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Background: Traditional surgical outcomes are measured retrospectively and intermittently, limiting opportunities for early intervention., Objectives: The objective of this study was to use risk-adjusted cumulative sum (RA-CUSUM) to track perioperative surgical outcomes for laparoscopic gastric bypass. We hypothesized that RA-CUSUM could identify performance variations between surgeons., Setting: Two mid-Atlantic quaternary care academic centers., Methods: Patient-level data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were abstracted for laparoscopic gastric bypasses performed by 3 surgeons at 2 high-volume centers from 2014 to 2021. Estimated probabilities of serious complications, reoperation, and readmission were derived from the MBSAQIP risk calculator. RA-CUSUM curves were generated to signal observed-to-expected odds ratios (ORs) of 1.5 (poor performance) and .5 (superior performance). Control limits were set based on a false positive rate of 5% (α = .05)., Results: We included 1192 patients: Surgeon A = 767, Surgeon B = 188, and Surgeon C = 237. Overall rates of serious complications, 30-day reoperations, and 30-day readmissions were 3.9%, 2.5%, and 5.2% respectively, with expected rates of 4.7%, 2.2%, and 5.8%. RA-CUSUM signaled lower-than-expected (OR < .5) rates of readmission and serious complication in Surgeon A, and higher-than-expected (OR > 1.5) readmission rate in Surgeon C. Surgeon A further demonstrated an early period of higher-than-expected (OR > 1.5) reoperation rate before April 2015, followed by superior performance thereafter (OR < .5). Surgeon B's performance generally reflected expected standards throughout the study period., Conclusions: RA-CUSUM adjusts for clinical risk factors and identifies performance outliers in real-time. This approach to analyzing surgical outcomes is applicable to quality improvement, root-cause analysis, and surgeon incentivization., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

We evaluated the effect of preoperative standard medical care (SC) vs. unsupervised aerobic exercise combined with SC (EX + SC) on cardiometabolic health and quality of life (QoL) 30 days after bariatric surgery. Bariatric patients (n = 14, age: 42.3 ± 2.5 years, body mass index: 45.1 ± 2.5 kg/m 2 ) were match-paired to presurgical SC (n = 7) or EX + SC (n = 7; walking 30 min/day, 5 day/week, 65-85% HR peak ) for 30 days. Body composition, peak cardiorespiratory fitness (VO 2 peak), QoL, inflammation (adiponectin, leptin, cytokeratin-18), and a 120 min mixed meal tolerance test was performed to assess aortic waveforms (augmentation index, AIx@75), insulin sensitivity, and glucose total area under the curve (tAUC) at the time of surgery (post-intervention) and 30 days post-surgery. EX + SC had significantly higher high molecular weight (HMW) adiponectin (p = 0.01) and ratio of HMW to total adiponectin (p = 0.04) than SC at 30 days post-surgery, although they significantly (p = 0.006; ES = 1.86) decreased total time spent in moderate to vigorous physical activity (MVPA). SC had a significantly greater increase in VO 2 peak (p = 0.02; ES = 1.54) and decrease in 120 min AIx@75 (p = 0.02; ES = 1.78) than EX + SC during the post-surgical period. The increase in MVPA was associated with a reduction in cytokeratin-18 (r = -0.67, p = 0.02). Increased VO 2 peak was associated with increased activity/mobility QoL domain (r = 0.52, p = 0.05) and decreased 120 min AIx@75 (r = -0.61, p = 0.03) from surgery to post-surgery. Preoperative EX + SC did not maintain more favorable cardiometabolic health 30 days post-operation in this pilot study. However, changes in MVPA appear important for QoL and should be considered in future work., (© 2021 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Objective: Examine if adding aerobic exercise to standard medical care (EX+SC) prior to bariatric surgery improves metabolic health in relation to surgical outcomes., Methods: Fourteen bariatric patients (age: 42.3±2.5y, BMI: 45.1±2.5 kg/m2) met inclusion criteria and were match-paired to pre-operative SC (n = 7) or EX+SC (n = 7; walking 30min/d, 5d/wk, 65-85% HRpeak) for 30d. A 120min mixed meal tolerance test was performed pre- and post-intervention (~2d prior to surgery) to assess insulin sensitivity (Matsuda Index) and metabolic flexibility (indirect calorimetry). Aerobic fitness (VO2peak), body composition (BodPod), and adipokines (adiponectin, leptin) were also measured. Omental adipose tissue was collected during surgery to quantify gene expression of adiponectin and leptin, and operating time and length of hospital stay were recorded. ANOVA and Cohen's d effect size (ES) was used to test group differences., Results: SC tended to increase percent body fat (P = 0.06) after the intervention compared to EX+SC. Although SC and EX+SC tended to raise insulin sensitivity (P = 0.11), EX+SC enhanced metabolic flexibility (P = 0.01, ES = 1.55), reduced total adiponectin (P = 0.01, ES = 1.54) with no change in HMW adiponectin and decreased the length of hospital stay (P = 0.05) compared to SC. Albeit not statistically significant, EX+SC increased VO2peak 2.9% compared to a 5.9% decrease with SC (P = 0.24, ES = 0.91). This increased fitness correlated to shorter operating time (r = -0.57, P = 0.03) and length of stay (r = -0.58, P = 0.03). Less omental total adiponectin (r = 0.52, P = 0.09) and leptin (r = 0.58, P = 0.05) expression correlated with shorter operating time, and low leptin expression was linked to shorter length of stay (r = 0.70, P = 0.01), and low leptin expression was linked to shorter length of stay (r = 0.70, P = 0.01)., Conclusion: Adding pre-operative aerobic exercise to standard care may improve surgical outcomes through a fitness and adipose tissue derived mechanism., Competing Interests: The authors have declared that no competing interests exist.

Objective: Examine the effect of aerobic exercise (EX) combined with standard medical care (SC) (EX + SC) compared to SC alone on cardiometabolic health and quality of life in relation to surgical outcomes., Methods: Patients receiving bariatric surgery were match-paired to 30 days of pre-operative SC ( n = 7, 1 male, 39.0 ± 5.3 years, body mass index 46.4 ± 3.0 kg/m 2 ; low calorie diet) or EX + SC ( n = 7, 0 males, 45.6 ± 4.8 years, body mass index 43.9 ± 4.2 kg/m 2 ; walking 30 min/day, 5 days/week, 65-85% HR peak ). Body mass, waist circumference, cardiorespiratory fitness (VO 2 peak), high sensitivity C-reactive protein (hs-CRP), cytokeratin 18 (CK18), weight related quality of life (QoL), and a 120 min mixed meal tolerance test (MMTT) was performed to assess arterial stiffness via augmentation index normalized to a heart rate of 75 beats per minute (AIx@75), whole-body insulin sensitivity, and glucose total area under the curve (tAUC) pre- and post-intervention (∼2 days prior to surgery). Length of hospital stay (admission to discharge) was recorded., Results: EX + SC had a greater effect for decreased intake of total calories ( P = 0.14; ES = 0.86) compared to SC, but no change in body weight or waist circumference was observed in either group. EX + SC had a greater effect for increased VO 2 peak ( P = 0.24; ES = 0.91) and decreased hs-CRP ( P = 0.31; ES = 0.69) compared to SC. EX + SC reduced circulating CK18 ( P = 0.05; ES = 3.05) and improved QoL ( P = 0.02) compared to SC. Although EX + SC had no statistical effect on arterial stiffness compared to SC, we observed a modest effect size for AIx@75 tAUC ( P = 0.36; ES = 0.52). EX + SC had a significantly shorter length of hospital stay ( P = 0.05; ES = 1.38) than SC, and a shorter length of hospital stay was associated with decreased sugar intake ( r = 0.55, P = 0.04). Decreased AIx@75 tAUC significantly correlated with improved whole-body insulin sensitivity ( r = -0.59, P = 0.03) and glucose tAUC ( r = 0.57, P = 0.04)., Conclusion: EX with SC for 30 days prior to bariatric surgery may be important for cardiometabolic health, quality of life, and surgical outcomes in the bariatric patient., (Copyright © 2020 Gilbertson, Eichner, Khurshid, Rexrode, Kranz, Weltman, Hallowell and Malin.)

Background: Fostering medical students' appreciation for team members particularly those from other disciplines with varying levels of experience promotes a promising beginning to a health care career., Methods: During surgical clerkship orientation, third-year medical students completed 30-item TeamSTEPPS Teamwork Attitudes Questionnaire preintervention and postintervention, spent 7 min identifying errors in a simulated operating room, followed by recorded physician-led 30-min discussions., Results: Postintervention (67) compared with preintervention (141) mean TeamSTEPPS Teamwork Attitudes Questionnaire domain scores were statistically significantly higher for team structure (4.59, 4.70; P = 0.03) and higher but not significant for leadership (4.74, 4.75; P = 0.86), situation monitoring (4.62, 4.68; P = 0.32), communication (4.40, 4.50; P = 0.14), and decreased for mutual support (4.43, 4.36; P = 0.43). Medical students identified 2%-93% of 33 staged errors and 291 additional errors, which were placed into 14 categories. Soiled gloves in the operative field and urinary bag on the floor were the most frequently identified staged errors. Experienced nurses compared with medical students identified significantly more errors (mean, 17.7 versus 11.7, respectively; P < 0.001). Recognizing errors when lacking familiarity with the operative environment and appreciating teammates' perspectives were themes that emerged from discussions., Conclusions: This well-received teamwork exercise enabled medical students to appreciate team members' contributions and other disciplines' perspectives, in addition to the synergy that occurs with multidisciplinary teams., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Obesity and obesity-related comorbidities are associated with increased risk of coronary artery disease (CAD). Bariatric surgery results in durable weight loss and improvement in numerous CAD risk factors, yet limited data exist on CAD-related outcomes. We hypothesized that bariatric surgery would lead to decreased risk of CAD and reduced rates of coronary revascularization procedures., Methods: All patients who underwent bariatric surgery at a single medical center from 1985 to 2015 were identified. A control population of morbidly obese patients who did not undergo bariatric surgery was identified using an institutional clinical data repository over the same study period, propensity score matched 1:1 on patient demographics and comorbidities including cardiac history. Univariate analyses were performed to compare outcomes in the surgery and non-surgery groups., Results: A total of 3410 bariatric surgery patients and 45,750 non-surgical patients were identified. After 1:1 propensity-score matching, a total of 3242 patients in each group were found to be well balanced in baseline characteristics and risk factors. With a median follow-up of greater than 6 years, the surgery group had significantly lower rates of myocardial infarction (1.8% vs. 10.0%; RR 0.18), coronary catheterization (1.9% vs. 8.8%; RR 0.22), percutaneous coronary intervention (0.4% vs. 7.8%; RR 0.05), and coronary artery bypass grafting (0.6% vs. 2.3%; RR 0.26). Similar benefits were observed for subgroups of patients with and without diabetes., Conclusions: Bariatric surgery was associated with a significant reduction in the incidence of myocardial infarction as well as lower rates of coronary revascularization in a propensity-matched cohort of morbidly obese patients. Though the retrospective nature of this study may have introduced a degree of selection bias, these outcomes support increased utilization of bariatric surgery for the prevention of heart disease.

Objective: We hypothesize the Distressed Communities Index (DCI), a composite socioeconomic ranking by ZIP code, will predict risk-adjusted outcomes after surgery., Summary of Background Data: Socioeconomic status affects surgical outcomes; however, the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) database does not account for these factors., Methods: All ACS NSQIP patients (17,228) undergoing surgery (2005 to 2015) at a large academic institution were paired with the DCI, which accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies. Developed by the Economic Innovation Group, DCI scores range from 0 (no distress) to 100 (severe distress). Multivariable regressions were used to evaluate ACS NSQIP predicted risk-adjusted effect of DCI on outcomes and inflation-adjusted hospital cost., Results: A total of 4522 (26.2%) patients came from severely distressed communities (top quartile). These patients had higher rates of medical comorbidities, transfer from outside hospital, emergency status, and higher ACS NSQIP predicted risk scores (all P < 0.05). In addition, these patients had greater resource utilization, increased postoperative complications, and higher short- and long-term mortality (all P < 0.05). Risk-adjustment with multivariate regression demonstrated that DCI independently predicts postoperative complications (odds ratio 1.1, P = 0.01) even after accounting for ACS NSQIP predicted risk score. Furthermore, DCI independently predicted inflation-adjusted cost (+$978/quartile, P < 0.0001) after risk adjustment., Conclusions: The DCI, an established metric for socioeconomic distress, improves ACS NSQIP risk-adjustment to predict outcomes and hospital cost. These findings highlight the impact of socioeconomic status on surgical outcomes and should be integrated into ACS NSQIP risk models.

Introduction: Obesity is a risk factor for non-alcoholic steatohepatitis (NASH) and hepatocellular carcinoma (HCC). Bariatric surgery can provide durable weight-loss, but little is known about the later development of NASH and HCC after surgery., Methods: Bariatric surgery (n = 3,410) and obese controls (n = 46,873) from an institutional data repository were propensity score matched 1:1 by demographics, comorbidities, BMI, and socioeconomic factors. Comparisons were made through paired univariate analysis and conditional logistic regression., Results: Total of 4,112 patients were well matched with no significant baseline differences except initial BMI (49.0 vs 48.2, p = 0.04). Bariatric group demonstrated fewer new-onset NASH (6 0.0% vs 10.3%, p < 0.0001) and HCC (0.05% vs 0.34%, p = 0.03) over a median follow-up of 7.1 years. After risk-adjustment, bariatric surgery was independently associated with reduced development of NASH (OR 0.52, p < 0.0001)., Conclusions: Bariatric surgery is associated with reduced incidence of NASH and HCC in this large propensity matched cohort. This further supports the use of bariatric surgery for morbidly obese patients to ameliorate NASH cirrhosis and development of HCC., (Copyright © 2019. Published by Elsevier Inc.)

Background: Socioeconomic status affects surgical outcomes, however these factors are not included in clinical quality improvement data and risk models. We performed a prospective registry analysis to determine if the Distressed Communities Index (DCI), a composite socioeconomic ranking by zip code, could predict risk-adjusted surgical outcomes and resource utilisation., Methods: All patients undergoing surgery (n=44,451) in a regional quality improvement database (American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP) were paired with DCI, ranging from 0-100 (low to high distress) and accounting for unemployment, education level, poverty rate, median income, business growth and housing vacancies. The top quartile of distress was compared to the remainder of the cohort and a mixed effects modeling evaluated ACS-NSQIP risk-adjusted association between DCI and the primary outcomes of surgical complications and resource utilisation., Results: A total of 9369 (21.1%) patients came from severely distressed communities (DCI >75), who had higher rates of most medical comorbidities as well as transfer status (8.4% vs 4.8%, p<0.0001) resulting in higher ACS-NSQIP predicted risk of any complication (8.0% vs 7.1%, p<0.0001). Patients from severely distressed communities had increased 30-day mortality (1.8% vs 1.4%, p=0.01), postoperative complications (9.8% vs 8.5%, p<0.0001), hospital readmission (7.7 vs 6.8, p<0.0001) and resource utilisation. DCI was independently associated with postoperative complications (OR 1.07, 95% CI 1.04 to 1.10, p<0.0001) as well as resource utilisation after adjusting for ACS-NSQIP predicted risk CONCLUSION: Increasing Distressed Communities Index is associated with increased postoperative complications and resource utilisation even after ACS-NSQIP risk adjustment. These findings demonstrate a disparity in surgical outcomes based on community level socioeconomic factors, highlighting the continued need for public health innovation and policy initiatives., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Surgical outcomes are affected by socioeconomic status, yet these factors are poorly accounted for in clinical databases. We sought to determine if the Distressed Communities Index (DCI), a composite ranking by zip code that quantifies socioeconomic risk, was associated with long-term survival after bariatric surgery., Methods: All patients undergoing Roux-en-Y gastric bypass (1985-2004) at a single institution were paired with DCI. Scores range from 0 (no distress) to 100 (severe distress) and account for unemployment, education, poverty, median income, housing vacancies, job growth, and business establishment growth. Distressed communities, defined as DCI ≥75, were compared with all other patients. Regression modeling was used to evaluate the effect of DCI on 10-year bariatric outcomes, whereas Cox Proportional Hazards and Kaplan-Meier analysis examined long-term survival., Results: Gastric bypass patients (n = 681) come from more distressed communities compared with the general public (DCI 60.5 ± 23.8 versus 50 ± 10; P < 0.0001). A total of 221 (32.3%) patients came from distressed communities (DCI ≥75). These patients had similar preoperative characteristics, including BMI (51.5 versus 51.7 kg/m 2 ; P = 0.63). Socioeconomic status did not affect 10-year bariatric outcomes, including percent reduction in excess body mass index (57% versus 58%; P = 0.93). However, patients from distressed communities had decreased risk-adjusted long-term survival (hazard ratio, 1.38; P = 0.043)., Conclusions: Patients with low socioeconomic status, as determined by the DCI, have equivalent outcomes after bariatric surgery despite worse long-term survival. Future quality improvement efforts should focus on these persistent disparities in health care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Obesity and breast density are associated with breast cancer in postmenopausal women. Bariatric surgery effectively treats morbid obesity, with sustainable weight loss and reductions in cancer incidence. We evaluated changes in qualitative and quantitative density; hypothesizing breast density would increase following bariatric surgery., Methods: Women undergoing bariatric surgery from 1990 to 2015 were identified, excluding patients without a mammogram performed both before and after surgery. Changes in body mass index (BMI), time between mammograms and surgery, and American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) scores were assessed. VolparaDensity™ automated software calculated volumetric breast density (VBD), fibroglandular volume (FGV), and total breast volume for the 82 women with digital data available. Differences between pre- and postsurgery values were assessed., Results: One hundred eighty women were included. Median age at surgery was 50.0 years, with 8.8 months between presurgery mammogram and surgery and 62.3 months between surgery and postsurgery mammogram. Median BMI significantly decreased over the study period (46.0 vs 35.4 kg/m 2 ; P < 0.001). No change in BI-RADS scores was seen between the pre- and postsurgery mammograms. Eighty-two women had VolparaDensity™ data available. While VBD increased in these patients, FGV and total breast volume both decreased following bariatric surgery., Conclusions: Increased VBD, decreased FGV, and decreased total breast volume were seen following bariatric surgery-induced weight loss. There was no difference in qualitative breast density, highlighting the discrepancy between BI-RADS and VolparaDensity™ measurements. Further investigation will be required to determine how differential changes in components of breast density may affect breast cancer risk., (© 2019 Wiley Periodicals, Inc.)

The objective of this study was to test if a low-calorie diet plus interval exercise (LCD+INT) improves adiposopathy, an endocrine dysfunction, when compared with an energy-deficit-matched LCD in obese women. Subjects (age: 48.2 ± 2.4 years, body mass index: 37.8 ± 1.3 kg/m 2 ) were randomized to a 13-day LCD ( n = 12; mixed meals of ∼1200 kcal/day) or LCD+INT ( n = 12; 12 sessions of 60 min/day alternating 3 min at 50% and 90% peak heart rate). Exercise was estimated to expend 350 kcal per oxygen uptake-heart rate regression analysis and individuals were refed calories expended to match energy availability between groups. Absolute (post - pre caloric intake) and relative (total daily and exercise energy expenditure relative to calorie intake) energy deficits were calculated. Fitness (peak oxygen uptake) and body composition (BodPod; Cosmed USA Inc.) were measured and a 120-min, 75g oral glucose tolerance test was performed at pre- and post-intervention to assess adiposopathy (i.e., ratio of high molecular weight-adiponectin to leptin) and estimate insulin sensitivity. LCD and LCD+INT had similar absolute ( P = 0.55) and relative ( P = 0.76) energy deficits. LCD and LCD+INT had similar reductions in fat mass (both P < 0.001), despite LCD inducing greater weight loss ( P = 0.02) than LCD+INT. Both treatments improved adiposopathy ( P = 0.003) and peripheral insulin sensitivity ( P = 0.02). Absolute energy deficit correlated to improved adiposopathy ( r = - 0.41, P = 0.05), and absolute and relative energy deficits were associated with increased insulin sensitivity ( r = -0.47, P = 0.02; and r = -0.40, P = 0.05, respectively), independent of body composition changes and increased peak oxygen uptake. Taken together, LCD, with or without INT, improves adiposopathy in relation to insulin sensitivity in obese women, suggesting that a short-term energy deficit is key for reducing risk of type 2 diabetes.

Background: Obesity is a risk factor for colorectal cancer and possibly the formation of precancerous, colorectal polyps . Bariatric surgery is very effective for long-term weight loss; however, it is not known whether bariatric surgery decreases the risk of subsequent colonic neoplasia. We hypothesized that bariatric surgery would decrease the risk of developing colorectal lesions (new cancer and precancerous polyps)., Methods: We reviewed all patients (n = 3,676) who underwent bariatric surgery (gastric bypass, sleeve gastrectomy, or gastric banding) at the University of Virginia (Charlottesville, VA) 1985-2015. Obese, nonoperative patients (n = 46,873) from an institutional data repository were included as controls. Cases and controls were propensity score matched 1:1 by demographics, comorbidities, body mass index, and socioeconomic factors. The matched cohort was compared by univariate analysis and conditional logistic regression., Results: A total of 4,462 patients (2,231 per group) with a median follow-up of 7.8 years were well-matched with no statistically significant baseline differences in initial body mass index (48 vs 49 kg/m 2 ), sex, and age in addition to other comorbidities (all P > .05). The operative cohort had more weight loss (55.5% vs -1.4% decrease in excess body mass index, P < .0001). The operative cohort developed fewer colorectal lesions (2.4% vs 4.8%, P < .0001). We observed no differences in polyp characteristics or staging for patients who developed cancer (all P > .05). After risk adjustment, bariatric surgery was independently associated with a decrease in new colorectal lesions (OR 0.62, 95% CI 0.42-0.91, P = .016)., Conclusion: Bariatric surgery was associated with lesser, risk-adjusted incidence of new colorectal lesions in this large population of propensity matched patients undergoing bariatric surgery compared with a control group not undergoing bariatric surgery. These results suggest the benefits of bariatric surgery may extend beyond weight loss and mitigation of comorbidities., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Early discharge after laparoscopic sleeve gastrectomy (SG) is common and safe, but two-thirds of patients are still hospitalized longer than 1 day. The purpose of this study was to evaluate factors associated with early discharge at a single institution with intention to discharge on postoperative day 1., Methods: Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing SG at an academic hospital between 2010 and 2016. The primary outcome measure was length of stay (LOS). Multivariate logistic regression was used to identify independent predictors of prolonged LOS., Results: A total of 367 patients undergoing SG were included. Two hundred eighty-seven (78%) were women and 294 (80%) were Caucasian. Mean age was 45.5 years and mean body mass index (BMI) was 48.7 kg/m2. One hundred twenty-three patients (33.5%) had a LOS ≤ 1 day. Compared to patients staying ≥ 2 days, early discharge patients had significantly lower BMI, creatinine, and American Society of Anesthesiologists class, were more likely to be White, married, have private insurance, and were more likely to have a morning start and no postoperative upper gastrointestinal (UGI) swallow study. Regression analysis demonstrated several independent predictors of prolonged LOS including institutional experience (OR 0.5, p < 0.001), case start time (OR 0.6, p = 0.04), and routine UGI swallow (OR 8.8, p < 0.0001) postoperatively., Conclusions: LOS after SG is affected by multiple factors, including patient health, socioeconomic status, case order, and postoperative management. Optimization of these may allow for improvement in preoperative education and streamlined postoperative pathways, resulting in reduced LOS.

Background: Prior studies investigating racial, socioeconomic, and/or insurance disparities with regard to access to care and outcomes in bariatric surgery have been performed with varying results., Objectives: Our aim was to determine if racial or ethnic disparities exist in referral patterns for bariatric surgery at a single center., Methods: An institutional, retrospective chart review from January 2012 through June 2017 was performed for patients meeting referral criteria to bariatric surgery. Data collection was limited to patients referred to the bariatric surgery clinic from on-site primary care clinics., Results: In total, 4736 patients were eligible for bariatric surgery during the study period. Patients were 63.8% female (n = 3022), and 36.2% male (n = 1714); 53.9% white (n = 2553), 37.8% black (n = 1790), and 8.3% Hispanic (n = 393). Female patients were more likely to be referred than male patients (5.5% versus 4.1%, χ 2 4.59, P = .032). On univariate comparison, Hispanic patients were less likely to be referred compared with black or white patients (2.0% versus 5.3% and 5.2%, χ 2 7.88, P = .019)., Conclusion: Hispanic patients were less likely to be referred at our institution for bariatric surgery compared with white or black patients. A barrier to referral may be explained by the disproportionate number of Hispanic patients that were designated as "self-pay" rather than private insurance or Medicaid/Medicare coverage that is required for bariatric surgery referral. This finding underscores the need for further research surrounding barriers to access to care for Hispanic patients., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Bariatric surgery treats morbid obesity resulting in long-lasting weight loss. Elevated body mass index (BMI) increases breast cancer risk. We hypothesized that patients undergoing bariatric surgery would have decreased overall and estrogen receptor (ER)-positive breast cancer incidences compared to a propensity-matched non-surgical cohort., Methods: The bariatric population included all female patients who underwent weight loss surgery at a single institution from 1985 to 2015. Patients from all outpatient visits were propensity score matched 1:1 with bariatric patients using BMI, comorbidities, demographics, and insurance status. The primary outcome was breast cancer incidence. Univariate analyses compared the groups., Results: A total of 4860 patients were included, with 2430 in both groups. Median follow-up time from date of surgery or morbid obesity diagnosis was 5.7 years. There were no differences in age or comorbidities aside from gastroesophageal reflux disease. Seventeen (0.7%) patients in the surgery group were subsequently diagnosed with breast cancer versus 32 (1.3%) in the non-surgery group (p = 0.03). The non-surgery group had more ER-positive tumors [4 (36.4%) vs. 22 (71.0%); p = 0.04]., Conclusion: Female patients who underwent bariatric surgery were less frequently diagnosed with any breast cancer and ER-positive breast cancer versus a propensity-matched cohort suggesting a possible oncologic benefit to weight loss surgery.

Background: Obesity is associated with an increased risk of atrial fibrillation (AF). Bariatric surgery results insubstantial long-term weight loss and the amelioration of several chronic comorbidities. We hypothesized that weightreduction with bariatric surgery would reduce the long-term incidence of AF., Objectives: To assess the association between bariatric surgery and AF prevention., Setting: University Hospital, United States., Methods: All patients who underwent bariatric surgery at a single institution from 1985-2015 (n = 3,572) were propensity score matched 1:1 to a control population of obese patients with outpatient appointments (n = 45,750) in our clinical data repository. Patients with a prior diagnosis of AF were excluded. Demographics, relevant comorbidities, and insurance status were collected and a chart review was performed for all patients with AF. Paired univariate analyses were used to compare the two groups., Results: After propensity score matching, 5,044 total patients were included (2,522 surgical, 2,522 non-surgical). There were no differences in preoperative body mass index (BMI) (47.1 vs 47.7 kg/m 2 , P = 0.76) or medical comorbidities between groups. The incidence of AF was lower among surgical patients (0.8% vs 2.9%, P = 0.0001). In patients ultimately diagnosed with AF, time from enrollment to development of AF did not differ between groups; however, surgical patients with AF experienced a significantly higher reduction in excess BMI compared to non-surgical patients with AF (57.9% vs -3.8%, P<0.001)., Conclusion: The incidence of AF was lower among patients who underwent bariatric surgery compared to their medically managed counterparts. Weight reduction with bariatric surgery may reduce the long-term incidence of AF., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity as a single-stage operation for the treatment of morbid obesity, as patients undergoing LSG have been shown to achieve similar weight loss and resolution of obesity-related comorbidities in comparison to those undergoing Roux-en-Y gastric bypass (RYGB), the "gold standard" bariatric operation. Although LSG poses fewer technical challenges than RYGB, little is known about differences in short-term outcomes among patients undergoing LSG and RYGB. We hypothesized that LSG is associated with lower 30-day risk-adjusted serious morbidity., Methods: Preoperative characteristics and 30-day outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) Participant Use Files (PUF) 2010-2014 were selected for all patients who underwent LSG or RYGB. Descriptive comparisons were performed using chi-square and Wilcoxon's rank-sum tests as appropriate. The primary outcome was a risk-adjusted composite measure of 30-day serious morbidity and mortality., Results: We analyzed records for 47,982 (42.0%) and 66,380 (58.0%) patients undergoing LSG and RYGB, respectively. On univariate analysis, LSG patients had a lower rate of organ space infection (0.45% vs. 0.68%, p < 0.001), lower rate of bleeding requiring transfusions (1.00% vs. 1.60%, p < 0.001), lower rate of sepsis (0.34% vs. 0.49%, p < 0.001), and septic shock (0.12% vs. 0.22%, p < 0.001) and required fewer unplanned reoperations (1.34% vs. 2.56%, p < 0.001) than RYGB patients. Both groups had similar rates of deep venous thrombosis (0.33% vs. 0.28%, p = 0.15) and pulmonary embolism (0.17% vs. 0.21%, p = 0.15). Mortality was lower among LSG patients (0.09% vs. 0.14%, p = 0.01). On multivariate analysis, RYGB was associated with higher risk-adjusted 30-day serious morbidity than LSG (odds ratio 1.61; 95% CI 1.52-1.71, p < 0.001). Older age, female gender, higher BMI, and insulin-dependent diabetes were also associated with risk of serious morbidity (C-statistic = 0.60)., Conclusion: Serious morbidity following bariatric surgery is uncommon; however, LSG may be associated with modest protection from adverse 30-day outcomes in comparison to RYGB. Our conclusion is limited by the difference in baseline risk factors of the populations studied.

Background: Bariatric surgery is the most effective intervention for achieving durable weight loss and improvement of comorbidities in patients with obesity. Limited data exist on the impact of Medicare status in patients undergoing Roux-en-Y gastric bypass. We hypothesized that there is no difference in outcomes between Medicare beneficiaries and non-Medicare patients at the 10-year follow-up., Methods: All patients who underwent Roux-en-Y gastric bypass with 10-year follow-up at a single medical center from 1985 to 2005 were stratified by Medicare insurance status. Outcomes included 10-year percent reduction in excess body mass index and comorbidity resolution., Results: Of 617 patients who underwent Roux-en-Y gastric bypass with 10-year follow-up, 117 (19%) were insured under Medicare. Medicare patients were older (43 vs 40 years, P = .01) and had a greater preoperative body mass index (53.2 vs 51.0 kg/m 2 , P = .03) than non-Medicare patients, but there were no differences in preoperative median comorbidity index scores (3 [interquartile range 1-4] vs 2 [interquartile range 1-5], P = .33). At 10 years, weight loss (58.3% vs 57.0 percent reduction in excess body mass index, P = .16) and the decrease in median comorbidity index (1 [interquartile range 0-3] vs 1 [interquartile range 0-3], P = .85) were equivalent between groups., Conclusions: Roux-en-Y gastric bypass is equally beneficial in Medicare Disability and non-Medicare patients at 10 years. These findings support the continued and expanded coverage of bariatric surgery operations by Medicare., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Numerous studies have established the effectiveness of Roux-en-Y gastric bypass (RYGB) for weight loss and co-morbidity amelioration. However, its safety and efficacy in elderly patients remains controversial., Objectives: To evaluate outcomes in patients aged ≥60 years who underwent RYGB compared with nonsurgical controls with the hypothesis that RYGB provides weight loss benefits without differences in survival., Setting: University-affiliated tertiary center., Methods: All patients who underwent RYGB from 1985 to 2015 were identified and divided into elderly (age ≥60) and nonelderly (age <60) groups. A nonsurgical elderly control population was identified using a clinical data repository of outpatient visits to propensity match elderly patients 4:1 on demographic characteristics, co-morbidities, and relevant preoperative substance/medication use. Unpaired appropriate univariate analyses compared each stratified group. Kaplan-Meier survival curves were fitted based on social security death data., Results: A total of 2306 patients underwent RYGB. The 107 elderly patients had lower median body mass index (47.0 versus 49.9; P = .007) and higher rates of co-morbidities. Rates of complications did not differ between elderly and nonelderly patients. Elderly surgical patients were propensity matched 4:1 (10,044 controls) yielding 428 well-matched nonsurgical controls. The elderly group demonstrated significant percent reduction in excess body mass index compared with the control group (81.8% versus 10.3%; P < .001). Kaplan-Meier survival analysis with log-rank test demonstrated no difference in midterm survival (P = .63)., Conclusions: A significant weight reduction benefit was identified after RYGB in elderly patients without a difference in midterm survival compared with propensity-matched controls, suggesting RYGB is a safe and efficacious weight loss strategy in the elderly., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Although low-calorie diets (LCD) improve glucose regulation, it is unclear if interval exercise (INT) is additive. We examined the impact of an LCD versus LCD + INT training on ß-cell function in relation to glucose tolerance in obese adults. Twenty-six adults (Age: 46 ± 12 year; BMI 38 ± 6 kg/m²) were randomized to 2-week of LCD (~1200 kcal/day) or energy-matched LCD + INT (60 min/day alternating 3 min at 90 and 50% HRpeak). A 2 h 75 g oral glucose tolerance test (OGTT) was performed. Insulin secretion rates (ISR) were determined by deconvolution modeling to assess glucose-stimulated insulin secretion ([GSIS: ISR/glucose total area under the curve (tAUC)]) and ß-cell function (Disposition Index [DI: GSIS/IR]) relative to skeletal muscle (Matsuda Index), hepatic (HOMA-IR) and adipose (Adipose-IR fasting ) insulin resistance (IR). LCD + INT, but not LCD alone, reduced glucose and total-phase ISR tAUC (Interactions: p = 0.04 and p = 0.05, respectively). Both interventions improved skeletal muscle IR by 16% ( p = 0.04) and skeletal muscle and hepatic DI (Time: p < 0.05). Improved skeletal muscle DI was associated with lower glucose tAUC ( r = -0.57, p < 0.01). Thus, LCD + INT improved glucose tolerance more than LCD in obese adults, and these findings relate to ß-cell function. These data support LCD + INT for preserving pancreatic function for type 2 diabetes prevention.

Introduction: The purpose of this study was to determine the long-term incidence of bone fracture after bariatric surgery, identify specific risk factors for fracture, and compare these data to baseline risk in a comorbidity-matched morbidly obese population. We hypothesize that, despite prior studies with conflicting results, bariatric surgery increases a patient's long-term risk of fracture., Methods: All patients who underwent bariatric surgery at a single institution 1985-2015 were reviewed. Univariate analysis of patient demographic data including comorbidities, insurance payer status, procedure type, and BMI was performed. Multivariate logistic regression was used to identify independent predictors of fracture in this population. Finally, we identified a propensity-matched control group of morbidly obese patients from our institutional Clinical Data Repository in the same timeframe who did not undergo bariatric surgery to determine expected rate of fracture without bariatric surgery., Results: A total of 3439 patients underwent bariatric surgery, with 220 (6.4%) patients experiencing a bone fracture at mean follow-up of 7.6 years. On multivariate logistic regression, independent predictors of increased fracture included tobacco use and Roux-en-Y gastric bypass while private insurance and race were protective (table). Additionally, 1:1 matching on all comorbidity and demographic factors identified 3880 patients (1940 surgical patients) with equal propensity to undergo bariatric surgery. Between the propensity-matched cohorts, patients who had a history of bariatric surgery were more than twice as likely to experience a fracture as those who did not (6.4 vs. 2.7%, p < 0.0001)., Conclusions: This study of bariatric surgery patients at our institution identified several independent predictors of postoperative fracture. Additionally, these long-term data demonstrate patients who had bariatric surgery are at a significantly increased risk of bone fracture compared to a propensity-matched control group. Future efforts need to focus on nutrient screening and risk modification to reduce the impact of this long-term complication.

Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m-2. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P > 0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis (P < 0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intraoperative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.

Background: The number of robotic surgical procedures performed yearly is constantly rising, due to improved dexterity and visualization capabilities compared with conventional methods. We hypothesized that outcomes after robotic-assisted inguinal hernia repair would not be significantly different from outcomes after laparoscopic or open repair., Methods: All patients undergoing inguinal hernia repair between 2012 and 2016 were identified using institutional American College of Surgeons National Surgical Quality Improvement Program data. Demographics; preoperative, intraoperative, and postoperative characteristics; and outcomes were evaluated based on method of repair (Robot, Lap, or Open). Categorical variables were analyzed by Chi-square test and continuous variables using Mann-Whitney U., Results: A total of 510 patients were identified who underwent unilateral inguinal hernia repair (Robot: 13.8% [n = 69], Lap: 48.1% [n = 241], Open: 38.1% [n = 191]). There were no demographic differences between groups other than age (Robot: 52 [39-62], Lap: 57 [45-67], and Open: 56 [48-67] years, p = 0.03). Operative duration was also different (Robot: 105 [76-146] vs. Lap: 81 [61-103] vs. Open: 71 [56-88] min, p < 0.001). There were no operative mortalities and all patients except one were discharged home the same day. Postoperative occurrences (adverse events, readmissions, and death) were similar between groups (Robot: 2.9% [2], Lap: 3.3% [8], Open: 5.2% [10], p = 0.53). Although rare, there was a significant difference in rate of postoperative skin and soft tissue infection (Robot: 2.9% [2] vs. Lap: 0% [0] vs. Open: 0.5% [1], p = 0.02). Cost was significantly different between groups (Robot: $7162 [$5942-8375] vs. Lap: $4527 [$2310-6003] vs. Open: $4264 [$3277-5143], p < 0.001)., Conclusions: Outcomes after robotic-assisted inguinal hernia repair were similar to outcomes after laparoscopic or open repair. Longer operative duration during robotic repair may contribute to higher rates of skin and soft tissue infection. Higher cost should be considered, along with surgeon comfort level and patient preference when deciding whether inguinal hernia repair is approached robotically.

Background: Bariatric surgery provides durable weight loss and decreases the incidence of co-morbid conditions for people with obesity. Most patients benefit from resultant weight loss, but some are at risk for postoperative refractory malnutrition, a serious but poorly understood complication., Objective: To evaluate differences in bariatric surgery patients who received a feeding tube postoperatively for malnutrition compared with other indications., Setting: Retrospective cohort study at an academic bariatric surgery center (1985-2015)., Methods: All bariatric surgery patients that received a feeding tube postoperatively over a 30-year period were identified. Data abstraction from the medical record was performed to assess demographic characteristics, operative details, tube indication, and resultant body mass index (BMI) changes., Results: From a total of 3487 patients who underwent bariatric surgery during the study period, 139 (3.9%) required placement of a feeding tube postoperatively. Refractory malnutrition was the indication in 24 patients, all after Roux-en-Y gastric bypass. There were no significant differences between these patients and other bariatric surgery patients in terms of mean age (40.6±9.9 versus 43.1±13.4 years, P = .4) and preoperative BMI (47.5±10.5 versus 51.0±9.6 kg/m 2 , P = .1). The median time from surgery to tube placement for malnutrition patients was 4 years. Compared with other feeding tube indications, malnutrition patients had higher percent excess BMI lost after surgery (126.2±31.9 versus 52.5±44.3%, P<.0001). After tube placement, malnutrition patients had a significant increase in mean BMI compared with other indications (14.5±20.9 versus-13.0±14.0%, P< .001)., Conclusion: Patients with refractory malnutrition benefit from feeding tube placement, which results in a significant increase in BMI., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric surgery leads to dramatic weight loss and improved overall health, which may affect insurance status for certain patients. Traditional Medicaid provides coverage for children, pregnant women, and disabled adults, while expanded Medicaid provides insurance coverage to all adults with incomes up to 138% of the federal poverty level. We hypothesized that successful bariatric surgery would lead to improved health status but an unintended loss of Medicaid coverage., Methods: All patients who underwent bariatric surgery at a single institution in a non-expansion state from 1985 through 2015 were identified using a prospectively collected database. Univariate and multivariate analyses were used to identify differences in patients who lost Medicaid coverage after bariatric surgery., Results: Over the 30-year study period, 3487 patients underwent bariatric surgery, with 373 (10.7%) having Medicaid coverage at the time of surgery. This cohort of patients had a median age of 37 years and a preoperative Body Mass Index (BMI) of 54 kg/m 2 . At one-year follow-up, 155 (41.6%) patients lost Medicaid coverage, of which 76 (49.0%) had no coverage. The preoperative prevalence of diabetes (32.3 vs. 44.0%, p = 0.02), age (36 vs. 38 years, p = 0.01), and BMI (53 vs. 55 kg/m 2 , p = 0.04) were significantly lower in patients who no longer qualified for Medicaid after bariatric surgery. Multivariate regression demonstrated that for every 10 point increase in BMI (OR 0.755, p = 0.01), a patient was 25% less likely to lose their coverage at one year., Conclusions: Successful surgery in a state not expanding Medicaid resulted in over 40% of patients losing Medicaid coverage postoperatively, with half of those patients returning for follow-up with no insurance coverage at all. This barrier to care has major implications in patients undergoing bariatric surgery, which requires life-long follow-up and nutrition screening.

Purpose: The purposes of this study are to identify the cumulative incidence of post-bariatric surgery hypoglycemia (PBSH), describe its symptomatology, and characterize treatment patterns at a large academic institution., Materials and Methods: All patients who underwent bariatric surgery at a single institution from 1985 to 2015 were identified using a clinical database, administrative billing data identified patients who were treated for hypoglycemia, and chart reviews were performed to make a diagnosis of PBSH based on Whipple's triad. PBSH cases were reviewed including patient diabetes history, symptomatology, and treatment measures. Univariate analyses were performed to identify correlations based on symptomatology, laboratory values, and treatments utilized., Results: Ninety (2.6%) of 3487 patients were diagnosed with PBSH with preoperative median age of 43 years, mean BMI of 50.0 kg/m 2 , and median glycated hemoglobin of 6.0%. Median time-to-first hypoglycemic event was 40.6 months. No factors were identified which predict symptom severity or resolution. The 24 (27%) patients who received pharmacotherapy to treat hypoglycemia were younger, had lower nadir blood glucose levels, and more frequent symptoms. Sixty-nine (79%) cases eventually resolved., Conclusions: PBSH onset and severity are highly variable. Successful management of these patients can prove difficult and should include dietary therapy, the selective use of pharmacotherapy and surgery, and the use of a multidisciplinary team including bariatric surgeons and endocrinologists.

Bariatric surgery is an effective and durable treatment for individuals with obesity and its associated comorbidities. However, not all patients meet weight loss and/or cardiometabolic goals following bariatric surgery, suggesting that some people are bariatric surgery resistant. The reason for this resistance is unclear, but potential factors, such as adiposity-derived inflammation, insulin resistance, hyperglycemia, and aerobic fitness prior to surgery, have been related to blunted surgery responsiveness. Exercise, diet, and/or pharmacology are effective at reducing inflammation and improving insulin action as well as physical function. Herein, we present data that supports the novel hypothesis that intervening prior to surgery can enhance disease resolution in people who are resistant to bariatric surgery.

Background: Laparoscopic sleeve gastrectomy (LSG) has gained popularity for the treatment of morbid obesity as gastric banding (BAND) has fallen out of favor. As a result, simultaneous conversion (CONV) of BAND to LSG is commonly performed. We hypothesized that CONV is associated with higher 30-day risk-adjusted serious morbidity., Methods: Preoperative characteristics and 30-day outcomes from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files 2010-2014 were selected for patients who underwent LSG. Patients undergoing CONV were identified. Descriptive comparisons were performed using Chi-square and Wilcoxon rank-sum tests as appropriate. Multivariate logistic regression was performed to assess the association between CONV and a composite measure of 30-day serious morbidity and mortality., Results: Overall, 35,307 patients met criteria for inclusion, of which 943 (2.7%) underwent CONV. The median age of patients undergoing CONV was higher (46 vs 44 years, p < 0.001) and a greater percentage of CONV patients was female (84.8 vs 77.9%, p < 0.001) than LSG patients. CONV patients had lower rates of common comorbidities, including diabetes (14.9 vs 23.1%, p < 0.001), hypertension (41.9 vs 48.6%, p < 0.001), and tobacco use (7.2 vs 9.8%, p < 0.001), as well as lower median BMI (41 vs 44, p < 0.001). Individual unadjusted outcomes of serious 30-day complications were similar between both groups, as was a composite measure of serious morbidity (CONV 4.3% vs LSG 3.6%, p = 0.1). However, after controlling for demographics, comorbidities, and concurrent band removal, CONV was associated with increased odds of serious 30-day morbidity (1.44, 95% CI 1.03-1.97) (c-statistic: 0.60)., Conclusions: Serious morbidity following LSG is uncommon; however, CONV is associated with a modest increase in risk-adjusted adverse 30-day outcomes. Patients being evaluated for CONV should be counseled about the added risks versus LSG alone. Further research is warranted to identify whether the incremental risks of CONV may be modifiable.

Background: Increasingly, patients are faced with greater travel distances to undergo bariatric surgery at high-volume centers., Objectives: This study sought to evaluate the impact of travel distance on access to care and outcomes after bariatric surgery., Setting: Patients who underwent Roux-en-Y gastric bypass at an academic bariatric surgery center from 1985 to 2004 were examined and stratified by patient travel distance., Methods: Univariate analyses were performed for preoperative risk factors, 30-day complications, and long-term (10-yr) weight loss between "local," defined as<1 hour of travel time, and "regional," defined as>1 hour of travel time. Survival analysis was performed with Kaplan-Meier and Cox proportional hazards models., Results: A total of 650 patients underwent Roux-en-Y gastric bypass, of whom 316 (48.6%) traveled<1 hour to undergo surgery and 334 (51.4%) traveled>1 hour. Median body mass index was equivalent between the groups (local, 52.9 kg/m 2 ; regional, 53.2 kg/m 2 ; P = .76). Patients who traveled longer distances had higher rates of preoperative co-morbidities, including chronic obstructive pulmonary disease, congestive heart failure, diabetes, and sleep apnea (all P<.05). Complications within 30 days of surgery and long-term reduction of excess body mass index were equivalent between groups. Travel time was an independent predictor of risk-adjusted reduced long-term survival (hazard ratio, 1.23, P = .0002)., Conclusions: A majority of patients who underwent bariatric surgery at our center traveled>1 hour. Despite longer travel time for care, 30-day complications and long-term weight loss were equivalent with that of local patients. As expected, patients who lived in close proximity were more likely to adhere to yearly follow-up in surgery clinic. Travel time was an independent predictor of risk-adjusted reduced long-term survival., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Although Roux-en-Y gastric bypass (RYGB) induces short-term weight loss and co-morbidity amelioration, long-term data suggest that a subset of patients return to their preoperative body mass index (BMI)., Objectives: To identify the clinical implications of 10-year weight loss failure after RYGB., Setting: An academic teaching hospital., Methods: Adults undergoing RYGB (1985-2004) were included in this study (n = 1087). Absolute weight loss failure was defined as ≤0% reduction in excess BMI 10 years after surgery. Univariate analyses compared co-morbidity rates and resolution by weight loss classification. Multivariable regression modeling analyzed preoperative predictors of 10-year percent reduction in excess BMI and weight loss failure., Results: Complete follow-up was available for 617 (57%) patients with a 10-year median percent reduction in excess BMI of 57.1%; 10.2% of patients had weight loss failure. Prevalence of all co-morbidities decreased, even in patients with weight loss failure (all P<.05). Compared with patients with successful weight loss, patients with weight loss failure had similar rates of resolution of pre-existing co-morbidities, except for reduced resolution of apnea and cardiac co-morbidities (both P<.05). Risk factors for weight loss failure included lower BMI, nongovernmental insurance, longer travel time to hospital, and year of surgery. Nongovernmental insurance (odds ratio 2.03, P = .036) conferred the highest adjusted odds of weight loss failure., Conclusions: The vast majority of patients experience dramatic health improvement 10 years after RYGB, even though some patients fail to maintain their weight loss. Renewed focus should be placed on prevention and treatment of chronic disease, with further investigation of weight loss independent mechanisms of health improvement., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Roux-en-Y gastric bypass (RYGB) effectively treats obesity and gastroesophageal reflux disease (GERD). As more surgeons recommend RYGB to treat GERD in patients with obesity, there are concerns about this approach in patients with previous non-bariatric foregut surgery. This study aims to evaluate the effect of previous non-bariatric foregut surgery on subsequent RYGB., Methods: Retrospective review of 2089 patients undergoing RYGB between January 1985 and June 2015 was conducted to identify all patients with previous non-bariatric foregut surgery. Perioperative and postoperative data was collected by retrospective chart review., Results: A total of 11 patients with prior non-bariatric foregut surgery underwent RYGB with median time between operations of 95.6 months. Of note, 7/11 (63.6%) had previous Nissen fundoplication. Conversion to open operation was required in 3/7 (42.9%) with previous Nissen compared to 1/4 (25%) in those without previous Nissen. The average length of stay (LOS) was 3.9 ± 0.9 days, significantly longer than our institutional average for RYGB of 3.2 ± 3.2 days (p = 0.02). Mean percentage of excess body mass index loss (%EBMIL) was 64.7 ± 23.5 at 4-year median follow-up, comparable to our institution's previously reported data. No mortalities were attributed to RYGB and the overall complication rate was 18.2%, compared to our institutional complication rate for RYGB of 8.5% (p = 0.253)., Conclusion: Despite increased technical difficulty and increase perioperative morbidity, patients undergoing RYGB with previous non-bariatric foregut surgery had long-term symptom resolution and robust weight loss. This indicates that in the right hands, RYGB after non-bariatric foregut surgery may be performed safely and effectively.

Background: Following weight-loss surgery, patients who failed to achieve or sustain weight loss have nevertheless reported high satisfaction with their long-term bariatric experience. Understanding this phenomenon better will likely improve patients' experiences., Objective: The purpose of this study was to explore patients' long-term experiences following bariatric surgery., Setting: A 604-bed academic health system in the USA., Methods: Participants rated satisfaction and shared spontaneous comments regarding their gastric bypass experience. A phenomenological mode of inquiry explored participants' experiences. Transcribed phrases were categorized and themes identified., Results: In a 2004 surgical cohort, with 55% (155/281) participation, 99% of participants rated bariatric experience satisfaction (mean score 8.4) and 74% (115/155) shared comments regarding experiences. Responses were categorized as positive (63% 72/115), neutral (25% 29/115), or negative (12% 14/115). Satisfaction, Appreciation, and Gratefulness emerged as themes from positive comments, with 8% (6/72) explicitly acknowledging amount of weight loss achieved. Twenty-five percent (18/72) spontaneously mentioned undergoing surgery again or recommending the procedure to others. Neutral comments contained the themes of Reflection, Acknowledgment, and Wistfulness. Themes of Dissatisfaction, Disappointment, and Regret emerged from negative comments. Forty-three percent (6/14) of negative comments remarked on regaining weight or not reaching goal weight. Twenty-one percent (3/14) of negative comments explicitly stated regret at having undergone surgery., Conclusions: Participants readily shared comments regarding their gastric bypass experience. Exploring themes provided insight into patients' satisfaction with bariatric surgery even when weight-loss goals were not met and conversely substantial dissatisfaction even when weight loss occurred. This study underscores the importance of understanding the patients' long-term experience following bariatric surgery.

Background: Many insurance companies have considerable prebariatric surgery requirements despite a lack of evidence for improved clinical outcomes. The hypothesis of this study is that insurance-specific requirements will be associated with a decreased progression to surgery and increased delay in time to surgery., Methods: Retrospective data collection was performed for patients undergoing bariatric surgery evaluation from 2010-2015. Patients who underwent surgery (SGY; n = 827; mean body mass index [BMI] 49.1) were compared with those who did not (no-SGY; n = 648; mean BMI: 49.4). Univariate and multivariate analysis were performed to identify specific co-morbidity and insurance specific predictors of surgical dropout and time to surgery., Results: A total of 1475 patients using 12 major insurance payors were included. Univariate analysis found insurance requirements associated with surgical drop out included longer median diet duration (no-SGY = 6 mo; SGY = 3 mo; P<.001); primary care physician letter of necessity (P<.0001); laboratory testing (P = .019); and evaluation by cardiology (P<.001), pulmonology (P<.0001), or psychiatry (P = .0003). Using logistic regression to control for co-morbidities, longer diet requirement (odds ratio [OR] .88, P<.0001), primary care physician letter (OR .33, P<.0001), cardiology evaluation (OR .22, P = .038), and advanced laboratory testing (OR 5.75, P = .019) independently predicted surgery dropout. Additionally, surgical patients had an average interval between initial visit and surgery of 5.8±4.6 months with significant weight gain (2.1 kg, P<.0001)., Conclusion: Many prebariatric surgery insurance requirements were associated with lack of patient progression to surgery in this study. In addition, delays in surgery were associated with preoperative weight gain. Although prospective and multicenter studies are needed, these findings have major policy implications suggesting insurance requirements may need to be reconsidered to improve medical care., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objective(s): Monitoring and prevention of long-term nutrient deficiency after laparoscopic Roux-en-Y gastric bypass (LRYGB) remains ill defined due to limited surgical follow-up after bariatric surgery. This study compared nutrient supplementation as well as surgeon and primary care physician (PCP) follow-up between patients with short-term versus long-term follow-up., Methods: All patients undergoing LRYGB at a single institution in 2004 (long-term group, n = 281) and 2012-2013 (short-term group, n = 149) were evaluated. Prospectively collected database, electronic medical record (EMR) review and telephone survey were used to obtained follow-up for both cohorts. Multivariate logistic regression was used to assess factors independently predicting multivitamin use., Results: Complete follow-up was achieved in 172 (61 %) long-term and 107 (72 %) short-term patients. We demonstrate a significant difference (p < 0.0001) in time since last surgeon follow-up (13.3 ± 7.8 vs 86.9 ± 39.9 months) for the long-term group with no difference in PCP follow-up, (3.1 ± 4.3 vs 3.7 ± 3.4). Nutrient supplementation was higher in the short-term group, including multivitamin (70.3 vs 58.9 %, p < 0.05), iron (84.2 vs 67.1 %, p = 0.02), and calcium (49.5 vs 32.9 %, p = 0.01). After adjusting for interval since surgery, %EBMI and current comorbidities logistic regression (c = 0.797) demonstrated shorter time since last surgeon visit was independently predictive of multivitamin use (p = 0.001)., Conclusions: While it appears patients prefer to follow-up with their PCP, this study reveals a large disparity in malnutrition screening and nutrient supplementation following LRYGB. Therefore, implementation of multidisciplinary, best-practice guidelines to recognize and prevent malnutrition is paramount in the management of this growing population of high-risk patients.

Objective: Assess the role of inflammation on operating time in younger vs. older bariatric surgery patients., Methods: Fifty-five younger (F: 46, Age: 34.9 ± 4.0 years, body mass index [BMI]: 48.2 ± 1.0 kg m -2 ) and 48 older (F: 34, Age: 57.0 ± 5.1 years, BMI: 46.8 ± 1.0 kg m -2 ) adults were studied prior to surgery. Blood pressure, glycaemic control (fasting glucose/insulin, HbA 1c ), lipids (high-density lipoprotein and triglycerides) and inflammation (monocyte chemoattractant protein-1 [MCP-1]) were assessed. Metabolic risk severity z -scores were calculated from clinical outcomes. Omental adipose biopsies were collected at surgery for MCP-1 protein analysis. Operating time was used to characterize surgical difficulty., Results: Older vs. younger adults had higher HbA 1c ( P  = 0.03). There was no difference in BMI, lipids, metabolic risk severity or insulin between groups, but operating time was longer in older vs. younger individuals ( P  = 0.04). Circulating MCP-1 was also elevated in older vs. younger adults ( P  = 0.04) independent of HbA 1c , although this was not explained by omental fat. Nevertheless, serum MCP-1 was associated with increased metabolic risk severity ( R  = 0.27, P  = 0.01). In addition, operating time was linked to HbA 1c ( R  = 0.30, P  = 0.01) and omental MCP-1 protein ( R  = 0.31, P  < 0.01)., Conclusions: MCP-1 is associated with longer operating time and increased metabolic risk severity in older bariatric patients independent of glycaemic control. Pre-operative treatment of inflammation may be required to enhance surgery effectiveness.

Background: Accountable care organizations (ACOs) attempt to provide the most efficient and effective care to patients within a region. We hypothesized that patients who undergo surgery closer to home have improved survival due to proximity of preoperative and post-discharge care., Study Design: All (17,582) institutional American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) patients with a documented ZIP code and predicted risk, who underwent surgery at our institution (2005 to 2014), were evaluated. Google Maps calculated travel times, and patients were stratified by 1 hour of travel (local vs regional). Multivariable logistic regression and Cox proportional hazard models were used to evaluate the NSQIP risk-adjusted effects of travel time on operative morbidity, mortality, and long-term survival., Results: Median travel time was 65 minutes, with regional patients demonstrating significantly higher rates of ascites, hypertension, diabetes, disseminated cancer, >10% weight loss, higher American Society of Anesthesiologists (ASA) score, higher predicted risk of morbidity and mortality, and lower functional status (all p < 0.01). After adjusting for ACS NSQIP-predicted risk, travel time was not significantly associated with 30-day mortality (odds ratio [OR] 1.06; p = 0.42) or any major morbidities (all p > 0.05). However, survival analysis demonstrated that travel time is an independent predictor of long-term mortality (OR 1.24; p < 0.001)., Conclusions: Patients traveling farther for care at a quaternary center had higher rates of comorbidities and predicted risk of complications. Additionally, travel time predicts risk-adjusted long-term mortality, suggesting a major focus of ACOs will need to be integration of care at the periphery of their region., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Total abdominal colectomy (TAC) is the standard surgical treatment of Clostridium difficile infection (CDI). An alternative therapy, loop ileostomy and colonic lavage (IL), was described in 2011, but the results have never been validated., Methods: Patients treated surgically for CDI between April 2011 and June 2015 were included. Bivariable analysis was used to compare 30-day mortality, 1-year mortality, CDI recurrence, colon preservation and ileostomy reversal., Results: Ten IL patients and thirteen TAC patients were identified. 30-day mortality (30% vs 23%, p = 1.0) and 1-year mortality (40% vs 46%, p = 1.0) were similar. Four IL and three TAC patients (57% vs 30%, p = 0.35) experienced recurrent CDI. All six surviving IL patients had successful colon preservation; five underwent ileostomy reversal compared to three in the TAC group (83% vs 43%, p = 0.27)., Conclusions: Although IL allowed colon preservation and return of intestinal continuity in most patients, IL did not decrease mortality or recurrent CDI when compared to TAC., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective(s): Roux-en-Y Gastric Bypass (RYGB) is well known to ameliorate type 2 diabetes mellitus (T2DM), and recent work suggests that the preoperative DiaREM model predicts successful remission up to 1 year post-RYGB. However, no data exist for long-term validity. Therefore, we sought to determine the utility of this score on long-term RYGB effectiveness for T2DM resolution at 2 and 10 years, respectively., Methods: T2DM patients (Age: 48, BMI: 49, HbA 1C : 8.1) undergoing RYGB at the University of Virginia between 2004-2006 (n = 42) and 2012-2014 (n = 59) were evaluated prospectively to assess preoperative DiaREM score, defined from insulin use, age, HbA 1C , and type of antidiabetic medication. T2DM partial remission status was based on the American Diabetes Association guidelines (HbA 1C  < 6.5 % and fasting glycemia <125 mg/dL, and no anti-diabetic medications). Chi-square test was used to compare patient's T2DM status to their DiaREM probability of remission., Results: Among RYGB patients with 2-year postoperative data, 2 were lost (n = 1 no follow-up and n = 1 died) resulting in 57 patients for analysis. For the 10-year postoperative data, 11 were lost (n = 6 no follow-up and n = 5 died), thereby resulting in only 31 patients for analysis. Patients were distributed by DiaREM score to correlate with the predicted probability of remission as follows: 0-2 (Predicted 94 %, 2-year 100 % p = 0.61, 10-year 100 % p = 0.72), 3-7 (Predicted 76 %, 2-year 94 % p = 0.08, 10-year 83 % p = 0.57), 8-12 (Predicted 36 %, 2-year 47 % p = 0.38, 10-year 43 % p = 0.72), 13-17 (Predicted 22 %, 2-year 20 % p = 0.92, 10-year 33 % p = 0.64), and 18-22 (Predicted 9 %, 2-year 15 % p = 0.40, 10-year 14 % p = 0.64)., Conclusions: Preoperative DiaREM scores are a good tool for predicting both short- and long-term T2DM remissions following RYGB. This study highlights the need to identify strategies that improve T2DM remission in those at highest risk.

Objective(s): The aim of the study was to evaluate the clinical effectiveness and long-term durability of Roux-en-Y Gastric Bypass (RYGB) at an accredited center., Background: Short-term data have established the effectiveness of RYGB for weight loss and comorbidity amelioration. The long-term durability of this operation remains infrequently described in the American population., Methods: All patients (N = 1087) undergoing RYGB at a single institution over a 20-year study period (1985-2004) were evaluated. Univariate differences in preoperative comorbidities, operative characteristics (laparoscopic vs. open), postoperative complications, annual weight loss, and current comorbidities were analyzed to establish trends and outcomes 10 years after surgery., Results: Among 1087 RYGB patients, 651 (60%) had complete 10-year follow-up, including 335 open RYGB and 316 laparoscopic RYGB. Patients undergoing open RYGB had a higher preoperative body mass index. Otherwise, preoperative characteristics were similar. Postoperative incisional hernia rates were expectedly higher in open (vs laparoscopic) RYGB (16.9% vs 4.7%; P = 0.02). Annual % reduction in excess body mass index significantly improved over time, peaking at 74% by 24 months, with a slow trend down to 52% at 10 years (all P < 0.001). Importantly, a highly significant decrease in obesity-related comorbid disease persisted at 10 years of follow-up after RYGB., Conclusions: Roux-en-Y Gastric Bypass remains an excellent and durable operation for long-term weight loss and treatment of obesity-related comorbid disease. Laparoscopic RYGB results in highly favorable outcomes with reduced incisional hernia rates. These 10-year data help to more clearly define long-term outcomes and demonstrate outstanding reduction in comorbid disease following RYGB.

Background: The long-term durability of Roux-en-Y gastric bypass (RYGB) remains ill-defined in the American population secondary to poor follow-up after bariatric surgery., Objectives: This study evaluated the population lost to follow-up to better define the long-term durability of RYGB for weight loss and co-morbidity amelioration., Methods: All patients (n = 1087) undergoing RYGB at a single institution between 1985 and 2004 were evaluated. Univariate differences in preoperative co-morbidities, postoperative complications, annual weight loss, and 10-year co-morbidities were analyzed to compare outcomes between patients with routine follow-up and those without. Using electronic medical record review for all encounters at our academic medical center and telephone survey, we obtained data for patients lost to follow-up., Results: Among 1087 RYGB patients, 151 (14%) had consistent 10-year follow-up in our prospectively collected database, with yearly clinic visits beyond 2 years postoperatively. Electronic medical record review and telephone survey data were collected on an additional 500 (46%) patients, resulting in 60% of patients having 10-year follow-up after RYGB. There was no statistical difference in any preoperative or postoperative variables between the 2 groups. We found no difference in co-morbidity prevalence preoperatively or at 10 years between groups. Examination of percent excess body mass index lost at yearly intervals revealed no difference between the groups at each interval up to 10 years (P = .36)., Conclusion: We found no difference in 10-year outcomes, including weight loss and co-morbidity reduction, between patients with routine clinic visits and those lost to follow-up. These 10-year data address the gap in knowledge resulting from poor long-term follow-up after bariatric surgery., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The study objectives were to determine baseline endometrial histology in morbidly obese women undergoing bariatric surgery and to assess the surgical intervention's impact on serum metabolic parameters, quality of life (QOL), and weight., Methods: Women undergoing bariatric surgery were enrolled. Demographic and clinicopathologic data, serum, and endometrium (if no prior hysterectomy) were collected preoperatively and serum collected postoperatively. Serum global biochemical data were assessed pre/postoperatively. Welch's two sample t-tests and paired t-tests were used to identify significant differences., Results: Mean age of the 71 women enrolled was 44.2 years, mean body mass index (BMI) was 50.9 kg/m(2), and mean weight loss was 45.7 kg. Endometrial biopsy results: proliferative (13/30; 43%), insufficient (8/30; 27%), secretory (6/30; 20%) and hyperplasia (3/30; 10%-1 complex atypical, 2 simple). QOL data showed significant improvement in physical component scores (PCS means 33.9 vs. 47.2 before/after surgery; p<0.001). Twenty women underwent metabolic analysis which demonstrated significantly improved glucose homeostasis, improved insulin responsiveness, and free fatty acid levels. Significant perturbations in tryptophan, phenylalanine and heme metabolism suggested decreased inflammation and alterations in the intestinal microbiome. Most steroid hormones were not significantly impacted with the exception of decreased DHEAS and 4-androsten metabolites., Conclusions: Bariatric surgery is accompanied by an improved physical quality of life as well as beneficial changes in glucose homeostasis, insulin responsiveness, and inflammation to a greater extent than the hormonal milieu. The potential cancer protective effects of bariatric surgery may be due to other mechanisms other than simply hormonal changes., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: There is limited outcome data for super-super-obese (SSO) patients, those with Body Mass Index (BMI) ≥ 60 kg/m(2), who seek surgical treatment with Laparoscopic Roux-en-Y Gastric Bypass (LRYGB). A large single center LRYGB experience was reviewed to compare the safety and efficacy of LRYGB in SSO patients to the standard obese population undergoing this procedure., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database and an Institutional Review Board approved prospective database was used to identify all patients undergoing LRYGB by multiple surgeons at a single institution between 1/1/1994 and 11/15/2013. Preoperative co-morbidities, postoperative complications, 30-day outcomes, and weight loss at yearly intervals were analyzed to determine difference between SSO patients and NonSSO patients (BMI < 60 kg/m(2))., Results: Of the 2009 patients undergoing LRYGB over the past 20 years; 328 had BMI ≥ 60 kg/m(2). Preoperative co-morbidities, conversion to open, and length of stay were significantly increased among SSO patients; however there was no significant difference in postoperative outcomes or complications. Percent reduction of excess BMI beyond 12 months was significantly improved among NonSSO patients with less than 30% follow-up beyond 2 years., Conclusions: LRYGB appears well tolerated for super-super-obese patients with BMI ≥ 60 kg/m(2) in experienced centers. These patients still have significant reduction in excess BMI despite being less than NonSSO patients undergoing RYGB. The ACS NSQIP database provides excellent tracking of institutional progress with bariatric surgical outcomes to facilitate the improvement of best practice techniques., (Copyright © 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.)

Background: The two most commonly performed procedures for bariatric surgery include Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB). While many studies have commented on short-term, postoperative outcomes of these procedures, few have reported long-term data. The purpose of this study was to compare long-term, postoperative outcomes between RYGB and AGB., Methods: This was a retrospective, cohort comparing all patients undergoing RYGB or AGB at our institution, from 01/1998 to 08/2012. Patients were followed at 1-, 3-, and 5-year intervals. Adjusted, Cox proportional hazard regression and mixed effects repeated measures modeling were performed to generate cure ratios (CR) and 95 % confidence intervals (CI)., Results: Two thousand four hundred twenty bariatric surgery patients (380 AGB, 2,040 RYGB) were identified by CPT code. Median (range) follow-up for patients was 3 (1-5) years. Preoperatively, RYGB patients were significantly younger, more obese, had higher hemoglobin A1c, and less often suffered from hypertension (HTN), dyslipidemia, and asthma as compared to AGB patients. Postoperatively, RYGB patients experienced significantly longer operating room times, higher incidences of intensive care unit admissions, longer hospital lengths of stay, and increased incidence of small bowel obstruction compared to AGB patients. After adjusting for statistically significant and clinically relevant factors [e.g., age, gender, body mass index, degenerative joint disease (DJD), diabetes, HTN, dyslipidemia, heart disease, apnea, and asthma], RYGB was independently associated with a significantly greater percentage of total body weight loss (p = 0.0065) and greater CR (95 % CI) regarding gastroesophageal reflux disease [2.1(1.4-3.0)], DJD [3.4(2.0-5.6)], diabetes [3.4(2.2-5.4)], apnea [3.1(1.9-5.3)], HTN [5.5(3.4-8.8)], and dyslipidemia [6.3(3.5-11)] compared to AGB., Conclusion: Our results support previous studies that have observed a greater weight loss associated with RYGB as compared to AGB and provide further evidence toward the long-term sustainability of this weight loss. Additionally, RYGB appears to result in a greater reduction of medical comorbidity.

Background: The purpose of this study is to evaluate the long-term survival following gastric bypass using propensity-matched controls., Methods: We identified all patients who either received a gastric bypass (GBP) or met criteria to receive a GBP between January 1, 2002 and December 31, 2003. Propensity matching was performed. Long-term, all-cause mortality data were collected and evaluated using Kaplan-Meier curves., Results: Four hundred thirty GBP cases and 5,323 controls were identified from the enrollment period. Ultimately, 802 cases and controls (1:1 matching, 93.2% match rate) were identified using propensity matching. Median follow-up was similar between groups. Overall mortality was lower for the GBP group (odds ratio .48, 95% confidence interval .29 to .78). GBP demonstrated significantly increased survival when compared with controls (P = .002). Similar patterns were noted among diabetics., Conclusion: We have demonstrated that gastric bypass provides a clear long-term survival advantage compared with nonsurgical propensity-matched controls., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Gastric prolapse (GP) after laparoscopic adjustable gastric banding (LAGB) remains a complication that has the potential to result in significant morbidities. The purpose of this study was to evaluate the incidence of GP after LAGB and to determine its impact on patient outcomes among the morbidly obese. From 2005 to 2012, 379 consecutive morbidly obese patients underwent LAGB procedures at a single institution. Patients were placed into two groups based on the occurrence of gastric prolapse (GP vs no GP). Patient demographics and risk factors, operative features, and postoperative outcomes were analyzed by univariate analyses to assess the impact of GP. Average patient age was 47 ± 29 years and patients were commonly female (80%) with a median body mass index (BMI) of 44 kg/m(2). Incidence of GP was 4.2 per cent (n = 16). LAGB median BMIs at 1 month and 1 year were 41 and 36 kg/m2. There was no difference in 1-year weight loss (BMI GP: 36 kg/m(2) vs no GP: 36 kg/m(2), P = 0.617). Laparoscopic gastric banding results in significant weight reduction and a low incidence of gastric prolapse. Gastric prolapse has no difference in 1-year postoperative median BMI when compared with patients who did not prolapse.

Background: As obesity and type II diabetes continue to rise, bariatric surgery offers a solution, but few long-term studies are available. The purpose of this study was to evaluate the long-term outcomes of diabetic patients after gastric bypass., Materials and Methods: This was a retrospective cohort study of all diabetic patients undergoing gastric bypass at our institution, from 1998 to 2012. Patients were compared by postoperative diabetic response to treatment (i.e., response = off oral medication/insulin versus refractory = on oral medication/insulin) and followed at 1-, 3-, 5-, and 10-y intervals. Continuous data were analyzed using Student t-test or Wilcoxon rank-sum test. Multivariable, Cox proportional hazard regression model was performed to compute diabetic cure ratios and 95% confidence intervals., Results: A total of 2454 bariatric surgeries were performed at our institution during the time period. A total of 707 diabetic patients were selected by Current Procedural Terminology codes for gastric bypass. Mean follow-up was 2.1 y. Incidence of diabetic response was 56% (1 y), 58% (3 y), 60% (5 y), and 44% (10 y). Postoperatively, responsive patients experienced greater percentage of total body weight loss (1 y [P < 0.0001], 3 y [P = 0.0087], and 5 y [P = 0.013]), and less hemoglobin A1c levels (1 y [P = 0.035] and 3 y [P = 0.040]) at follow-up than refractory patients. Multivariable analysis revealed a significant, independent inverse trend in incidence of diabetic cure as both age and body mass index decreased (Ptrend = 0.0019 and <0.0001, respectively). In addition, degenerative joint disease was independently associated with responsive diabetes (cure ratio = 1.6 [95% confidence interval = 1.1-2.2])., Conclusions: At follow-up, both groups in our study experienced substantial weight loss; however, a greater loss was observed among the response group. Further research is needed to evaluate methods for optimizing patient care preoperatively and improving patient follow-up., (Copyright © 2014 Elsevier Inc. All rights reserved.)