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Trends in nutritional science are rapidly shifting as information regarding the value of eating unprocessed foods and its salutary effect on the human microbiome emerge. Unravelling the evolution and ecology by which humans have harboured a microbiome that participates in every facet of health and disease is daunting. Most strikingly, the host habitat has sought out naturally occurring foodstuff that can fulfil its own metabolic needs and also the needs of its microbiota, each of which remain inexorably connected to one another. With the introduction of modern medicine and complexities of critical care, came the assumption that the best way to feed a critically ill patient is by delivering fibre-free chemically defined sterile liquid foods (that is, total enteral nutrition). In this Perspective, we uncover the potential flaws in this assumption and discuss how emerging technology in microbiome sciences might inform the best method of feeding malnourished and critically ill patients. Humans and their microbiota are intrinsically linked. Owing to dynamic interactions within the gut, nutritional science needs to incorporate the microbiome. This Perspective re-examines the history, rationale and future prospects of chemically defined diets (enteral or parenteral) in relation to the burgeoning understanding of the human microbiota.

The Affordable Care Act (ACA) expanded Medicaid (ME) and instituted Essential Health Benefits (EHB) that included bariatric surgery coverage on a state-by-state opt-in basis, increasing insurance coverage of bariatric surgery. Using a difference-in-differences framework, changes in bariatric surgery rates, defined as utilization in the population of people with obesity, before and after the ACA were evaluated in four states. Bariatric surgery procedure data were taken from the Healthcare Cost and Utilization Project’s State In-patient Database 2012–2015. Adjusted multivariable regressions were run in the Medicaid and commercially insured populations. We identified 36,456 bariatric surgeries across the 286 Health Service Areas and time periods, with 31,732 covered by commercial insurers and 4724 covered by Medicaid. An unadjusted increase in utilization rates was seen in the Medicaid and Commercial populations in both ME- and EHB-covered states as well as non-expansion and EHB opt-out states over time. In the Medicaid population, after adjusting for confounders, there was a significant increase of 24.77 cases per 100,000 people with obesity (95% confidence interval: 12.41, 37.13) in the expansion states relative to the control and pre-period. The commercial population experienced a nonsignificant change in the rates of bariatric surgery, decreasing by 2.89 cases per 100,000 people with obesity (95% confidence interval: − 21.59, 15.81). There was a significant increase in bariatric surgery rates among Medicaid beneficiaries associated with Medicaid expansion, but there was no change among the commercially insured.

BACKGROUND: A processed diet, high in fat and low in fiber, is associated with differences in the gut microbiota and adverse health outcomes in humans; however, little is known about the diet–microbiota relation and its impact on pregnancy. Spontaneous preterm birth (SPTB), a pregnancy outcome with serious short- and long-term consequences, occurs more frequently in black and in obese women in the United States. OBJECTIVES: In a prospective, case-control sample matched for race and obesity (cases = 16, controls = 32), we compared the fecal gut microbiota, fecal and plasma metabolites, and diet in the late second trimester. We hypothesized that a Western diet would be associated with reduced microbiota richness and a metabolic signature predicting incidence of SPTB. METHODS: The fecal microbiota was characterized by 16S-tagged sequencing and untargeted metabolomics was used to analyze both plasma and fecal metabolites. Wilcoxon's rank-sum test was used for the comparison of microbiota genera, α-diversity, fecal and plasma metabolites, and dietary variables between term and SPTB. β-Diversity was analyzed using permutational multivariate ANOVA, and metabolite associations were assessed by module analysis. RESULTS: A decrease in α-diversity was strongly associated with the development of SPTB, especially in the taxonomic class of Betaproteobacteria. Of 824 fecal metabolites, 22 metabolites (mostly lipids) differed between cases and controls (P

Obese patients may have unrecognized primary aldosteronism due to high rates of concomitant hypertension. We hypothesized that obesity impacts the diagnosis and management of patients with primary aldosteronism.We conducted a retrospective analysis of all primary aldosteronism patients (n = 418) who underwent adrenal vein sampling (1997-2017). Patients were classified by body mass index as obese (body mass index ≥35) or nonobese (body mass index35) and diagnostic evaluation was compared between groups. Within the operative cohort (n = 285), primary outcomes were changes in both blood pressure and antihypertensive medications after adrenalectomy. Secondary outcome was clinical resolution by Primary Aldosteronism Surgery Outcomes criteria.Thirty-five percent of patients were obese. Obese patients were more likely to be male (67.8% vs 56.1%, P = .025), somewhat younger (51.5 vs 54.4 years old, P.012), and require more preoperative antihypertensive medications (6.7 vs 5.7, P = .04) than nonobese patients. Obese patients had lesser rates of radiologic evidence of adrenal tumors (68.4 vs 77.9%, P = .038) despite similar rates of lateralization on adrenal vein sampling. In the operative subset, obese patients had somewhat smaller tumors on final pathology (1.1 vs 1.5 cm, P = .014) but similar rates of complete and partial clinical resolution (P = 1.000).Obese primary aldosteronism patients have lesser rates of localization by imaging, likely due to smaller tumor size, however, experience similar benefit from adrenalectomy.

BACKGROUND Primary aldosteronism (PA) is the most common cause of secondary hypertension; early diagnosis and intervention correlate with outcomes. We hypothesized that race may influence clinical presentation and outcomes. METHODS We conducted a retrospective analysis of patients with PA (1997-2017) who underwent adrenal vein sampling (AVS). Patients were classified by self-reported race as black or non-black. Improvement was defined as postoperative decrease in mean arterial pressure (MAP), antihypertensive medications (AHM), or both. RESULTS Among patients undergoing AVS (n = 443), 287 underwent adrenalectomy. Black patients (28.2%) had higher body mass index (33.9 vs 31.8 kg/m2 ; P = .01), longer median duration of hypertension (12 vs 10 years; P = .003), higher modified Elixhauser comorbidity index (2 vs 1; P = .004), and lower median income ($47 134 vs $78 280; P

Background and aims Although germ-free mice are an indispensable tool in studying the gut microbiome and its effects on host physiology, they are phenotypically different than their conventional counterparts. While antibiotic-mediated microbiota depletion in conventional mice leads to physiologic alterations that often mimic the germ-free state, the degree to which the effects of microbial colonization on the host are reversible is unclear. The gut microbiota produce abundant short chain fatty acids (SCFAs), and previous studies have demonstrated a link between microbial-derived SCFAs and global hepatic histone acetylation in germ-free mice. Approach and results We demonstrate that global hepatic histone acetylation states measured by mass spectrometry remained largely unchanged despite loss of luminal and portal vein SCFAs after antibiotic-mediated microbiota depletion. In contrast to stable hepatic histone acetylation states, we see robust hepatic transcriptomic alterations after microbiota depletion. Additionally, neither dietary supplementation with supraphysiologic levels of SCFA nor the induction of hepatocyte proliferation in the absence of microbiota-derived SCFAs led to alterations in global hepatic histone acetylation. Conclusions These results suggest that microbiota-dependent landscaping of the hepatic epigenome through global histone acetylation is static in nature, while the hepatic transcriptome is responsive to alterations in the gut microbiota.

The Affordable Care Act (ACA) expanded Medicaid (ME) and instituted Essential Health Benefits (EHB) that included bariatric surgery coverage on a state-by-state opt-in basis, increasing insurance coverage of bariatric surgery.Using a difference-in-differences framework, changes in bariatric surgery rates, defined as utilization in the population of people with obesity, before and after the ACA were evaluated in four states. Bariatric surgery procedure data were taken from the Healthcare Cost and Utilization Project's State In-patient Database 2012-2015. Adjusted multivariable regressions were run in the Medicaid and commercially insured populations.We identified 36,456 bariatric surgeries across the 286 Health Service Areas and time periods, with 31,732 covered by commercial insurers and 4724 covered by Medicaid. An unadjusted increase in utilization rates was seen in the Medicaid and Commercial populations in both ME- and EHB-covered states as well as non-expansion and EHB opt-out states over time. In the Medicaid population, after adjusting for confounders, there was a significant increase of 24.77 cases per 100,000 people with obesity (95% confidence interval: 12.41, 37.13) in the expansion states relative to the control and pre-period. The commercial population experienced a nonsignificant change in the rates of bariatric surgery, decreasing by 2.89 cases per 100,000 people with obesity (95% confidence interval: - 21.59, 15.81).There was a significant increase in bariatric surgery rates among Medicaid beneficiaries associated with Medicaid expansion, but there was no change among the commercially insured.

Background Weight change offers the simplest indication of a patient’s recovery after an operation. There have been no studies that have thoroughly investigated postoperative weight dynamics after pancreatectomy. The aim of this study was to define postoperative weight change after a pancreatectomy and determine factors associated with optimal and poor weight trajectories. Methods From 2004 to 2019, 1,090 proximal (65%) and distal (35%) pancreatectomies were performed in patients with adequate data in the medical records. Patient weights were acquired preoperatively and at postoperative months 1, 3, and 12. Optimal (top quartile, weight restoration) and poor (bottom quartile, persistent weight loss) postoperative weight cohorts were identified at 1 year postoperatively. Results The median percentage weight change 1 year postpancreatectomy was –6.6% (interquartile range: –1.4% to –12.5%), –7.8% for proximal pancreatectomy, and –4.2% for distal pancreatectomy. For most patients (interquartile range cohort), the median percentage weight change at 1, 3, and 12 months was –6.2%, –7.2%, and –6.6%. The independent factors associated with weight restoration were age 10%, distal pancreatectomy, not undergoing vascular resection, and no readmission within 30 days. Conversely, persistent weight loss was associated with American Society of Anesthesiologists classes III to IV, obesity, malignancy, proximal pancreatectomy, blood loss ≥350mL, and experiencing readmission within 30 days. Focusing on pancreatic ductal adenocarcinoma (n = 372) patients, the factors associated with persistent weight loss were obesity, proximal pancreatectomy, and experiencing recurrence within 1 year; however, weight cohorts were not associated with overall survival for pancreatic ductal adenocarcinoma patients. Conclusion These data define weight kinetics after pancreatectomy. Ultimately, postoperative weight trajectories appear to be largely predetermined but may be mitigated by limiting readmissions and complications. Clinicians should use these data to identify patients who continue to lose weight between the first and third month postoperatively with a high suspicion for the requirement of nutritional monitoring or other interventions.

Background Initial development of a prominent bariatric surgery mortality risk calculator comprising cases that now account for Objectives To validate and improve a bariatric-surgery-specific mortality calculator with updated case mix and outcomes data. Setting Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited bariatric surgery programs. Methods The Metabolic and Bariatric Accreditation and Quality Improvement Program Participant Use File from years 2015 to 2017 was used for the analysis. C-statistics were calculated with observed death as the outcome and estimated 30-day mortality risk as the only predictor and receiver operating characteristic curve was plotted. Similar analyses were repeated for each body mass index (BMI) subgroup. Backward selection logistic regression was used to investigate the potential of improving the robustness of the model. Results Patients were predominantly female (n = 446,149, 80.4%) and white (n = 409,350, 73.7%) with a mean (standard deviation) age of 45.4 (12.0) years and BMI of 44.5 (8.4) kg/m2, and the most commonly performed operation was sleeve gastrectomy (n = 338,061, 60.9%). Assessing previous model using present data, area under the curve was .7412. By BMI subgroup, area under the curve for BMI 60 kg/m2 was .6576. Discussion The present study found that the model previously developed maintains discrimination with changing surgical procedures. Though variables in the initial calculator are helpful, additional factors should be considered when weighing risk, such as sex, previous surgery, and renal function. Future studies are needed to determine whether changes in modifiable risk factors will impact mortality rates.

Although bariatric surgery has proven beneficial for those with cardiovascular disease (CVD), the overall and procedure-specific risk associated with bariatric surgery in this patient population remains unknown. Patients who underwent primary laparoscopic, laparoscopic-assisted, or robotic-assisted Roux-En-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at a MBSAQIP-accredited center were included (n = 494,611). Exposures include history of MI, PCI, or cardiac surgery who underwent RYGB or SG. Outcome measures were 30-day mortality, perioperative cardiac arrest, and rehospitalization. Of 494,611 patients enrolled in MBSAQIP, 15,923 had a history of MI, PCI, or cardiac surgery (prior cardiac history). Patient history of MI, PCI, and cardiac surgery was associated with significantly increased adjusted risk of perioperative cardiac arrest requiring CPR (OR: 2.31, 2.12, 2.42, respectively) and adjusted 30-day mortality (OR: 1.72, 1.50, 1.68, respectively). Prior cardiac history was associated with increased adjusted 30-day readmission rate (MI – OR, 1.42; PCI – OR, 1.45; and cardiac surgery – OR, 1.68). Further, 30-day postoperative readmission, postoperative cardiac arrest, and death were lower for patients undergoing SG compared to RYGB (OR: 0.48, 0.49, and 0.54 respectively). Prior cardiac history was associated with significant greater risk of perioperative cardiac arrest and 30-day mortality among patients undergoing bariatric surgery. SG was associated with less adverse events than RYGB among this population. While there is a clear benefit to weight loss in patients with CVD, it is important to consider whether cardiac patients considering bariatric surgery may require additional preoperative optimization, perioperative interventions, and postoperative monitoring.

Despite the American public following recommendations to decrease absolute dietary fat intake and specifically decrease saturated fat intake, we have seen a dramatic rise over the past 40 years in the rates of non-communicable diseases associated with obesity and overweight, namely cardiovascular disease. The development of the diet-heart hypothesis in the mid twentieth century led to faulty but long-held beliefs that dietary intake of saturated fat led to heart disease. Saturated fat can lead to increased LDL cholesterol levels, and elevated plasma cholesterol levels have been shown to be a risk factor for cardiovascular disease; however, the correlative nature of their association does not assign causation. Advances in understanding the role of various lipoprotein particles and their atherogenic risk have been helpful for understanding how different dietary components may impact CVD risk. Numerous meta-analyses and systematic reviews of both the historical and current literature reveals that the diet-heart hypothesis was not, and still is not, supported by the evidence. There appears to be no consistent benefit to all-cause or CVD mortality from the reduction of dietary saturated fat. Further, saturated fat has been shown in some cases to have an inverse relationship with obesity-related type 2 diabetes. Rather than focus on a single nutrient, the overall diet quality and elimination of processed foods, including simple carbohydrates, would likely do more to improve CVD and overall health. It is in the best interest of the American public to clarify dietary guidelines to recognize that dietary saturated fat is not the villain we once thought it was.

Obesity and its related comorbidities make up a large part of healthcare expenditures. Despite a wide array of options for treatment of obesity, rates of sustained weight loss continue to be low, leading patients to seek alternative treatment options. Although the first medically utilized ketogenic diet was described nearly 100 years ago, it has made a resurgence as a treatment option for obesity. Despite increased popularity in the lay public and increased use of ketogenic dietary strategies for metabolic therapy, we are still beginning to unravel the metabolic impact of long-term dietary ketosis. There are a number of recent trials that have highlighted the short- and long-term benefits of ketogenic diet on weight, glycemic control, and other endocrine functions including reproductive hormones. This review is a summary of available data on the effectiveness and durability of the ketogenic diet when compared to conventional interventions. Ketogenic dietary strategies may play a role in short-term improvement of important metabolic parameters with potential for long-term benefit. However, response may vary due to inter-individual ability to maintain long-term carbohydrate restriction.

PURPOSE OF THE REVIEW: The goal of this paper is to review current literature on the gut microbiome within the context of host response to surgery and subsequent risk of developing complications, particularly anastomotic leak. We provide background on the relationship between host and gut microbiota with description of the role of the intestinal mucus layer as an important regulator of host health. RECENT FINDINGS: Despite improvements in surgical technique and adherence to the tenets of creating a tension-free anastomosis with adequate blood flow, the surgical community has been unable to decrease rates of anastomotic leak using the current paradigm. Rather than adhere to empirical strategies of decontamination, it is imperative to focus on the interaction between the human host and the gut microbiota that live within us. The gut microbiome has been found to play a potential role in development of post-operative complications, including but not limited to anastomotic leak. Evidence suggests that peri-operative interventions may have a role in instigating or mitigating the impact of the gut microbiota via disruption of the protective mucus layer, use of multiple medications, and activation of virulence factors. SUMMARY: The microbiome plays a potential role in the development of surgical complications and can be modulated by peri-operative interventions. As such, further research into this relationship is urgently needed.

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Due to the wide range of presentation in GERD patients with esophageal and/or extraesophageal syndromes that are common symptoms but often overlapping those of other upper gastrointestinal and cardiopulmonary disorders, a systematic approach to the preoperative workup of these patients must be undertaken to identify objective evidence of esophageal reflux prior to surgery. The workup should include upper endoscopy, barium esophagram, manometry and pH study with very few exceptions. Only after successful objective identification of pathologic acid exposure should surgery be pursued for select patients.

PURPOSE OF THE REVIEW: The goal of this paper is to review current literature on nutritional ketosis within the context of weight management and metabolic syndrome—namely insulin resistance, lipid profile and cardiovascular disease risk, and development of non-alcoholic fatty liver disease. We provide background on the mechanism of ketogenesis and describe nutritional ketosis. RECENT FINDINGS: Nutritional ketosis has been found to improve metabolic and inflammatory markers, including lipids, HbA1c, high-sensitivity CRP, fasting insulin and glucose levels, and aid in weight management. We discuss these findings and elaborate on potential mechanisms of ketones for promoting weight loss, decreasing hunger, and increasing satiety. SUMMARY: Humans have evolved with the capacity for metabolic flexibility and the ability to use ketones for fuel. During states of low dietary carbohydrate intake, insulin levels remain low and ketogenesis takes place. These conditions promote breakdown of excess fat stores, sparing of lean muscle, and improvement in insulin sensitivity.

The goal of this review is to summarize available data on the impact of bariatric surgery on diabetes and to explore the mechanisms responsible for these outcomes. In randomized controlled trials and when compared to standard medical management, bariatric surgery is consistently superior with regards to weight loss and remission of type 2 diabetes. Remission rates are proportional to weight loss. The likelihood of remission from type 2 diabetes after bariatric surgery can be estimated from several available clinical parameters. Bariatric surgery is superior in improving glycemic control when compared to standard medical management, but is associated with higher risk. However, for some patients with type 2 diabetes, the goal of sustained remission may only be achievable with surgery. The mechanisms by which this is achieved are multifold and continue to be the focus of ongoing studies.

As prevalence of obesity continues to rise in the United States, we are beginning to elucidate the complex role of obesity-associated chronic inflammation, endocrine dysfunction, and hormone production as a driver for increased breast cancer risk. Epidemiological data suggest that obesity (BMI > 30) is associated with increased breast cancer incidence, worse prognosis, and higher mortality rates. Mechanistically, obesity and excess fat mass represent a state of chronic inflammation, insulin resistance, adipokine imbalance, and increased estrogen signaling. This pro-tumorigenic environment stimulates cancer development through abnormal growth, proliferation, and survival of mammary tissue. Importantly, obesity is a modifiable risk factor; alterations in cell proliferation, apoptosis, circulating estrogen, and insulin sensitivity are observed in response to weight loss attainable through behavior modification including dietary and exercise changes.

Adrenal myelolipoma (AM) is a benign lesion for which adrenalectomy is infrequently indicated. We investigated operative indications and outcomes for AM in a large single-institution series.A retrospective cohort study of prospectively collected data was conducted. Patients (≥16 years of age) who underwent adrenalectomy in the Division of General Surgery at Barnes-Jewish Hospital (1993-2010) were grouped by operative indication (myelolipoma versus other pathology) and compared using nonparametric tests (α0.05).Sixteen patients (4.0%) had myelolipomas resected out of 402 patients who underwent adrenalectomy. Fourteen patients with suspected AM underwent adrenalectomy, 13 (93%) of whom had AM confirmed on pathology. Indications for adrenalectomy were abdominal or flank pain, large tumor size (8 cm), atypical radiologic appearance, and/or inferior vena cava compression. Three patients with suspected other adrenal lesions had AM confirmed on final pathology. Operative approach was laparoscopic in 15 cases and open in 1 case of a 21-cm lesion. Patients who underwent laparoscopic adrenalectomy for AM (n=15) or other adrenal pathology (n=343) were similar with respect to age, gender, American Society of Anesthesiologists classification, prior abdominal operation, tumor side, operative time, conversion rate, estimated blood loss, intraoperative complications, hospital length of stay, and 30-day morbidity. However, patients with resected AM had a higher body mass index (36.5±8.1 kg/m(2) versus 30.1±7.5 kg/m(2); P.01) and a larger preoperative tumor size (8.4±3.0 cm versus 3.1±1.7 cm; P.01).Laparoscopic adrenalectomy may be appropriate for patients with a presumptive diagnosis of AM and abdominal or flank pain, large tumor size, and/or uncertain diagnosis after imaging. Outcomes and morbidity following LA for AM and other adrenal pathology appear comparable.

Background: Type 2 diabetes (T2D) has long been identified as an incurable chronic disease based on traditional means of treatment. Research now exists that suggests reversal is possible through other means that have only recently been embraced in the guidelines. This narrative review examines the evidence for T2D reversal using each of the three methods, including advantages and limitations for each. Methods: A literature search was performed, and a total of 99 original articles containing information pertaining to diabetes reversal or remission were included. Results: Evidence exists that T2D reversal is achievable using bariatric surgery, low-calorie diets (LCD), or carbohydrate restriction (LC). Bariatric surgery has been recommended for the treatment of T2D since 2016 by an international diabetes consensus group. Both the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) now recommend a LC eating pattern and support the short-term use of LCD for weight loss. However, only T2D treatment, not reversal, is discussed in their guidelines. Conclusion: Given the state of evidence for T2D reversal, healthcare providers need to be educated on reversal options so they can actively engage in counseling patients who may desire this approach to their disease.

We evaluated suturing skills performance and retention in senior medical students (MS4) at the beginning of their fourth year and 7 months later.MS4 students entering a surgery specialty were randomized to a proficiency-based suturing/knot-tying curriculum at the beginning of fourth year (Intervention, n = 11) versus no training (Control, n = 10). Time and technical proficiency (TP, proficiency ≥3) were assessed at baseline and 7 months. Performance was compared with past "Boot-Camp" MS4, categorical PGY-1 interns and PGY-2 residents. Data are mean ± SD.At baseline, Intervention and Control MS4 had similar total task times (848 ± 199 vs 845 ± 209 seconds) and TP scores (1.8 ± 0.15 vs 1.8 ± 0.3). At 7 months, Intervention MS4 total task times were faster (549 ± 80 vs 719 ± 151 seconds, P.01) and mean TP scores greater (3.3 ± 0.6 vs 2.1 vs 0.4, P.001) than Control MS4. Intervention MS4 also performed better at 7 months than Boot-Camp MS4 (662 ± 171 seconds and 2.6 ± 0.5, P.04) and were similar to PGY-1 interns (601 ± 74 seconds, TP 2.7 ± 0.7 seconds) and end of PGY-2 residents (475 ± 81 seconds and 3.6 ± 0.3 seconds).A proficiency-based suturing and knot-tying curriculum taught early in the fourth year results in improved MS4 performance compared with no training or a traditional "boot camp" program.

Medullary thyroid carcinoma (MTC) comprises approximately 5 % of all thyroid cancers. While the majority of cases are sporadic, as many as 25 % of cases are attributed to inherited mutations in the REarranged during Transfection (RET) proto-oncogene. Primary treatment is thyroidectomy and removal of involved nodal basins. Preventative thyroidectomy is recommended in at-risk RET mutation carriers. Due to the lack of randomized trials and limited widespread clinical expertise, certain aspects of treatment remain controversial. This chapter aims to elucidate the best practices based on the existing literature, the most current published guidelines, and expert surgeon recommendations. Clarification of controversial issues, including, but not limited to, age of surgery in at-risk gene carriers, extent of lymphadenectomy and parathyroid management in preventative thyroidectomy, extent of thyroidectomy and lymphadenectomy in primary and reoperations for MTC, usefulness of radiation therapy, and timing of systemic treatment, will be discussed in this chapter.

Risk factors for selecting patients for open adrenalectomy (OA) and for conversion are limited in most series. This study aimed to investigate variables that are important in selecting patients for OA, predict risk of conversion from laparoscopic adrenalectomy (LA), and impact 30-day outcomes of OA and LA.A retrospective cohort study of prospectively collected data was conducted. Patients (≥ 16 years old) who underwent adrenalectomy in the Division of General Surgery at Barnes-Jewish Hospital (1993-2010) were grouped by operative approach (LA vs. OA) and compared using nonparametric tests and regression analyses (α0.05).In total, 402 patients underwent 422 adrenalectomies. Compared to LA patients, those in the OA group were older (p = 0.02), had higher ASA scores (p = 0.04), larger tumor size (p0.01), and fewer functioning lesions (p0.01). OA patients more often required concurrent procedures (p0.01), had a longer operative time (p = 0.04), more intraoperative complications (p = 0.02), higher estimated blood loss (EBL), and larger transfusion requirement. Preoperative factors that predicted selection for OA were higher patient age (p = 0.01), higher ASA score (p = 0.03), larger tumor size (p0.01), nonfunctioning lesion (p0.01), diagnosis of adrenocortical carcinoma (p0.01), and the need for concomitant procedures (p0.01). Conversion to open or hand-assisted approach occurred in 6.2 % of LA patients. Preoperative risks for conversion included large tumor size (8 cm) and need for concomitant procedures (p0.01). Multivariate analysis revealed that large indeterminate adrenal mass, adrenocortical carcinoma, tumor size (6 cm), an open operation, conversion, concomitant procedures, operative time180 min, and EBL200 mL were predictors of 30-day morbidity.Adrenal tumor size and need for concurrent procedures significantly impact the selection of patients for OA, the likelihood of conversion, and perioperative morbidity. These metrics should be considered when assessing operative approach and risks for adrenalectomy.