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Introduction: Socioeconomic factors predispose certain populations to an increased exposure to emergent operative procedures. The aim of this study is to evaluate the role socioeconomic factors play in emergent repairs of inguinal, ventral and umbilical hernias.Methods: The SPARCS database was used to identify all patients undergoing emergent ventral hernia repair (EVR), emergent inguinal hernia repair (EIR), and emergent umbilical hernia repair (EUR) between 2008 and 2015. Chi-square test with exact p values from Monte Carlo simulation determined marginal associations between repairs (elective vs. emergent), and patient characteristics and comorbidities. Multivariable logistic regression models were further utilized to examine socioeconomic disparity.Results: 107,887 ventral hernias, 66,947 inguinal hernias, and 63,515 umbilical hernias (total 238,349) were noted. African Americans were most likely to undergo an EVR compared to Caucasians (OR 1.55, 95% CI: 1.48-1.61), Asians (OR 1.31, 95% CI: 1.15-1.5), and Hispanics (OR 1.3, 95% CI: 1.23-1.37). African Americans were most likely to undergo EIR compared to Caucasians (OR 2.2, 95% CI: 2.06-2.36), Asians (OR 1.74, 95% CI: 1.49-2.02), and Hispanics (OR 1.22, 95% CI: 1.12-1.34). African Americans were most likely to undergo EUR compared to whites (OR 1.29, 95% CI: 1.22-1.36), Asians (26.62%, OR 1.21, 95% CI: 1.01-1.46) and Hispanic (28.03%, OR 1.08, 95% CI: 1.01-1.16). Medicaid patients were also more likely to undergo EVR (OR 1.31, OR 1.73), EIR (OR 2.92, OR 4.55) and EUR (OR 1.63, OR 2.31) compared to Medicare and commercial insurance.Conclusion: Race is a contributing factor in who undergoes an emergent hernia repair in New York State. A significantly larger proportion of the African American population is undergoing hernia repair in the emergent setting. Socioeconomic status, as indicated by the significant number of Medicaid patients undergoing emergent hernia repairs, also plays a role. [ABSTRACT FROM AUTHOR]

Background: The incidence of massive ventral hernias among the elderly will increase as the population ages. Advanced age is often viewed as a contraindication to elective hernia repair. A relationship between age and complications of component separation procedures for ventral hernias is not well established. This study evaluated the effect of age on the peri-operative safety of AWR.Methods: The 2005-2013 ACS-NSQIP participant use data were reviewed to compare surgical site infection (SSI), overall morbidity, and serious morbidity in non-emergent component separation procedures among all age groups. All patients were stratified into four age quartiles and evaluated. Baseline characteristics included age, body mass index (BMI) and ASA 3 or 4 criteria. Statistical analysis was performed using SPSS. Odds ratios (OR) and 95% confidence intervals were reported as appropriate.Results: 4485 patients were identified. Majority of the cases were clean (76.8%). Patients were divided into the following quartiles based on age. The older quartile had a mean age of 72.7 ± 4.87 years. There were baseline differences in BMI and chronic comorbidity severity (measured by incidence of ASA score of 3 or 4) between the age groups, with the oldest group having lower BMI but higher rate of ASA 3 or 4 (p < 0.0001 for both). The rate of postoperative SSI was significantly different between age quartile groups (ranging from 16.3% from the youngest group to 9.4% for the oldest group, p < 0.0001). After adjusting for other baseline differences, advanced age was independently associated with lower SSI rate (OR 0.55, 95% CI 0.41-0.73). There was no significant difference in overall morbidity (p = 0.277) and serious morbidity (p = 0.131) between groups.Conclusion: AWR is being performed with safety across all age groups. In selected patients of advanced age, AWR can be performed with similar safety profile and low SSI rate. [ABSTRACT FROM AUTHOR]

Background: With the prevalence of obesity rising in the US, medical management is of increasing importance. Two popular options for the treatment of obesity are bariatric surgery (e.g. sleeve gastrectomy and Roux-en-Y gastric bypass) and the increasingly popular GLP-1 Receptor Agonists (GLP-1 s). This study examines the initial and long-term costs of GLP-1 s compared to bariatric surgery., Study Design: We compared average 2023 national retail prices for GLP-1 s to surgical cost estimates from 2015 adjusted for inflation. We then plotted the cumulative medication cost over time against the flat cost of each surgery, thus calculating "break-even points" (when medication costs equal surgery costs). The findings revealed a crucial insight, for some GLP-1 s like Saxenda and Wegovy, the high cost of ongoing use surpasses the cost of RYGB in less than a year and sleeve gastrectomy within nine months. Even the most affordable option, Byetta, becomes costlier than surgery after around 1.5 years., Results: This highlights the importance of looking beyond the initial financial investment when considering cost-effectiveness. Additionally, while not directly assessed, this study acknowledges that GLP-1 s take time to reach full effectiveness, potentially delaying weight loss while accumulating costs. Concerns also exist about weight regain after discontinuing the medication., Conclusion: This study is limited by the real-world variation for individual treatment costs (e.g. insurance), a limited evaluation of long-term costs associated with either treatment modality and their co-morbidities, and the reality of patient preference providing subjective value to either modality. Overall, the study offers insights into the financial trade-offs between GLP-1 s and bariatric surgery., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Weight regain and inadequate weight loss are common after bariatric surgery. Literature is emerging regarding the use of pharmacotherapy with bariatric surgery as a potential solution to these adverse effects. Pharmacotherapy may be used before (neoadjuvant) or after (adjuvant) bariatric surgery, although this terminology has not been standardized. As a rapidly growing area of research, there is opportunity to standardize terminology for future ease of research, data synthesis, and communication. This review aimed to comprehensively evaluate the use of the terms "adjuvant" and "neoadjuvant" to describe pharmacotherapy used in combination with bariatric surgery and propose standardized terminology for future research., Methods: Literature search was conducted systematically and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they were published after 1999; were randomized controlled trials, prospective/retrospective cohort studies, or case series; and used human subjects that were adults at least 18 years of age. The use of the terms "neoadjuvant" and "adjuvant" was analyzed over time., Results: Thirty-four publications were included. Thirty-two (94.1%) studied the use of adjuvant pharmacotherapy after bariatric surgery. Four (11.8%) studied the use of pharmacotherapy before bariatric surgery, and 1 used the term "neoadjuvant" to describe medications used before bariatric surgery. Eight publications used the term "adjuvant" to describe medications used after bariatric surgery., Conclusion: Standardized terminology is needed to ease future understanding, evidence synthesis, and dissemination of work. We propose that the terms "neoadjuvant" and "adjuvant" become the standard terminology to describe pharmacotherapy use before and after bariatric surgery, respectively., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: To comprehensively summarize the current body of literature on the topic of adjuvant and neoadjuvant pharmacotherapy used in combination with bariatric surgery., Recent Findings: Anti-obesity medications (AOMs) have been used since the mid-1900s; however, their use in combination with bariatric surgery is a newer area of research that is rapidly growing. Pharmacotherapy may be used before (neoadjuvant) or after (adjuvant) bariatric surgery. Recent literature suggests that adjuvant AOMs may address weight regain and inadequate weight loss following bariatric surgery. Research on neoadjuvant AOM used to optimize weight loss before bariatric surgery is more limited. A literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-four studies were included after screening and exclusion of irrelevant records. Included studies were as follows: seven prospective studies on adjuvant AOM use, 23 retrospective studies on adjuvant AOM use, one prospective study on adjuvant and neoadjuvant AOM use, one retrospective study on adjuvant or neoadjuvant AOM use, one prospective study on neoadjuvant AOM use, and one case series on neoadjuvant AOM use. In the following scoping review, each of these studies is discussed with the goal of presenting a complete synthesis of the current body of literature on AOM use in combination with bariatric surgery., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Endoscopes are an essential tool in the diagnosis, screening, and treatment of gastrointestinal diseases. In 2019, the Food and Drug Administration issued a news release, recommending that duodenoscope manufacturers and health care facilities phase out fully reusable duodenoscopes with fixed endcaps in lieu of duodenoscopes that are either fully disposable or those that contain disposable endcaps. With this study, we systematically reviewed the published literature on single-use disposable gastrointestinal scopes to describe the current state of the literature and provide summary recommendations on the role of disposable gastrointestinal endoscopes., Materials and Methods: For our inclusion criteria, we searched for studies that were published in the year 2015 and afterward. We performed a literature search in PubMed using the keywords, "disposable," "reusable," "choledochoscope," "colonoscope," "duodenoscope," "esophagoscope," "gastroscope," and "sigmoidoscope." After our review, we identified our final article set, including 13 articles relating to disposable scopes, published from 2015 to 2023., Results: In this review, we show 13 articles discussing the infection rate, functionality, safety, and affordability of disposable gastrointestinal scopes in comparison to reusable gastrointestinal scopes. Of the 3 articles that discussed infection rates (by Forbes and colleagues, Ridtitid and colleagues, and Ofosu and colleagues), each demonstrated a decreased risk of infection in disposable gastrointestinal scopes. Functionality was another common theme among these articles. Six articles (by Muthusamy and colleagues, Bang and colleagues, Lisotti and colleagues, Ross and colleagues, Kang and colleagues, and Forbes and colleagues) demonstrated comparable functionality of disposable scopes to reusable scopes. The most reported functionality issue in disposable scopes was decreased camera resolution. Disposable scopes also showed comparable safety profiles compared with reusable scopes. Six articles (by Kalipershad and colleagues, Muthusamy and colleagues, Bang and colleagues, Lisotti and colleagues, Luo and colleagues, and Huynh and colleagues) showed comparable rates of AEs, whereas 1 article (by Ofosu and colleagues) demonstrated increased rates of AEs with disposable scopes. Lastly, a cost analysis was looked at in 3 of the articles. Two articles (by Larsen et al and Ross and colleagues) remarked that further research is needed to understand the cost of disposable scopes, whereas 1 article (by Kang and colleagues) showed a favorable cost analysis., Conclusions: After a review of the literature published since the 2015 Food and Drug Administration safety communication, disposable scopes have been shown to be effective in decreasing infection risks while maintaining similar safety profiles to conventional reusable scopes. However, more research is required to compare disposable and reusable scopes in terms of functionality and cost-effectiveness., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite recent advancements, the advantage of robotic surgery over other traditional modalities still harbors academic inquiries. We seek to take a recently published high-profile narrative systematic review regarding robotic surgery and add meta-analytic tools to identify further benefits of robotic surgery., Methods: Data from the published systematic review were extracted and meta-analysis were performed. A fixed-effect model was used when heterogeneity was not significant (Chi 2 p ≥ 0.05, I 2  ≤ 50%) and a random-effects model was used when heterogeneity was significant (Chi 2 p < 0.05, I 2  > 50%). Forest plots were generated using RevMan 5.3 software., Results: Robotic surgery had comparable overall complications compared to laparoscopic surgery (p = 0.85), which was significantly lower compared to open surgery (odds ratio 0.68, p = 0.005). Compared to laparoscopic surgery, robotic surgery had fewer open conversions (risk difference - 0.0144, p = 0.03), shorter length of stay (mean difference - 0.23 days, p = 0.01), but longer operative time (mean difference 27.98 min, p < 0.00001). Compared to open surgery, robotic surgery had less estimated blood loss (mean difference - 286.8 mL, p = 0.0003) and shorter length of stay (mean difference - 1.69 days, p = 0.001) with longer operative time (mean difference 44.05 min, p = 0.03). For experienced robotic surgeons, there were less overall intraoperative complications (risk difference - 0.02, p = 0.02) and open conversions (risk difference - 0.03, p = 0.04), with equivalent operative duration (mean difference 23.32 min, p = 0.1) compared to more traditional modalities., Conclusion: Our study suggests that compared to laparoscopy, robotic surgery may improve hospital length of stay and open conversion rates, with added benefits in experienced robotic surgeons showing lower overall intraoperative complications and comparable operative times., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: As the use of the robotic platform increases among general surgeons, the amount of robotic cholecystectomies is expected to increase as well. The use of intraoperative cholangiography is valuable in assessing for choledocholithiasis. We describe our technique of performing robotic intraoperative cholangiograms with choledochoscopy. Out technique aids in efficiency since no undocking is required., Methods: Preoperatively, the decision to perform a cholangiogram is made based on physical exam, labs, and imaging findings. The procedure begins with obtaining a critical view of safety. The robotic arms are positioned in a manner that allows all 4 robotic arms to remain docked. A ductotomy is made and the cholangiocatheter is introduced. The cholangiogram images are then interpreted and if a stone is seen in the common bile duct we will then perform a transcystic common bile duct exploration using the SpyGlass Discover digital. A complete cholangiogram is then performed. The cystic duct is secured and the gallbladder is removed from the liver bed. The patients are watched overnight and discharged on postoperative day 1., Conclusions: A robotic approach to performing a transcystic common bile duct exploration is a safe and reproducible treatment method for choledocholithiasis. Our approach offers an advantage since no undocking is required., Competing Interests: S.D. is a consultant for Intuitive, Medtronic, and BD. He has received an honorarium from BD, Medtronic, and Boston Scientific. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Use of biologic or synthetic mesh in hernia repair shifts is based on evolving evidence. Poly-4-hydroxybutyrate (P4HB) biosynthetic mesh is a potential alternative to biologic and synthetic mesh in ventral hernia repair (VHR). This meta-analysis assesses the efficacy of P4HB mesh in clean and contaminated surgical settings., Methods: Two authors searched literature on PubMed, reviewing titles and abstracts of all articles to determine inclusion eligibility. Post-operative data were compared via transformation method to convert the proportion of patients with the outcome of interest into a suitable quantity for random-effects synthesis using STATA software., Results: Initial search yielded 287 citations. Six studies were included and categorized on whether hernia repairs were conducted in clean (CDC class I) or contaminated cases (CDC class II-IV). The pooled proportion of surgical site infection (SSI), surgical site occurrence (SSO), hernia recurrence, total surgical complications, and reoperation were calculated in 391 clean and 81 contaminated cases. For clean vs. contaminated cases, the following pooled proportions were noted: SSI (2% (CI 0-7%) vs 9% (CI 0-025) (p = 0.03), SSO: 14% (CI 5-25%) vs 35% (CI 22-50%) (p = 0.006), hernia recurrence (8% (CI 1-19%) vs 4% (CI 0-12%) (p = 0.769); surgical complications (17% (CI 6-32%) vs 50% (CI 27-72%) (p = 0.009). Reoperation data were available in 298 clean cases across four studies: 5% (CI 0-15%)., Conclusions: P4HB biosynthetic mesh may be more effective than previously thought, particularly in clean wounds. P4HB may also be superior to biologic mesh when compared to clinical trial data. Further research is necessary for more direct comparison., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Various staple line reinforcement (SLR) techniques in sleeve gastrectomy, including oversewing/suturing (OS/S), gluing, and buttressing, have emerged to mitigate postoperative complications such as bleeding and leaks. A meta-analysis of randomized controlled trials has demonstrated OS/S as an efficacious strategy for preventing postoperative complications, encompassing leaks, bleeding, and reoperations. Given that OS/S is the sole SLR technique not incurring additional costs during surgery, our study aimed to compare postoperative outcomes associated with OS/S versus alternative SLR methods. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we reviewed the literature and conducted fifteen pairwise meta-analyses of comparative studies, each evaluating an outcome between OS/S and another SLR technique. Thirteen of these analyses showed no statistically significant differences, whereas two revealed notable distinctions., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Sleeve gastrectomy (SG) is the most performed bariatric surgery worldwide. However, this surgery may be associated with long-term weight regain and severe gastroesophageal reflux disease (GERD), sometimes necessitating conversion to Roux-en-Y gastric bypass (RYGB) to improve quality of life (QoL). We conducted a systematic review on QoL measures following the conversion of SG to RYGB. We searched various databases for studies conducted between January 2005 and September 2023. Four studies, involving 196 participants in total, met the inclusion criteria. Different assessment methods were used to evaluate QoL following the conversion. In the included studies, we observed that GERD symptoms and proton pump inhibitor (PPI) use both decreased following conversion to RYGB. Excess weight loss (EWL) was also observed in all studies., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Repair options for ventral hernias in bariatric patients include performing a staged approach in which bariatric surgery is performed before definitive hernia repair (BS-first), a staged approach in which hernia repair is performed before bariatric surgery (HR-first), or a concomitant approach., Objectives: This meta-analysis aims to determine which surgical approach is best for bariatric patients with hernias., Setting: PubMed, CENTRAL, and Embase databases., Methods: A comprehensive search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to screen for all studies that focused on outcomes of patients who underwent both hernia repair and bariatric surgery, either simultaneously or separately. Exclusion criteria included hiatal and inguinal hernia studies, case reports, and case series., Results: 27 studies fit our inclusion criteria after identifying 1584 studies initially. Seven comparative studies were included, enrolling 8548 staged patients (6458 BS-first) and 3528 concomitant patients. A total of 7 single-arm staged studies and 13 single-arm concomitant studies were also included. Data on hernia recurrence, mesh infection, reoperation, surgical site infections, seroma, bowel complications, and mortality were abstracted. The concomitant approach was associated with decreased odds of experiencing surgical site infections, reoperation, and seromas. The staged approach (BS-first) was associated with decreased odds of mesh infection. The single-arm studies suggest a lower incidence of hernia recurrence in a staged BS-first approach than in a concomitant approach., Conclusions: The data suggest a concomitant approach is appropriate for hernias that the surgeon feels do not require mesh, while the staged (BS-first) approach is more appropriate if the hernia requires mesh placement., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The optimal distance between the starting point of gastric transection and the pylorus during laparoscopic sleeve gastrectomy (LSG), which can be referred to as the distance from pylorus (DFP), is controversial. No consensus exist for what DFP is considered antral preservation, and what DFP is considered antral resection. Some surgeons prefer shorter DFP to maximize excess weight loss percentage (EWL%), while others prefer longer DFP because they believe that it shortens length of stay (LOS) and protects against leaks, prolonged vomiting, and gastroesophageal reflux disease (GERD). We sought to compare 6-cm DFP and 2-cm DFP in postoperative outcomes. In addition, we sought to evaluate the magnitude of any observed benefit through number needed to treat (NNT) analysis., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Contributing factors to postlaparoscopy hernia are unknown. We hypothesized that postlaparoscopy incisional hernias are increased when the index surgery was performed in teaching hospitals. Laparoscopic cholecystectomy was chosen as the archetype for open umbilical access., Materials and Methods: Maryland and Florida SID/SASD databases (2016-2019) wereused to track 1-year hernia incidence in both inpatient and outpatient settings, which was then linked to Hospital Compare, Distressed Communities Index (DCI), and ACGME. Postoperative umbilical/incisional hernia following laparoscopic cholecystectomy was identified using CPT and ICD-10. Propensity matching and eight machine learning modes were utilized including logistic regression, neural network, gradient boosting machine, random forest, gradient boosted trees, classification and regression trees, k nearest neighbors and support vector machines., Results: Postoperative hernia incidence was 0.2% (total = 286; 261 incisional and 25 umbilical) in 117,570 laparoscopic cholecystectomy cases. Days to presentation (mean ± SD) were incisional 141 ± 92 and umbilical 66 ± 74. Logistic regression performed best (AUC 0.75 (95% ci 0.67-0.82) and accuracy 0.68 (95% ci 0.60-0.75) using 10-fold cross validation) in propensity matched groups (1:1; n = 279). Postoperative malnutrition (OR 3.5), hospital DCI of comfortable, mid-tier, at risk or distressed (OR 2.2 to 3.5), LOS >1 d (OR 2.2), postop asthma (OR 2.1), hospital mortality below national average (OR 2.0) and emergency admission (OR 1.7) were associated with increased hernias. A decreased incidence was associated with patient location of small metropolitan areas with <1 million residents (OR 0.5) and Charlson Comorbidity Index-Severe (OR 0.5). Teaching hospitals were not associated with postoperative hernia after laparoscopic cholecystectomy., Conclusions: Different patient factors as well as underlying hospital factors are associated with postlaparoscopy hernias. Performance of laparoscopic cholecystectomy at teaching hospitals is not associated with increased postoperative hernias., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: This retrospective cohort study aims to investigate emergency department (ED) visits and readmission after bariatric surgery among patients with a history of anxiety and/or depression. We predict that patients with a reported history of anxiety and/or depression will have more ED visits in the year following surgery than patients without a history of mental illness., Methods: Data were collected from the charts of all consecutive patients who underwent sleeve gastrectomy or gastric bypass surgery between March 2012 and December 2019. Data on baseline body mass index, mental health diagnosis and treatment and emergency department visits and hospital readmissions were retrospectively reviewed over the first year following surgery., Results: One thousand two hundred ninety-seven patients were originally included in this study and 1113 patients were included in the final analysis. Patients with a history of depression (OR 1.23; 95% CI 0.87-1.73), anxiety (OR 1.14; 95% CI 0.81-1.60), or both (OR 1.17; 95% CI 0.83-1.65) did not have a statistically significant increase in ED visits compared to patients without these disorders. Patients with a history of depression (OR 1.49; 95% CI 0.86-2.61), anxiety (OR 1.45; 95% CI 0.80-2.65) or both (OR 1.47; 95% CI 0.94-2.29) did not have a statistically significant increase in hospital readmissions in the first year after surgery compared to patients without these disorders. Patients treated with a sleeve gastrectomy were readmitted due to postoperative complications less frequently than those treated with other surgeries (OR 0.20; 95% CI 0.05-0.83)., Conclusion: Patients with a history of anxiety, depression or both did not have an increased rate of emergency department visits and hospital readmissions within the first year following bariatric surgery. This contradicts current literature and may be due to the multidisciplinary program patients undergo at this study's home institution., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Previous studies have been published evaluating the benefits and drawbacks of clearing the common bile duct of stones using a single-stage approach (LCBDE + LC) versus a two-stage approach (ERCP followed by LC). These studies have demonstrated that a single-stage approach offers similar outcomes and morbidities as a two-stage approach, with the added benefit of a lower cost and shorter length of stays. However, it is significant we understand why LCBDE is not commonly performed currently and also the lapse in surgical trainee exposure and competence in LCBDE. This paper aims to address the lapse in surgical trainee exposure to LCBDE, evaluate the scopes currently available to perform LCBDE, and review current data evaluating the risks and benefits of single-stage versus two-stage approaches to., Methods: We utilized PubMed to analyze all publications related to the various disposable scopes utilized to perform choledochoscopy. We also discuss the need for disposable scopes and how this new market niche is transforming the choledochoscopy space., Results: We analyzed the data related to single-stage and two-stage approach to choledocholithiasis. We noted an overall shorter length of stay and also decreased costs in favor of a single-stage approach., Conclusion: A single-stage LCBDE is the most cost-effective treatment option for choledocholithiasis in patients with choledocholithiasis undergoing a cholecystectomy. In addition, single-stage approach is associated with shorter length of stay. Knowledge of the available choledochoscopes and tools available to surgeons to perform choledochoscopy is significant. The evidence does support the use of disposable choledochoscope from a cost and cross-contamination perspective. Additionally, efforts should be made to incorporate LCBDE into the teaching paradigm of surgical training programs., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Healthcare disparities continue to be an ongoing struggle in Bariatrics. Limited availability of Spanish online material may be a correctible barrier for accessibility to Hispanic patients. We sought to evaluate accredited Bariatric Centers of Excellence (COE) for Spanish readability via their websites to determine accessibility for Spanish speakers., Methods: This was an internet research study. 103 COE accredited by American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS) were evaluated and assigned one of five Spanish Visibility Categories. The United States was divided into 4 regions. Regional Spanish visibility was calculated by dividing each category count by the number of institutions in each region. County Spanish-speaking populations were obtained from the US Census Bureau's 2009-2013 American Community Survey. Differences in their distributions across the Spanish Visibility Categories were investigated using the Mann-Whitney U test., Results: 25% of websites were translatable to Spanish, and a regional discrepancy was found with 61% translatable in the West, 19% in Northeast, 19% in Midwest, and 15% in South. Median Spanish-speaking population was higher in counties where websites were translatable to Spanish than where websites were not translatable., Conclusion: Healthcare disparities in Bariatrics continue to be an ongoing struggle. We suggest that Spanish readability for ASMBS ACS COE websites should be improved regardless of geographic differences in Spanish-speaking populations. We believe it would be valuable for these websites to have standards for readability of Spanish and other languages., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Bleeding and leaks are the most ominous postoperative complications after laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) techniques have been innovated such as oversewing/suturing (OS/S), omentopexy/gastropexy, buttressing, and gluing. Currently, no high-quality evidence supports the use of one method over the others or even supports the use of SLR over no SLR. This study aimed to compare postoperative outcomes between LSG with OS/S versus LSG without any SLR., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Hernias can present with unique challenges when it comes to management and repair. Prediction models can be a useful tool for clinicians to better anticipate and understand the severity of a hernia, the type of surgical technique, or presurgical planning that may be required to treat the patient, and the risk of complications. Our goal is to evaluate and consolidate prediction models in hernia repair present in the literature for which physicians can reference to best improve patient outcomes and postoperative management., Methods: We performed a literature search in PubMed using keywords, "rectus width to defect width ratio," "predicting myofascial release," "computed tomography hernia repair prediction," "component separation radiology prediction hernia," "fat volume and hernia repair," "body morphometrics and Query hernia repair," "body morphometrics and reherniation," "computed tomography findings and risk of emergency hernia repair," "loss of domain and hernia radiology," and "volumetry and hernia repair." We searched for publications that used radiographic parameters to predict hernia severity, interventions, and outcomes., Results: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we found twenty-three studies related to prediction models in hernia repair published between 2000 and 2021. We summarized studies pertaining to predicting acute care, predicting operative planning with loss of domain and component separation, predicting complications, paraesophageal hernia predictions, and predicting postoperative respiratory complications., Conclusion: Radiographic prediction models can be an objective and efficient way for surgeons to analyze hernias and better understand a patient's situation so that they can inform patients about the best treatment options and the risk of complications., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: CMS Hospital Quality Star ratings reflect the quality of care given to patients. It is hypothesized that increased Star-rating is associated with higher cost and that the value proposition is diminished., Methods: This study used the Florida AHCA inpatient dataset, CY2019. Partial colectomy was selected as a representative inpatient surgical procedure. Analysis was performed on this data to compare high and low Star-rated hospitals., Results: Total costs were equivalent among all Star levels on initial analysis. In a propensity matched comparison with 1 Star, 5 Star hospitals had significantly lower length-of-stay and ICU, anesthesia, radiology and lab costs, and conversely, had higher total (+2%), operating room and med-surg supply costs., Conclusions: These results demonstrate that total colectomy costs are functionally equivalent among the CMS 1- and 5- Star categories. The results indicate that higher CMS Star ratings fulfill the value proposition and indeed offer higher quality without significantly increased cost., Competing Interests: Declaration of competing interest None of the authors have any conflicts of interest to report., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Patients with adjustable gastric banding (AGB) often require revision to one-stage or two-stage sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)., Objective: To compare the long-term durability of revisional SG and RYGB, in terms of subsequent revision or conversion (RC)., Methods: The New York Statewide Planning and Research Cooperative Systems dataset was queried from 2006 to 2013 for patients who underwent primary SG and RYGB, one-stage, and two-stage conversion from AGB to SG and RYGB. Patients who required RC were identified. A multivariable Cox proportional hazard model was used to compare the RC risk among these groups., Results: 13,749 had primary SG, 621 one-stage, and 321 two-stage AGB to SG. 31,814 had primary RYGB, 555 one-stage, and 248 two-stage AGB to RYGB. The estimated 5-year cumulative RC incidence rate was significantly lower after primary surgery than after prior AGB (one-stage AGB to SG 14.4%, two-stage AGB to SG 11.6%, primary SG 5.2%, one-stage AGB to RYBG 3.4%, two-stage AGB to RYGB 2.9%, and primary RYGB 1.1%, p-value < 0.0001). RYGB and SG did not differ significantly in terms of the elevation effect of one- and two-stage AGB conversion over primary surgeries (RYGB vs SG: one stage vs primary ratio of HR = 0.97, 95% CI = [0.58, 1.63], p-value = 0.9153; two stage vs primary ratio of HR = 1. 02, 95% CI = [0.50, 2.07], p-value = 0.9596)., Conclusion: RC after AGB to SG or RYGB is more frequent compared to primary surgeries with procedures following AGB to SG being more common than AGB to RYGB. However, that difference was proportionally similar to the RC rate ratio differences noted for primary SG and RYGB., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Biliary disease is common occurrence and can make up a large portion of the practice of a general surgeon. Choledocholithasis is a common entity amongst those with biliary disease. Although modern trends favor endoscopic retrograde cholangiopancreatography (ERCP) and other imaging modalities for the diagnosis and management of choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is likely underutilized., Methods: A literature summary utilizing a PUBMED search was performed to provide an up-to-date account regarding the latest data on LCBDE. A video identifying and explaining the critical components of a LBCDE procedure is provided., Results: LCBDE is an underutilized procedure which offers equivalent clinical outcomes compared with ERCP along with a shorter length of stay and reduced costs. LCBDE is also noted to be an effective option for common bile duct stones in the setting of altered anatomy, such as a Roux-en-Y gastric bypass., Conclusion: Although modern trends favor ERCP and other imaging modalities for the diagnosis and management of choledocholithiasis, LCBDE is likely underutilized by surgeons. LCBDE can provide many benefits to patients including avoidance of additional procedures, shorter length of stay, higher success rates, and less costs. Out video should act is a guide for those surgeons interested in implementation LCBDE in their practice., Competing Interests: A.P.: personal fees from Ethicon, personal fees from Medtronic, personal fees from Stryker, from Gore, grants from Baranova, grants from Obalon. S.D.: receives honorarium from Medtronic, Intuitive and is a consultant for Boston Scientific. J.C. has no conflict of interest or financial ties to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The following literature search is in response to inquiries made to the American Society for Metabolic and Bariatric Surgery (ASMBS) regarding antiobesity medication (AOM) use in patients who are having or have already had metabolic and bariatric surgery (MBS). These recommendations are based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. This paper is not intended to establish a local, regional, or national standard of care. The paper will be revised in the future as additional evidence becomes available., (Copyright © 2022 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Health literacy is considered the single best predictor of health status. Organizations including the American Medical Association (AMA) and the National Institutes of Health (NIH) have recommended that the readability of patient education materials not exceed the sixth-grade level. Our study focuses on the readability of self-designated hernia centers websites at both academic and community organizations across the United States to determine their ability to dispense patient information at an appropriate reading level., Methods: A search was conducted utilizing the Google search engine. The key words "Hernia Center" and "University Hernia Center" were used to identify links to surgical programs within the United States. The following readability tests were conducted via the program: Flesch-Kincaid Grade Level (FKGL), Gunning Fox Index (GFI), Coleman-Liau Index (CLI), Simple Measure of Gobbledygook (SMOG), and Flesch Reading Ease (FRE) score., Results: Of 96 websites, zero (0%) had fulfilled the recommended reading level in all four tests. The mean test scores for all non-academic centers (n = 50) were as follows: FKGL (11.14 ± 2.68), GFI (14.39 ± 3.07), CLI (9.29 ± 2.48) and SMOG (13.38 ± 2.03). The mean test scores [SK1] for all academic programs (n = 46) were as follows: FKGL (11.7 ± 2.66), GFI (15.01 ± 2.99), CLI (9.34 ± 1.91) and SMOG (13.71 ± 2.02). A one-sample t test was performed to compare the FKGL, GFI, CLI, and SMOG scores for each hernia center to a value of 6.9 (6.9 or less is considered an acceptable reading level) and a p value of 0.001 for all four tests were noted demonstrating statistical significance. The Academic and Community readability scores for both groups were compared to each other with a two-sample t test with a p value of > 0.05 for all four tests and there were no statistically significant differences., Conclusion: Neither Academic nor Community hernia centers met the appropriate reading level of sixth-grade or less. Steps moving forward to improve patient comprehension and/or involving with their care should include appropriate reading level material, identification of a patient with a low literacy level with intervention or additional counseling when appropriate, and the addition of adjunct learning materials such as videos., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Surgical education was limited during the COVID-19 pandemic due to redeployment, limited clinical activity, and cancelation of elective procedures and educational conferences. Closed Facebook groups became a tool for surgical education while upholding social distancing guidelines. We aim to evaluate the use of Online Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) closed Facebook groups, during and prior to the COVID-19 pandemic., Methods: Institutional Review Board evaluation and written consent was not indicated as the data does not pertain to any human subjects. Data files pertaining to new membership activity, posts, comments and reactions of eight closed Facebook groups. The pandemic group was defined as March 19th to April 30, 2020. The pre-pandemic group was defined as February 6th, to March 18th, 2020. The percentage increase of new memberships, posts, comments and reactions were calculated for each period. A two-tailed t-test, using a significance level of 0.05 was used to evaluate significance., Results: A statistically significant increase in membership during the pandemic period was noted for each group. In regards to posts, the Flex Endo, Acute Care, Colorectal, Foregut, and Bariatric groups were noted to have a statistically significant increase in the pandemic period. Colorectal and Bariatric groups were the only two groups that were noted to have a significant increase in comments in the pandemic period. For reactions, Flex Endo, Colorectal, Foregut, and Bariatric groups were noted to have experienced a significant increase during the pandemic., Conclusions: The COVID-19 pandemic halted surgical education at all levels. The membership and utilization of closed Facebook groups increased significantly in many instances, demonstrating the importance of internet-based surgical education now and into the future. Further development of internet-based curriculums is warranted., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the need and possible strategies for screening endoscopic examination before metabolic and bariatric surgery (MBS), as well as the rationale, indications, and strategies for postoperative surveillance for mucosal abnormalities, including gastroesophageal reflux disease and associated esophageal mucosal injuries (erosive esophagitis and Barrett's esophagus) that may develop in the long term after MBS, specifically for patients undergoing sleeve gastrectomy or Roux-en-Y gastric bypass. The general principles described here may also apply to procedures such as biliopancreatic diversion (BPD) and BPD with duodenal switch (DS); however, the paucity of procedure-specific literature for BPD and DS limits the value of this statement to those procedures. In addition, children with obesity undergoing MBS may have unique considerations and are not specifically addressed in this position statement. This recommendation is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to be and should not be construed as stating or establishing a local, regional, or national standard of care. The statement will be revised in the future as additional evidence becomes available., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Heart failure is a disease with significant healthcare utilization and a prioritized target for readmission prevention. Although obesity is related to heart failure morbidity, the effects of bariatric surgery in obese patients with heart failure are not well studied., Objectives: To evaluate the impact of bariatric surgery on hospital-based healthcare utilization for patients with heart failure., Setting: Administrative statewide database., Methods: The New York Statewide Planning and Research Cooperative System database was used to identify patients with obesity and heart failure who underwent bariatric surgery from 2005 to 2015. Emergency department (ED) visits and hospitalization records from 1 year presurgery and up to 2 years postsurgery were compared., Results: Our study identified 899 patients with heart failure who underwent bariatric surgery. In the year presurgery, 11.48% of patients had any ED visit or hospitalization with a primary diagnosis of heart failure. The rate decreased drastically in the first year after surgery, with only 3.70% of patients having any heart failure-related hospital visits. The rate of heart failure-related visits was also lower in the second year postsurgery (3.44%) compared with the year before surgery. The risk of heart failure-related hospital visits was lower in both the first year (odds ratio [OR], .29; 95% confidence interval [CI], .19-.43) and second year postsurgery (OR, .26; 95% CI, .17-.41; P < .0001) than in the year before surgery., Conclusions: These findings suggest that bariatric interventions might be associated with decreased risks of ED visits or hospitalizations due to heart failure exacerbations in obese patients with preexisting heart failure., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Bariatric surgery is effective therapy for weight loss and diabetes control. While patients with poorly controlled type 2 diabetes (T2D) experience significant benefit from bariatric surgery, the impact of hyperglycemia on perioperative risks is unclear., Objective: This study aims to investigate effect of elevated glycated hemoglobin (HbA1C) on perioperative risks for patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)., Settings: 117,644 patients undergoing RYGB or SG between the years of 2017 and 2018 in the United Stated were analyzed. Data was obtained using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database., Methods: Three commonly used cutoff levels of HbA1C were selected (6.5, 7.0, and 8.5). Complications were compared between groups of patients above and below each HbA1C level. Multivariable logistic regression models were used to account for confounders., Results: Without risk adjustment, HbA1C is indirectly associated with increased rates of surgical complications. However, after adjusting for underlying co-morbidities, HbA1C is not associated with overall complications, including 30 day readmissions, reoperations, reinterventions, or death at any HbA1C cutoff: 6.5 (odds ratio [OR] 1.041, P value = .219), 7.0 (OR 1.020, P value = .551), or 8.5 (OR 1.051, P value = .208)., Conclusion: There is no direct relationship between HbA1C and early postoperative complications of SG and RYGB. Thus, optimizing preoperative HbA1C values alone, may not translate into decreased surgical complications of bariatric surgery. (Surg Obes Relat Dis 2020;17:271-275.) © 2020 American Society for Metabolic and Bariatric Surgery. All rights reserved., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The treatment of gastroparesis refractory to medical therapy has evolved to include purely endoscopic techniques. Per oral pyloromyotomy (POP) has evolved from traditional laparoscopic or open pyloroplasty to become a safe and effective minimally invasive option for patients with gastroparesis. As compared to laparoscopic pyloroplasty (LP), POP produces similar improvements in gastric emptying and symptom mitigation, while having shorter lengths of stay. There are slight variations in technique that vary by institution. Described here is a technique utilizing a lesser curve approach, with a mucosotomy closure using clips in an effort to maximize efficiency of the procedure., Methods: Preoperative workup includes a scintigraphic gastric emptying study or a wireless motility capsule study, and the Gastroparesis Cardinal Symptom Index (GCSI). After an upper endoscopy, the procedure begins with injection into the submucosal space with methylene blue in saline on the lesser curve, 3-5 cm proximal to the pylorus. A 1.5 cm incision is then made with the ERBE hybrid knife. A submucosal tunnel is created past the distal end of the pylorus, and the muscle is hooked, and divided with the hybrid knife. The mucosotomy is closed with clips (Boston Scientific Resolution 360, Boston, MA) after the completion of the myotomy. Post-operatively, patients are discharged home after an overnight stay with a proton pump inhibitor, sucralfate, and a full liquid diet for 2 weeks., Conclusions: A lesser curve approach with mucosotomy closure using clips is a safe, effective, and efficient modality for performing POP. As more centers adopt POP as a tool for gastroparesis management, the lesser curve method limits the length of the submucosal tunnel needed, and allows for wide adoption of the technique.

Background: Although bariatric surgery has been associated with a reduction in risk of obesity-related cancer, data on the effect of bariatric interventions on other cancers are limited., Objectives: This study aimed to examine the relationship between bariatric interventions and the incidence of various cancers after bariatric surgery., Setting: Administrative statewide database., Methods: The New York Statewide Planning and Research Cooperative System database was used to identify all adult patients diagnosed with obesity between 2006 and 2012 and patients who underwent bariatric procedures without preexisting cancer diagnosis and alcohol or tobacco use. Subsequent cancer diagnoses were captured up to 2016. Multivariable proportional subdistribution hazard regression analysis was performed to compare the risk of having cancer among obese patients with and without bariatric interventions., Results: We identified 71,000 patients who underwent bariatric surgery and 323,197 patients without a bariatric intervention. Patients undergoing bariatric surgery were less likely to develop both obesity-related cancer (hazard ratio.91; 95% confidence interval, .85-.98; P = .013) and other cancers (hazard ratio .81; 95% confidence interval, .74-.89; P < .0001). Patients undergoing Roux-en-Y gastric bypass had a lower risk of developing cancers that are considered nonobesity related (hazard ratio .59; 95% confidence interval, .42-.83; P = .0029) compared with laparoscopic sleeve gastrectomy., Conclusions: Bariatric surgery is associated with a decreased risk of obesity-related cancers. More significantly, we demonstrated the relationship between bariatric surgery and the reduction of the risk of some previously designated nonobesity-related cancers, as well. Reclassification of nonobesity-related cancers and expansion of bariatric indications for reducing the risk of cancer may be warranted., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Wide-area transepithelial sampling of the esophagus with computer-assisted three-dimensional analysis (WATS3D, CDx Diagnostics, Suffern, NY) is an adjunctive technique to random biopsies for early detection of Barrett's esophagus. The aim of the SAGES Technology and Value Assessment Committee aims is to evaluate the efficacy, value, and safety of WATS3D., Methods: Clinical studies involving WATS3D were identified via a search of the PubMed/Medline databases ( www.ncbi.nlm.nih.gov/pubmed ) conducted in March of 2019 using search terms, such as wide-area transepithelial sampling, three-dimensional (3D) computer-assisted analysis, WATS-3D, Barrett's esophagus and WATS-3D, Barrett's esophagus and wide-area transepithelial sampling with three-dimensional computer-assisted analysis, Barrett's esophagus, and emerging technology. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded., Results: No significant morbidity or mortality was reported within the literature associated with the WATS 3D technology. WATS 3D increases diagnostic yield by 38-150% for Barrett's Esophagus, by 40-150% for Low Grade Dysplasia; and by 420% for High Grade Dysplasia; when compared to forceps biopsy alone. WATS 3D technique has very high inter-observer agreement for the pathological diagnosis of non-dysplastic and dysplastic Barrett's Esophagus. Increased detection of pre-malignant diseases of the esophagus by the adjunctive use of WATS 3D supports screening and surveillance by the adjunctive use of WATS 3D during upper endoscopy in appropriate patients., Conclusion: Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS 3D , CDx Diagnostics) is a safe and effective adjunct to forcep biopsies in the evaluation of Barrett's Esophagus, Low Grade Dysplasia, and High Grade Dysplasia.

Background: Within surgical education, there has been a recent emphasis on preparing medical students for the rigors of residency in an effort to improve confidence and technical preparedness throughout postgraduate training. The aim of this study is to test the impact of a boot camp course using the American College of Surgeons-based curriculum and objective, observer-based rating tools on both subjective confidence and objective skills of fourth-year medical students., Materials and Methods: Informed consent was obtained on the first day of the boot camp. Before any teaching, students performed 5 tasks (patient handoff, suturing, knot tying, central line placement, and chest tube placement), which were scored using objective rating tools provided by the American College of Surgeons. Students also completed 2 confidence measures. After 2 weeks of dedicated teaching and review, students were scored on the 5 same tasks and repeated the confidence measures., Results: Fourth-year medical students (N = 12) who had matched into surgical subspecialties were invited to participate in a 2-week surgical boot camp. All students beginning the study completed the study. The average age was 26.7 years; 25% of students were female. Subspecialties represented included general surgery (n = 5), orthopedics (n = 3), integrated plastics (n = 2), urology (n = 1), and neurosurgery (n = 1). Scores on objective skills improved significantly in all 5 tasks measured. Confidence improved significantly on individual task items, while overall self-efficacy remained unchanged., Conclusions: Implementation of a 2-week, multimodal surgical boot camp improved student performance on objectively rated surgical skills and increased student confidence., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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

Background: While sleeve gastrectomy (SG) has lower perioperative risk compared with Roux-en-Y gastric bypass (RYGB), long-term data about their differential impact on overall health are unclear. Hospital use after bariatric surgery is an important parameter for improving peri- and postoperative care., Objective: This present study was aimed to compare SG and RYGB in terms of their effect on long-term hospital-based healthcare utilization., Setting: Multicenter, statewide database., Methods: A retrospective cohort study of adult patients who underwent SG and RYGB between 2009 and 2011, with follow-up until 2015 and 2-year presurgery information. Propensity score-matched SG and RYGB groups were created using preoperative demographic characteristics, co-morbidities, and presurgery hospital use, measured by cumulative length of stay (LOS) and frequency of emergency department visits. Postsurgery yearly LOS, incidence of hospital visits, and the reason for the visit were compared. Primary outcomes included postoperative hospital visits during years 1 to 4 after bariatric surgery and cumulative LOS. Secondary outcomes included specific reasons for hospital use., Results: There were 3540 SG and 13,587 RYGB patients, whose mean (95% confidence interval [CI]) LOS was 1.3 (1.3-1.4), .9 (.8-1), 1 (.9-1.1), and 1.2 (1-1.3) days at years 1 through 4, respectively. Postoperative yearly LOS was similar between the 2 propensity-matched groups. The risk of hospitalizations (odd ratio .73, 95% CI .64-.84, P < .0001) and emergency department visits (odds ratio .84, 95% CI .75-.95, P = .005) was significantly lower for SG, during the first postoperative year. The reverse was seen at the fourth postoperative year, with higher risk of emergency department use after SG (odds ratio 1.16, 95% CI 1.01-1.33, P = .035)., Conclusion: Postoperative 4-year hospital utilization remains low for both SG and RYGB. The previously established lower early perioperative risk of SG was not appreciated for longer-term hospital use compared with RYGB., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The increase in life expectancy along with the obesity epidemic has led to an increase in the number of older patients undergoing bariatric surgery. There is conflicting evidence regarding the safety of performing bariatric procedures on older patients., Objective: The purpose of this study was to compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for older patients (>65 yr)., Setting: Nationwide analysis of accredited centers., Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2017 database was used to identify nonrevisional laparoscopic RYGB and SG procedures. Comparisons were made based on patient age. Clinical outcomes included postoperative events and mortality., Results: There was a total 13,422 and 5395 matched pairs for SG and RYGB in comparing patients aged 18 years to those aged 65 and >65 years, respectively, and 5395 matched RYGB and SG procedures performed in patients >65 years. The complication rate was higher in older patients undergoing RYGB compared with SG (risk difference = 2.39%, 95% confidence interval: 1.57%-3.21%, P < .0001). When comparing older to younger patients, the older group had a higher complication rate for SG but not for RYGB (SG: risk difference = 1.01%, 95% confidence interval: .59%-1.43%, P < .0001, RYGB: risk difference = .59%, 95% confidence interval: -.29% to 1.47%, P = .2003)., Conclusions: Overall complication rates of bariatric surgery are low in patients >65 years. SG appears to have a favorable safety profile in this patient population compared with RYGB. The overall complication rate for RYGB is not significantly different between the older and younger groups., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Pathways for enhanced recovery after surgery (ERAS) have been shown to improve length-of-stay (LOS) and post-operative complications across various surgical fields, however there is a lack of evidence-based studies in bariatric surgery. Specifically, the value of early feeding within an ERAS program in bariatric surgery is unclear. The objective of the current study was to determine the effect of early feeding on LOS for patients who underwent primary or revisional laparoscopic sleeve gastrectomy (LSG) and Roux-en-y gastric bypass (RYGB)., Methods: Retrospective single institution study of implementation of a new diet protocol in which initiation of oral intake changed from post-operative day 1 to day 0. LOS and 30-day events were compared. Patients were excluded if they were planned for 23-h stay, had significant intra-operative complications, or required reoperation within the same admission. Mann-Whitney U tests were done to compare LOS and chi-squared tests to compare 30-day events pre- and post-intervention., Results: A total of 244 patients were included; 84.4% were primary cases. 50.8% of cases occurred prior to early feeding implementation. Median age was 43.5 years (IQR 33-53) and majority of patients were female (78.7%). Median LOS was 32.6 (IQR 30.0-50.6). Median LOS across the whole sample was shorter in the early feeding group (36.2 vs. 31.0 h; p < 0.001). This difference remained statistically significant for primary, but not revisional cases. Post-operative events at 30 days were similar between pre- and post-intervention groups., Conclusions: Early feeding the day of surgery is associated with significantly shorter LOS for patients who undergo bariatric surgery with no difference in 30-day readmissions.

Background: To quantify the impact of body mass index (BMI) on surgical site infection (SSI) following abdominal wall reconstruction (AWR) using component separation techniques and attempt to identify obesity-related targets, such as BMI, that can be potentially used to guide preoperative patient optimization. Though AWR has established perioperative outcomes for hernia repair, the applicability in the obese population is not well established., Methods: The 2005-2013 ACS-NSQIP participant use file was reviewed to compare SSI, severe, and overall morbidity in non-emergent AWR patients based on BMI. Multivariable logistic regression was used to control for patient demographics and comorbidities. Odds ratios (OR) with 95% confidence intervals were reported., Results: We identified 4488 patients. The average BMI was 32.76 ± 7.70 kg/m 2 . The majority of cases (76.8%) had wound classified as clean. The SSI rate significantly increased at a BMI of ≥ 35 kg/m 2 compared to < 35 (18.5% vs. 10.5%, p < 0.0001). There was no significant different in SSI rate between BMI 35-40 and > 40. After controlling for differences in baseline characteristics and wound classification, BMI ≥ 35 kg/m 2 was independently associated with SSI (OR 1.47, 1.21-1.78), minor complications (OR 1.65, 1.41-1.94), major complications (OR 1.91, 1.60-2.27), re-operation (OR 1.59, 1.23-2.05), and hospital re-admission (OR 1.93, 1.23-3.02)., Conclusion: There is a significant increase in SSI and other perioperative complications in patients with a BMI ≥ 35 kg/m 2 undergoing AWR. Higher BMI is also independently associated with higher resource utilization in this patient population. Severely obese patients in need of AWR may benefit from a structured preoperative weight loss intervention.

Background: Patients undergoing abdominal wall reconstruction (AWR) are at an increased risk of developing respiratory complications. Previous studies have demonstrated that postoperative findings, such as an increase in plateau pressure greater than 6 cm H 2 O following fascial closure, creates an increased risk of postoperative respiratory complications. The purpose of this study is to determine if specific preoperative characteristics are an indicator for postoperative respiratory failure., Methods: The 2005-2013 ACS-NSQIP participant use data were reviewed to evaluate post-operative intubation status following AWR procedures for ventral hernias. Prolonged intubation, defined as intubation up to 48 h post-operatively, was evaluated. Multivariable logistic regression was used to control for patient demographics and comorbidities. Odds ratios and 95% confidence intervals were reported as appropriate using SPSS., Results: 4378 patients were identified. Majority (51%) of patients were female. 2.96% of patients experienced a prolonged intubation. Factors such as a history of severe COPD, ASA 3 or 4, current smoker within 1 year, and a BMI of 40 were all found to have a significant association with a prolonged intubation., Conclusions: Post-operative prolonged intubation is a known complication of AWR. We have demonstrated that pre-operative factors, such as a history of COPD, ASA 3 or 4, current smoker, and a BMI > 40 kg/m 2 are factors associated with a prolonged intubation. Optimization of each may allow for a reduction in the risk of prolonged intubation in patients undergoing AWR.

Obesity is associated with the development of gastroesophageal reflux disease (GERD) and hiatal hernia (HH). This study aimed to assess practice patterns regarding concomitant HH repair (HHR) during laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). The incidence of concomitant HHR with LSG or LRYGB was analyzed using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. One hundred thirty thousand, seven hundred seventy-two patients underwent RYGB (30.5%) and LSG (69.5%). Concomitant HHR was more common, despite less GERD, in SG patients compared to RYGB (21.0% vs 10.8%, p < 0.0001; adjusted OR 2.14, 95% CI 2.06-2.22). This marked difference in the intraoperative management of HH during bariatric surgeries may hinder our ability to evaluate the long-term effects of bariatric surgery on GERD.

The number of patients undergoing bariatric surgery continues to increase. The American Society for Metabolic and Bariatric Surgery (ASMBS) estimates the number of bariatric surgical procedures performed increased from 158 000 in 2011 to 190 000 in 2015. Concurrently, the incidence of postoperative complications specific to bariatric patients will inevitably increase as well. Endoscopic evaluation of postoperative bariatric patients and endoscopic interventions are rapidly evolving. We present a review of the postoperative anatomy of bariatric patients, what complications to expect, and treatment options.

Background: The previous popularity of adjustable gastric banding (AGB), along with inconsistent long-term results, has resulted in the need for conversion to other procedures. The perioperative safety of laparoscopic sleeve gastrectomy (SG) and gastric bypass (RYGB) as single-stage conversion procedures is unclear., Objectives: To compare the early safety of SG and RYGB when performed as single-stage conversion procedures at the time of AGB removal., Setting: Nationwide analysis of accredited centers., Methods: The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file for 2015 was queried for all patients who underwent single-stage conversion to SG or RYGB. Multivariable logistic regression was performed to control for baseline differences, and odds ratios (ORs) with 95% confidence intervals are reported., Results: There were 4865 patients who underwent a single-stage AGB conversion. SG was performed in 3364 (69.1%). The 30-day reoperation (1.6% versus 2.7%, P = .008), readmission (4% versus 5.7%, P = .006), reintervention (1.7% versus 2.7%, P = .024), and overall morbidity (2.9% versus 6.5%, P<.0001) were significantly less common in the SG group. After controlling for baseline characteristics, RYGB was independently associated with higher overall 30-day reoperation (OR 1.81, 1.19-2.75), readmission (OR 1.42, 1.07-1.88), reintervention (OR 1.59, 1.06-2.4), and overall morbidity (OR 2.17, 1.62-2.9)., Conclusions: AGB conversions are associated with low overall 30-day event rates. Patients undergoing RYGB as a single-stage conversion experience higher complication rates and the need for additional early procedures compared with SG., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: There is an association between obesity and more complicated diverticular disease. We hypothesize that this link may be due to an increased level of visceral fat rather than an elevated body mass index alone. Adipose tissue secretes inflammatory cytokines, and chronic inflammation may account for the link between obesity and a more severe presentation of diverticular disease. We have applied a quantitative measure of visceral fat content in a series of patients admitted with diverticulitis, comparing those who required emergent versus elective surgical procedures for diverticulitis., Methods: We performed a retrospective review of all adult patients who underwent emergent or elective surgery at our institution for diverticulitis from 2010 to 2014. Data were collected on demographics, comorbidities, operative findings, complications, and length of stay. Radiologic measurements of adiposity were obtained from preoperative CT scans. Visceral fat areas and subcutaneous fat areas were measured, and the V/S ratio was calculated., Results: Thirty-four patients underwent emergent and 32 patients underwent elective surgery. The mean age was 66.3 years for the emergent and 57.11 for the elective group (p = 0.04178). The perinephric, visceral, subcutaneous fat, and V/S ratio for the emergent group were 1.71, 185.22, 338.22, and 0.56 and were 1.11, 127.18, 295.28, and 0.46 for the elective group. The difference between the V/S ratio for each group was significant (p = 0.0238). The emergent group had an average LOS of 16.11 days compared to 5.15 for the elective group (p = <0.00001). The complication rate was significantly higher (p = 0.024) in the emergent group (n = 12, 35.2 %) compared to the elective group (n = 4, 12.5 %)., Conclusion: Our study demonstrates a clinically significant link between visceral fat and severity of presentation of diverticulitis. Patients with higher V/S fat ratios were more likely to require emergency surgery and have more complications and a longer LOS.

Introduction: Per-oral endoscopic myotomy (POEM) is a less invasive therapy for achalasia with a shorter hospitalization but with similar short- and long-term outcomes as a laparoscopic Heller myotomy (LHM). Previous literature comparing POEM to LHM has focused primarily on postoperative outcome parameters such as complications, dysphagia scores and gastro-esophageal reflux severity. This study specifically compares postoperative pain following POEM to pain following LHM, the current gold-standard operation., Methods: A retrospective review of all patients undergoing POEM or LHM for achalasia was performed from 2006 to 2015. Data collection included demographics, comorbidities, length of stay (LOS) and pain scores (arrival to the recovery room, 1 h postoperative, average first 24 h and upon discharge). Statistical analysis was performed using Student's t test and Chi-square test., Results: Forty-four POEM patients and 122 LHM patients were identified. The average age (52.2 ± 20.75 vs 50.9 ± 17.89 years, p = 0.306) and BMI (28.1 ± 7.62 vs 27.6 ± 7.07 kg/m 2 , p = 0.824) did not differ between the POEM and LHM groups, respectively; however, the American Society of Anesthesiology scores were higher in the POEM patients (2.43 ± 0.62 vs 2.11 ± 0.71, p = 0.011). There were no differences in rates of smoking, diabetes, cardiac disease or pulmonary disease. The average pain scores upon arrival to the recovery room and 1 h postoperatively were lower in the POEM group (2.3 ± 3.014 vs 3.61 ± 3 0.418, p = 0.025 and 2.2 ± 2.579 vs 3.46 ± 3.063, p = 0.034, respectively). There was no difference in the average pain score over the first 24 h (2.7 ± 2.067 vs 3.29 ± 1.980, p = 0.472) or at the time of discharge (1.6 ± 2.420 vs 2.09 ± 2.157, p = 0.0657) between the POEM and LHM groups. After standardizing opioid administration against 10 mg of oral morphine, the POEM group used significantly less narcotics that the LHM group (35.8 vs 101.8 mg, p < 0.001) while hospitalized. The average LOS for the POEM group was 31.2 h and 55.79 for the LHM group (p < 0.0001). At discharge, fewer POEM patients required a prescription for a narcotic analgesic (6.81 vs 92.4 %, p < 0.0001)., Conclusion: POEM demonstrated significantly less postoperative pain upon arrival to the recovery room and 1 h postoperatively. To achieve similar pain scores during the first 24 h and at discharge, LHM patients required more narcotic analgesic administration. Despite a significantly shorter LOS, fewer POEM patients require a prescription for narcotic analgesics compared to LHM. POEM is a less painful procedure for achalasia than LHM, permitting earlier hospital discharge with little need for home narcotic use.

Introduction: Body mass index (BMI) has commonly been used as a parameter to assess obesity in trauma patients. However, the variability of height and weight data in trauma patients limits the use of BMI as an accurate assessment tool in the trauma population. Quantitative radiologic measurements of visceral adiposity is an accurate method for assessing obesity in patients but requires further analysis before it can be accepted as a measurement tool for trauma patients., Methods: A retrospective review of trauma cases with pre-operative CT scan from 2008 to 2015 produced 57 patients for evaluation. Preoperative BMI was calculated using measured height (m2) and weight (kg). Radiologic measurements of adiposity were obtained from preoperative CT scans using OsiriX DICOM viewer software. Visceral fat areas (VFA) and subcutaneous fat areas (SFA) were measured from a single axial slice at the level of L4-L5 intervertebral space., Results: No statistically significant results were found relating visceral fat:subcutaneous fat ratios to length of stay or post-operative complications. Initial clinical observations noting an increased incidence of complications among patients with a V/S ≥ 0.4 demonstrates a possible link between obesity and poor outcomes in trauma patients. A statistically significant correlation was noted between length of stay, peri-nephric fat and injury severity score., Discussion and Conclusion: Our pilot study should be viewed as the foundation for a larger prospective study, utilizing quantitative measurements of visceral adiposity to assess outcomes in trauma patients., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Digital rectal exams (DRE) are routinely used on trauma patients during the secondary survey as recommended by current Advanced Trauma Life Support (ATLS) protocols. However, recent literature has called the blanket use of the DRE on each trauma patient into question. The purpose of this study was to evaluate the efficacy of the DRE as a diagnostic tool in the setting of urethral, spinal cord, small bowel, colon, and rectal injuries and determine if it can be eliminated from routine use in the trauma setting. Trauma patients with small bowel, colon, rectal, urethral, and spinal cord injuries, age of 18 years or older, and a noted DRE were included. Exclusion criteria included an age less than 18, patients who received paralytics, a Glasgow Coma Scale (GCS) of 3, and a history of paraplegia or quadriplegia. One-hundred eleven patient records were retrospectively reviewed. Ninety-two male (82.9 %) and 19 (17.1 %) females with a GCS of 13.7 were evaluated. Sixty-two (55.9 %) injuries were penetrating with 49 (44.1) being blunt. The DRE missed 100 % of urethral, 91.7 % of spinal cord, 93.1 % of small bowel, 100 % of colon, and 66.7 % of rectal injuries. For injuries confirmed with radiologic modalities, the DRE missed 93.3 %. For injuries confirmed on exploratory laparotomy, the DRE missed 94.9 %. The DRE has poor sensitivity for the diagnosis of urethral, spinal cord, small bowel, and large bowel injury. The DRE was found to be the most sensitive in the setting of rectal injuries. The DRE offers no benefit or predictive value when compared to other imaging modalities.