Search

The COVID-19 pandemic required immediate systematic change in healthcare delivery. Many institutions relied on telemedicine as an alternative to in-person visits. There is limited data in the bariatric surgery literature to determine how telemedicine impacts patient volume. This study evaluates the effects of using telemedicine for introductory bariatric surgery seminars on patient volume at a single institution.A retrospective review was performed before and after implementing virtual introductory seminars for bariatric surgery patients at a comprehensive metabolic and surgery center. The effect on attendance rates for introductory seminars and completion rates of bariatric surgery was evaluated.The introductory seminar attendance rate for the in-person/pre-telemedicine period, April 2019 to February 2020, was compared to that of the virtual/post-telemedicine period, June 2020 to April 2021. A total of 836 patients registered for an introductory seminar during the pre-telemedicine period with a 65.79% attendance rate. In the post-telemedicine period, 806 patients registered with a 67.87% attendance rate, which was not statistically different (p = 0.37, 95% CI - 0.03-0.07). Completion rates of bariatric surgery were analyzed using June 2019 to October 2019 as the pre-telemedicine period and June 2020 to October 2020 as the post-telemedicine period. Similarly, there was no difference between the pre-telemedicine surgery rate of 23.43% and post-telemedicine surgery rate of 19.68% (p = 0.31, 95% CI - 0.11-0.04).Despite abruptly transitioning to virtual introductory bariatric seminars, there was no change in attendance rates nor was there a difference in the number of patients progressing through the program and undergoing bariatric surgery at our institution. This demonstrates similar efficacy of telemedicine and in-person introductory seminars for bariatric surgery patients, which supports telemedicine as a promising tool for this patient population in the post-pandemic era.

Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques. Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon–patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication. These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.

There is a paucity of data to inform appropriate opioid prescribing for patients who are discharged after a hospital admission for a surgical procedure.We studied 333 inpatients discharged to home after bariatric, benign foregut, liver, pancreas, ventral hernia, and colon surgery. Chronic opioid users or patients who had complications were excluded. Home opioid usage was quantified in 90% of the remaining patients by questionnaires and phone surveys.Eighty-five percent of patients were prescribed an opioid and 38% of prescribed opioid pills were taken. Fifteen opioid pills satisfied the opioid needs of 88% of patients discharged on postoperative day (POD) 1. For patients discharged after POD 1, in multivariate analysis, the number of opioid pills used at home was associated with the number taken the day before discharge (p0.0001) and patient age (p = 0.006), but not the type of surgery. Forty-one percent of patients took no opioids the day before discharge, 33% took 1 to 3, and 26% took more than 4 pills. Eighty-five percent of patients' home opioid requirements would be satisfied using the following guideline: if no opioid pills are taken the day before discharge, no prescription is needed; if 1 to 3 opioid pills are taken the day before discharge, then a prescription for 15 opioid pills is given at discharge; and if 4 or more pills are taken the day before discharge, then a prescription for 30 opioid pills is given at discharge. If these guidelines were used, the number of opioid pills prescribed would decrease by 40%.For patients admitted after surgical procedures, post-discharge opioid use is best predicted by usage the day before discharge. Use of this guideline could decrease opioid prescriptions substantially and effectively treat patients' pain.

An understanding of endoscope function and endoscopy tower setup is required for safe and successful endoscopy. In this chapter we review the basics of endoscope design and function, endoscope tower setup and troubleshooting, as well as patient positioning and endoscopy suite organization. Setup specifics are included for esophagogastroduodenoscopy (EGD), colonoscopy, and endoscopic retrograde cholangiopancreatography (ERCP).

Bariatric surgery is the most effective approach to treating morbid obesity, resulting in decreased morbidity, mortality, and improved quality of life. Research on outcomes has generally been restricted to young and middle-aged adults, despite a growing epidemic of obesity in older adults. The use of bariatric surgery has been limited in older individuals, in part due to concerns that pre-existing cognitive dysfunction increases the risk of poor post-surgical outcomes, including cognitive decline. The literature on the relationship between obesity and cognition in older adults is emerging, but fraught by several methodological limitations. While there is insufficient research to determine the nature of cognitive outcomes following bariatric surgery in older adults, the aim of this paper is to review the existing evidence and make the case for further study.

Bariatric surgery is the most effective long-term treatment for morbid obesity; however, it is under-utilized. This study examines the association between morbid obesity rates, bariatric surgeon presence, and utilization of bariatric surgery in the United States. Healthcare Cost and Utilization Project’s 2013 National Inpatient Sample was used to determine the incidence of inpatient bariatric procedures using ICD-9 codes. The Center for Disease Control’s 2013 Behavioral Risk Factor Surveillance System survey was analyzed to determine estimates of bariatric surgery qualified adults, aged 18–70, with BMI ≥ 40 or ≥ 35 with diabetes. The number of bariatric surgeons was determined from four online sources: searches of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program accredited bariatric programs, American Society for Metabolic and Bariatric Surgery membership, and two adjustable gastric band manufacturer “find a surgeon” search tools. Correlations between rates of morbid obesity, bariatric surgeon presence, and incidence of inpatient bariatric surgery were determined. The defined bariatric surgery eligible population comprised between 3.6% (New England) to 6.8% (East South Central) of the total division population (p

The stomach is one of the most commonly used conduits for esophageal replacement. Restoration of gastrointestinal continuity may be undertaken for a variety of underlying etiologies, including long-gap esophageal atresia in children or benign or malignant disease in adults. Regardless of underling etiology, the replacement esophagus must be able to adequately mimic the native esophagus over the lifetime of the patient. While the literature on long-term follow-up after esophageal replacement is somewhat limited, the published experience does highlight outcomes that result from the act of transposing conduit into the altered physiological environment of the chest. In this chapter we will review these outcomes, with particular focus on the results after gastric pull-up.

Assessment for thoracic surgery in elderly patients should proceed on the basis of physiologic rather than chronologic age. Thoracic surgery has been shown to be safe in selected elderly patients, and age should not be a contraindication to a therapy that offers the best chance of cure for early stage cancer patients. A targeted preoperative assessment can help individualize the morbidity and mortality risk of surgery for each patient and provide the surgeon and patient with the information needed for operative decision making. Operative interventions in the elderly require coordinated attention to the specific requirements of the aged. Specialized multidisciplinary care provided by primary care physicians, geriatric specialists, cardiologists, oncologists, surgeons, anesthesia personnel, nurses, physical therapists, and nutritionists will optimize care for the elderly thoracic surgery patient. Careful selection of patients for surgery has contributed to the improvement in operative mortality over time, and refinements in preoperative testing should continue this trend in the future.

OBJECTIVE To assess factors associated with nursing home admission, severe functional impairment, or death 1 year after surgery for stage I-IIIa non-small cell lung cancer. BACKGROUND Patients perceive long-term disability to be one of the most undesirable complications of lung cancer treatment. METHODS A multiregional cohort was surveyed 12 months after surgery. Logistic regression was used to determine adjusted predictors of long-term disability. Recursive partitioning was used to create a risk index based on preoperative factors. RESULTS Of the 1007 patients, 146 (15%) were admitted to a nursing home or died by 1 year after surgery, with higher risk among patients 80 years or older, those with severe comorbidities, and those with stage II-IIIa disease (all Ps ≤ 0.01). Among 759 survivors who completed the follow-up survey, 51 (7%) were admitted to a nursing home or reported inability to get out of bed, dress or wash themselves, or perform usual activities. Patients with moderate comorbidities (P < 0.001) or lack of high school diploma (P = 0.03) were more likely to experience nursing home admission or severe functional impairment. The risk of nursing home admission, severe functional impairment, or death was low (16%) for patients younger than 75 years and for those 75 years or older with stage I disease, intermediate (33%) for patients 75 years or older with stage II-IIIa disease and no or mild comorbidities, and high (60%) for those 75 years or older with stage II-IIIa disease and moderate or severe comorbidities. CONCLUSIONS Patients' risk of long-term disability should be incorporated in preoperative counseling.

Lung cancer is a disease of the elderly. Early stage disease is best cured by surgery, and with the aging of the US population, the elderly are more frequently being evaluated for resection of pulmonary malignancies. Elderly cancer patients should undergo a complete staging workup unless their degree of functional status impairment precludes treatment. A thorough preoperative workup can delineate patients who are at high risk for perioperative morbidity and mortality. The decision to proceed with resection should be based on the stage of disease, pulmonary function, functional status, and the patient’s goals, rather than the age alone. Lung resections in the aged must balance the need for complete oncologic resection with the ability of the elderly to recover from insult. The use of thoracoscopic techniques should be used whenever possible to avoid the risk associated with thoracotomy. The paradigm for surgical management of elderly patients will continue to coevolve with advances in technology.