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Background: Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB)., Objective: This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU)., Methods: PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee., Results: Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures., Conclusions: This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. All rights reserved.)

Introduction: Laparoscopic sleeve gastrectomy (LSG) is currently the most common bariatric procedure performed in adolescents and young adults in the United States (USA), but there are limited data available on long-term postoperative weight outcomes in these patients. This single-institution US study follows longitudinal weight data in a diverse group of patients undergoing LSG at age 25 years or younger., Methods: We retrospectively reviewed records of all patients 25 years or younger who underwent LSG at our institution between 2013 and 2020. All weight data documented in the medical record through January 2023 was included. We calculated weight change postoperatively as percent total weight loss (%TWL) relative to preoperative weight., Results: One hundred forty-one patients underwent LSG, at a mean age of 23.1 years. Within this cohort, 56.1% identified as non-Hispanic Black or Hispanic, and 39.7% had private health insurance. The mean %TWL at weight nadir was 28.5% at a mean of 1.35 years postoperatively. The mean long-term %TWL (in patients with ≥ 4 years of follow-up) was 11.8% at a mean of 5.6 years postoperatively, with 43 of the 84 patients with long-term weight data (51%) within 10% of their preoperative weight at most recent follow-up., Conclusion: Adolescents and young adults undergoing LSG at our institution had weight nadir comparable to published results during the first 1 to 2 years postoperatively, but the majority developed significant weight recurrence over the ensuing years. Our findings highlight the need for adjuvant weight loss strategies to improve the durability of weight outcomes after LSG in this population., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Rapid adoption of sleeve gastrectomy (SG) in the last decade aptly reflects the desire of patients and surgeons for alternatives to RYGB and DS. While SG provides good outcomes, other options that address specific patient needs are warranted. Recently approved by ASMBS, SADI, and OAGB have garnered increasing interest due to their single anastomosis technique., Methods: Using the Metabolic and Bariatric Surgery Quality Improvement Program database, we examined laparoscopic and robotic cases from 2018 to 2021 to understand the percentage of primary bariatric surgery cases that are SADI and OAGB. We used coarsened exact matching to match patients who underwent SADI or OAGB to patients who underwent Roux-en-Y gastric bypass (RYGB). We examined outcomes of matched patients using logistic regression., Results: Of the 667,979 patients that underwent bariatric-metabolic surgery, 1326 (0.2%) underwent SADI, and 2541 (0.4%) underwent OAGB. SADI was not identified in the database until 2020. In 2020, there were 487 SADI procedures compared to 839 in 2021. From 2018 to 2021, OAGBs went from 149 to 940. Compared with RYGB, SADI was associated with higher rates of anastomotic or staple line leak (OR 2.21 (95% CI 1.08-4.53)) and sepsis (OR 3.62 (95% CI 1.62-8.12)). Compared with RYGB, OAGB was associated with lower rates of gastrointestinal bleeding (OR 0.29 (95% CI 0.12-0.71)) and bowel obstruction (OR 0.10 (95% CI 0.02-0.39)). Of note, there were no differences between these procedures and RYGB for 30-day mortality., Conclusion: More SADIs and OAGBs are being performed. However, there were higher complication rates associated with the SADI procedure. Further studies will be needed to better understand the key drivers for these outcomes., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The incidence and impact of hypoalbuminemia in bariatric surgery patients is poorly characterized. We describe its distribution in laparoscopic sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) patients undergoing primary or revision surgeries and assess its impact on postoperative complications., Methods: The Metabolic and Bariatric Surgery Quality Improvement Program Database (2015 to 2021) was analyzed. Hypoalbuminemia was defined as Severe (< 3 g/dL), Moderate (3 ≤ 3.5 g/dL), Mild (3.5 ≤ 4 g/dL), or Normal (≥ 4 g/dL). Multivariable logistic regression was performed to calculate odds ratios of postoperative complications compared to those with Normal albumin after controlling for procedure, age, gender, race, body mass index, functional status, American Society of Anesthesia class, and operative length., Results: A total of 817,310 patients undergoing Primary surgery and 69,938 patients undergoing Revision/Conversion ("Revision") surgery were analyzed. The prevalence of hypoalbuminemia was as follows (Primary, Revision): Severe, 0.3%, 0.6%; Moderate, 5.2%, 6.5%; Mild, 28.3%, 31.4%; Normal, 66.2%, 61.4%. Primary and Revision patients with hypoalbuminemia had a significantly higher prevalence (p < 0.01) of several co-morbidities, including hypertension and insulin-dependent diabetes. Any degree of hypoalbuminemia increased the odds ratio of several complications in Primary and Revision patients, including readmission, intervention, and reoperation. In Primary patients, all levels of hypoalbuminemia also increased the odds ratio of unplanned intubation, intensive care unit admission, and venous thromboembolism requiring therapy., Conclusion: Over 30% of patients present with hypoalbuminemia. Even mild hypoalbuminemia was associated with an increased rate of several complications including readmission, intervention, and reoperation. Ensuring nutritional optimization, especially prior to revision surgery, may improve outcomes in this challenging population., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Some programs and insurers may require patients to undergo toxicology screening despite lack of evidence that this practice affects postoperative outcomes., Objectives: To understand the prevalence of screening positive on toxicology testing in the bariatric surgical population and to examine the association between testing positive and important surgical outcomes., Methods: We performed a retrospective review of patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from an academic health system from 2017-2020. We described the rate of preoperative toxicology positivity as determined by serum and urine testing. We examined the association between toxicology positivity and outcomes of preoperative length, 30-day complications (bleeding, venous thromboembolism, leak, wound infection, pneumonia, urinary tract infection, and myocardial infarction), readmissions, and 1-year weight loss using chi-square and t-test analysis., Results: Of 1057 patients, there were 134 patients (12.7%) who had positive toxicology testing. Of these, 37 (28%) were positive for opiates and 21 (16%) were positive for cotinine. Mean preoperative length was 381.8 days (standard deviation [SD], 222.5) for patients with positive testing versus 287.8 days (SD, 151.5; P = 1.00) for negative testing. Toxicology positivity was not associated with readmissions (5.2% versus 4.3%, X 2 = 0.22; P = .64). The loss to follow-up at 1 year was 32.5%. There was no association with 1-year mean change in body mass index (mean of loss 12.23kg/m 2 [SD, 5.61]) versus mean of loss 12.74 (SD, 6.44; P = .20)]., Conclusions: Our study is the first to describe preoperative toxicology positivity rates. We found no association between toxicology positivity and preoperative length, readmissions, or weight loss. Given its lack of impact on outcomes, toxicology testing prior to bariatric surgery may be an unnecessary burden on patients and healthcare, with regard to cost and wait times., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Physicians are frequently called on to make medical decisions despite being uncertain about the outcomes of these choices. The psychological stress associated with these dilemmas, known as "Uncertainty Intolerance" (UI), can significantly impact the quality of a physician's practice as well as their own mental health. Coping with uncertainty is an important competency that all residents must master, and some residency programs are introducing new education initiatives aimed at improving UI. However, currently there is no standard protocol for measuring UI or the effectiveness of such interventions and there are no established methods for identifying the residents who would most benefit from the training. In this study, we aim to use the Physician Reaction to Uncertainty (PRU) and Physician Risk Attitude (PRA) scales as assessments for UI in surgical residents, and to determine if Myers-Briggs Type Indicator (MBTI) personality factors are associated with PRU and PRA scores and can be used to identify residents who are more likely to have higher UI., Materials and Methods: The PRU and PRA scales, and the MBTI assessment were administered to a total pool of 71 general surgery residents. In addition to the survey questions, residents provided information regarding their gender (male or female), and stage of training (junior or senior)., Results: In total, 45 male residents and 25 female residents completed the PRA and PRU scales (98.6%). There were no statistically significant differences when comparisons were made between junior and senior residents or male and female residents. Thirty seven male residents and 18 female residents also completed the MBTI assessment (80.4% and 72%, respectively). PRU and PRA scores were analyzed with respect to personality factors to determine if certain dichotomies are associated with increased UI. There was a trend toward higher UI in individuals identifying with Judging., Conclusions: In this study, we have conducted a pilot study using the PRU and PRA scales to measuring the success of our new education initiatives aimed at improving uncertainty tolerance. We found that the PRU and PRA assessments were simple to administer and had a high completion rate. Our findings also suggest that individuals who identify with Judging may better tolerate the uncertainties associated with surgical practice, although larger studies will be required to determine if MBTI factors are linked to UI in surgical residents., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Postoperative hemorrhage is a rare complication in bariatric surgery. We aim to determine if differences in blood pressure or perioperative medication administration contribute to postoperative bleeding in patients who were hemodynamically stable intraoperatively., Methods: This was a retrospective case-control study of all bariatric surgery patients from 2014 to 2017 at a high volume academic center. We identified controls based on age, gender, ethnicity, type of procedure, and pre-operative blood pressure., Results: Patients with postoperative hemorrhage had a significantly lower MAP during the portion of the surgery in which the abdominal contents were inspected for leaks and bleeds. The timing of enoxaparin or ketorolac administration was not associated with bleeding., Conclusion: Blood pressure lability, but not enoxaparin or ketorolac administration, is associated with postoperative hemorrhage.

Background: Sleeve gastrectomy with ileal transposition has been shown to be superior to sleeve gastrectomy alone for promoting weight loss in rat and porcine models. The absence of a mouse model for this procedure has impeded efforts to understand the molecular physiology underlying its efficacy. This study demonstrates the long-term survivability of sleeve gastrectomy with ileal transposition in mice., Materials and Methods: In this study of technical feasibility, a sleeve gastrectomy with ileal transposition (SGIT), sleeve gastrectomy (SG), or sham surgery (SH) was performed on 7- to 8-week-old C57Bl/6J mice (n = 8 for each). To evaluate long-term survivability, mice were placed on an obesogenic diet and weighed weekly for 10 weeks. The intestinal identity of the transposed segment was assessed with gene expression analysis of duodenal-, jejunal-, and ileal-specific hormones using quantitative polymerase chain reaction., Results: Overall, SGIT better prevented weight gain than the SG or sham procedures (10-week post-operative weight: SH 45.3 ± 1.0 g, SG 41.25 ± 1.6 g, SGIT 35.4 ± 0.8 g). Gene expression pattern analysis of three markers of intestinal identity (gastrin, cholecystokinin, and peptide YY) suggests that the ileal identity of the transposed segment is maintained 10 weeks after transposition., Conclusions: We demonstrate for the first time a reproducible mouse model of sleeve gastrectomy with ileal transposition. Future studies utilizing this model will expand our understanding of the molecular pathways through which the hindgut regulates satiety.

Background: Few studies have examined whether preoperative period length, as defined by the amount of time from enrollment in a surgical weight loss program to the day of surgery, affects postoperative weight loss., Objectives: To identify associations between preoperative period length and postoperative weight loss., Setting: Single surgeon at an academic medical center in the United States., Methods: Retrospective chart review in 109 consecutive patients undergoing sleeve gastrectomy from 2014-2015., Results: When patients were grouped based on postoperative percentage of total weight loss, greater weight loss was associated with shorter preoperative wait time. During the preoperative period, 72.2% of our patients achieved a net weight loss, but 34.6% had gained net weight until they started the preoperative "liver-shrinking" diet; 71.4±8.3% of the total preoperative weight loss occurred after initiating the preoperative diet, which accounted for approximately 15% of the whole preoperative period length. There was no correlation between the length of the preoperative diet and preoperative weight loss., Conclusions: Shorter preoperative periods and earlier initiation of liver reduction diets may increase postoperative weight loss, although ultimately there may be a limit to the weight loss that patients can achieve while adhering to highly restrictive lifestyle modifications., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Antimicrobial stewardship may be important in long-term care facilities because of unnecessary or inappropriate antibiotic use observed in these residents, coupled with their increased vulnerability to health care-associated infections., Objectives: To assess antibiotic use in a long-term care facility in order to identify potential antimicrobial stewardship needs., Methods: A retrospective descriptive study was conducted at the Veterans Centre, a long-term care facility at Sunnybrook Health Sciences Centre, Toronto, Ontario. All residents taking one or more antibiotics (n = 326) were included as participants. Antibiotic-use data for patients residing in the facility between April 1, 2011, and March 31, 2012, were collected and analyzed., Results: Totals of 358 patient encounters, 835 antibiotic prescriptions, and 193 positive culture results were documented during the study period. For 36% (302/835) of antibiotic prescriptions, the duration was more than 7 days. Cephalosporins (30%; 251/835) and fluoroquinolones (28%; 235/835) were the most frequently prescribed antibiotic classes. Urine was the most common source of samples for culture (60%; 116/193)., Conclusions: Characteristics of antimicrobial use at this long-term care facility that might benefit from further evaluation included potentially excessive use of fluoroquinolones and cephalosporins and potentially excessive duration of antibiotic use for individual patients.