enteral (n = 9) and intermittent parenteral (n = 2) nutrition. No patients required reversal of their bariatric surgeries or pancreatic resection for management of hypoglycemia. The majority of the symptomatic patients had resolution of their symptoms (n = 76, 92%). Thirty-two patients had postprandial hypoglycemia with a median onset of hypoglycemia after bariatric surgery of 790 days (interquartile range 388-1334). All 32 patients with postprandial hypoglycemia had dietary adjustment and 53% received pharmacotherapy, which resulted in complete resolution of hypoglycemia (n = 29, 91%) and resolution with minimal disability (n = 3, 9%)., Conclusion: The rate of symptomatic hypoglycemia and postprandial hypoglycemia after bariatric surgery were 1.4% and .5%. The majority of patients were successfully managed with dietary counseling, nutritional intervention, and occasionally pharmacotherapy. No surgical reversal or pancreatic procedures were performed., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: While bariatric surgery leads to significant prevention and improvement of type 2 diabetes, patients may rarely develop diabetes after bariatric surgery. The aim of this study was to determine the incidence and the characteristic of new-onset diabetes after bariatric surgery over a 17-year period at our institution., Methods: Non-diabetic patients who underwent bariatric surgery at a single academic center (1997-2013) and had a postoperative glycated hemoglobin (HbA1c) ≥ 6.5%, fasting blood glucose (FBG) ≥ 126 mg/dl, or positive glucose tolerance test were identified and studied., Results: Out of 2263 non-diabetic patients at the time of bariatric surgery, 11 patients had new-onset diabetes in the median follow-up time of 9 years (interquartile range [IQR], 4-12). Bariatric procedures performed were Roux-en-Y gastric bypass (n = 7), adjustable gastric banding (n = 3), and sleeve gastrectomy (n = 1). The median interval between surgery and diagnosis of diabetes was 6 years (IQR, 2-9). At the last follow-up, the median HbA1c and FBG values were 6.3% (IQR, 6.1-6.5) and 95 mg/dl (IQR, 85-122), respectively. Possible etiologic factors leading to diabetes were weight regain to baseline (n = 6, 55%), steroid-induced after renal transplantation (n = 1), pancreatic insufficiency after pancreatitis (n = 1), and unknown (n = 3)., Conclusion: De novo diabetes after bariatric surgery is rare with an incidence of 0.4% based on our cohort. Weight regain was common (> 50%) in patients who developed new-onset diabetes suggesting recurrent severe obesity as a potential etiologic factor. All patients had good glycemic control (HbA1c ≤ 7%) in the long-term postoperative follow-up.

Background: Perioperative management of chronically anti-coagulated patients undergoing bariatric surgery requires a balance of managing hemorrhagic and thromboembolic risks. The aim of this study is to evaluate the incidence of hemorrhagic complications and their management in chronically anticoagulated (CAT) patients undergoing bariatric surgery., Methods: A retrospective review of CAT patients undergoing bariatric surgery at an academic center from 2008 to 2015 was studied., Results: A total of 153 patients on CAT underwent surgery [Roux-en-Y gastric bypass (n = 79), sleeve gastrectomy (n = 63), and adjustable gastric banding (n = 11)] during the study period: 85 patients (55%) were females; median age was 56 years (interquartile range [IQR] 49-64), and median BMI was 49 kg/m 2 (IQR 43-56). The most common indications for CAT were venous thromboembolism (n = 87) and atrial fibrillation (n = 83). Median duration of procedure and estimated intraoperative blood loss was 150 min (IQR 118-177) and 50 ml (IQR 25-75), respectively. Thirty-day postoperative complications were reported in 33 patients (21.6%) including postoperative bleeding (n = 19), anastomotic leak (n = 3), and pulmonary embolism (n = 1). Nineteen patients (12%) with early postoperative bleeding were further categorized to intra-abdominal (n = 10), intraluminal (n = 6), and at the port site or abdominal wall (n = 3). All-cause readmissions within 30 days of surgery occurred in 19 patients (12%). There was no 30-day mortality., Conclusion: In our experience, patients who require chronic anticoagulation medication are higher than average risk for postoperative complications and all-cause readmission rates. Careful surgical technique and close attention to postoperative anticoagulation protocols are essential to decrease perioperative risk in this high-risk cohort.

Background: Bariatric surgery has been shown to be safe and effective in patients aged 60-75 years; however, outcomes in patients aged 75 or older are undocumented., Methods: Patients aged 75 years and older who underwent bariatric procedures in two academic centers between 2006 and 2015 were studied., Results: A total of 19 patients aged 75 years and above were identified. Eleven (58%) were male, the median age was 76 years old (range 75-81), and the median preoperative body mass index (BMI) was 41.4 kg/m 2 (range 35.8-57.5). All of the bariatric procedures were primary procedures and performed laparoscopically: sleeve gastrectomy (SG) (n = 11, 58%), adjustable gastric band (AGB) (n = 4, 21%), Roux-en-Y gastric bypass (RYGB) (n = 2, 11%), banded gastric plication (n = 1, 5%), and gastric plication (n = 1, 5%). The median operative time was 120 min (range 75-240), and the median length of stay was 2 days (range 1-7). Three patients (16%) developed postoperative atrial fibrillation which completely resolved at discharge. At 1 year, the median percentage of total weight loss (%TWL) was 18.4% (range 7.4-22.0). The 1-year %TWL varied among the bariatric procedures performed: SG (21%), RYGB (22%), AGB (7%), and gastric plication (8%). There were no 30-day readmissions, reoperations, or mortalities., Conclusion: Our experience suggests that bariatric surgery in selected patients aged 75 years and older would be safe and effective despite being higher risk. Age alone should not be the limiting factor for selecting patients for bariatric surgery.