Faculty Bibliography

BACKGROUND:Some bariatric procedures have been associated with increased gastroesophageal reflux disease (GERD) symptoms; however, there are limited data on the long-term changes to the esophagus across bariatric procedures, and how preoperative esophageal disease is impacted by bariatric surgery. OBJECTIVES/OBJECTIVE:To estimate incidence of GERD, esophagitis, Barrett's esophagus, and esophageal adenocarcinoma before and after bariatric surgery and to identify potential risk factors for these conditions. SETTING/METHODS:Retrospective analysis of New York State Database (SPARCS). METHODS:Adult patients undergoing bariatric surgery (Roux-en-Y gastric bypass, adjustable gastric banding, laparoscopic sleeve gastrectomy, and biliopancreatic diversion) from 1995 to 2010. Multivariable Cox proportional hazard models were used to examine the association between preoperative diagnosis, surgery type, and postoperative diagnosis. RESULTS:A total of 48,967 records were analyzed; 30.3% had a diagnosis of GERD at the time of surgery and .4% had a diagnosis of esophagitis and Barrett's. Preoperative GERD/esophagitis/Barrett's was associated with higher risk of GERD, esophagitis, and Barrett's, but not esophageal adenocarcinoma, postoperatively. Roux-en-Y gastric bypass patients had lowest risk of being diagnosed with GERD postoperatively. Overall, esophageal adenocarcinoma incidence in the sample was .04%; the rate among patients with preoperative GERD and Barrett's was .1% and .9%, respectively. Incidence of esophageal adenocarcinoma did not differ by bariatric surgery type. CONCLUSIONS:Preoperative diagnosis is a risk factor for postoperative esophageal disease after bariatric surgery. Adjustable gastric banding and laparoscopic sleeve gastrectomy are associated with higher risk of postoperative GERD and esophagitis compared with Roux-en-Y gastric bypass. Incidence of esophageal adenocarcinoma did not differ by surgery type.

BACKGROUND:Prior studies have demonstrated an increase in gastroesophageal reflux after laparoscopic sleeve gastrectomy (LSG). However, it is unknown whether symptom severity varies or if outcomes are surgeon-specific. METHODS:A validated reflux symptom survey was obtained at baseline and at 1 year after primary LSG on 7358 patients participating in a state-wide quality improvement collaborative between 2013 and 2018. Patients with worsening symptoms after surgery were divided into terciles based on the degree of increase in survey score (0 = no symptoms, 50 = max symptoms). Surgeon-level data was obtained on 52 bariatric surgeons performing at least 25 LSG cases/year during the study period. Surgeon characteristics, operative experience, and risk-adjusted 30-day complication rates were compared between surgeons in the highest tercile for moderate worsening of symptoms vs those in the lowest. RESULTS:A total of 2294 (31.2%) patients had worsening symptoms of reflux after sleeve gastrectomy. Overall mean increase in severity score was 6.11 (range 1 to 48) and patients with minimal, mild, and moderate symptoms had a mean increase of 1.4, 4.2, and 13.8, respectively. There were no significant differences in surgeon-specific characteristics when comparing surgeons in the highest tercile for moderate worsening of symptoms (44.7% of patients) vs those in the lowest tercile (18.7% of patients). In addition, there were no significant differences in risk-adjusted rates of overall complications (3.70% vs. 4.33%, p = 0.686), endoscopic dilations (2.83% vs. 1.91%, p = 0.417), or concurrent hiatal hernia repair (34.3% vs. 27.0%, p = 0.415) between surgeons in the highest and lowest terciles. CONCLUSIONS:We found that 1/3 of patients had worsening symptoms of reflux after LSG and that severity of symptoms varied. Surgeons with the highest rates of worsening reflux had similar operative experience and complication rates than those with the lowest. Further assessment of operative technique and skill may be informative.

BACKGROUND:. OBJECTIVES/OBJECTIVE:. SETTING/METHODS:Teaching and nonteaching hospitals in Michigan. METHODS:). RESULTS:; 36.3% versus 6.01%, P < .0001), and had higher body image scores (50.6 versus 42.4, P < .0001). CONCLUSIONS:Despite being older and with higher rates of metabolic disease, low-BMI patients reported high-resolution rates for diabetes, hypertension, and hyperlipidemia (>50%) and were more likely to achieve a healthy weight after SG. Abolishing the BMI threshold for SG among patients with metabolic disease should be considered.

BACKGROUND:Sleeve gastrectomy has become the most common procedure performed for weight loss. But emerging data indicate that this procedure can result in lifestyle-limiting gastroesophageal reflux disease. The influence of these gastroesophageal reflux disease symptoms on patient satisfaction with the procedure has not been explored. METHODS:Using a statewide, bariatric-specific data registry, we studied 6,608 patients who underwent laparoscopic sleeve gastrectomy from 2013 to 2017. We used the Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire, which is 10 questions, each ranging from 0 (no symptoms) to 5 (severe symptoms). To assess the impact of sleeve gastrectomy on patient satisfaction, we calculated the change in this score at baseline versus 1 year after the procedure. We stratified the change in the gastroesophageal reflux disease score into 5 even-sized groups (quintiles). We then examined the relationship between change in the gastroesophageal reflux disease score and patient satisfaction at 1 year. We used generalized linear mixed models to assess the variation in patient satisfaction explained by the change in the gastroesophageal reflux disease score, excess body weight loss at 1 year, and other patient outcomes (serious complications, readmission, and reoperations). We controlled for patient factors (age, sex, race, and comorbidities) and year of sleeve gastrectomy. RESULTS:The average change in the gastroesophageal reflux disease score was 1.62 (range: -48 to 48); however, the change in the gastroesophageal reflux disease score varied across quintiles with a -7.3-point (range: -48 to -3) worsening in the bottom quintile versus a 2.6-point (range: 7 to 48) improvement in the top quintile. Overall, 77.7% of patients were satisfied, but the proportion of patients satisfied was highly dependent on whether their reflux symptoms improved or worsened. Only 48.9% in the bottom quintile were satisfied, compared with 78.1% in the top quintile (<.0001). In the multivariate model, changes in patient-reported gastroesophageal reflux disease score were the most predictive of patient satisfaction, explaining 10.1% of the variation in 1 year satisfaction. Among patients in the bottom quintile, reflux symptoms explained 30.2% of variation compared with 2.3% in quintiles with little change or improvement in reflux. Moreover, excess body weight loss explained only 2% of variation in satisfaction and <1% was explained by patient outcomes (serious complications, readmissions, reoperations, or surgical complications). CONCLUSION/CONCLUSIONS:In this statewide study of sleeve gastrectomy, we demonstrated that gastroesophageal reflux symptoms are an important determinant of 1 year satisfaction, particularly among patients whose symptoms worsened the most.

Objective/UNASSIGNED:The project enabled clinicians to utilize the electronic medical record (EMR) to easily prescribe preapproved online patient education resources to their patients. Background/UNASSIGNED:Physicians and other clinicians are concerned about the wide use of "Dr. Google" and the difficulties of responding to patients who demand unproven or unnecessary tests and therapies they found out about on the Internet. Setting/Participants/Resources/UNASSIGNED:Participants were providers at a large health system using Epic EMR. The institution maintains a web-based database that links to print and electronic patient education materials that have been vetted by content experts. Methods/UNASSIGNED:Clinicians worked with librarians to create web pages that link to the resources they recommend for their patients. Librarians collaborated with the information technology (IT) department to implement a solution that enables clinicians to quickly and easily send the uniform resource locator (URL) to the after visit summary (AVS) or as a message via the patient portal. Results/UNASSIGNED:This solution has been implemented in more than 20 units across the institution. Analytics data demonstrate that the majority of patients in a surgery clinic visited recommended resources. Conclusion/UNASSIGNED:This simple solution is effective in directing patients to reliable resources. It can be easily adapted by other institutions using an EMR system such as EPIC or Cerner.

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

BACKGROUND:Although multiple studies demonstrate that routine postoperative contrast studies have a low yield in diagnosing patients with early gastrointestinal (GI) leak after bariatric surgery, the practice pattern is unknown. Additionally, routine imaging may hinder procedural pathways that lead to accelerated postoperative discharge. OBJECTIVES/OBJECTIVE:To report on the nationwide use of routine upper GI studies (UGI) and evaluate the effect on hospital resource utilization. SETTING/METHODS:Nationwide analysis of accredited centers. METHODS:The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file for 2015 was used to identify patients who underwent routine UGI after nonrevisional Roux-en-Y gastric bypass or sleeve gastrectomy. Multivariable logistic regression models were developed to identify risk factors for early hospital discharge. RESULTS:Bariatric surgery was performed on 130,686 patients. Routine UGI was performed in 30.9% of Roux-en-Y gastric bypass and 43% of sleeve gastrectomy patients (P<.0001). Patients undergoing routine UGI were less likely to be discharged by postoperative day 1 (odds ratio .7, 95%; confidence interval .69-0.72). There was no difference in postoperative leak rate between the routine UGI versus nonroutine UGI group (.7% versus .8%, P = .208). Among patients who developed a GI leak, there was no significant difference in the rate of reoperation, readmission, and reintervention between the 2 groups. The time interval between index operation and any further management for the leak was longer in the routine UGI group. CONCLUSIONS:Routine UGI evaluation after bariatric surgery remains a common practice in accredited centers. This practice is associated with prolonged hospital length of stay, with no effect on the diagnosis of leak rate.

BACKGROUND:Little is known about the choice of reoperation after failed fundoplication for gastroesophageal reflux disease. Both redo fundoplication and conversion procedure to Roux-en-Y gastric bypass (RYGB) are safe and effective. We aimed to characterize the rates of different revisional procedures and to identify risk factors associated with failed fundoplication. METHODS:Using a statewide database, we examined records for patients who underwent fundoplication between 2000 and 2010. The primary outcomes were the rate of each type of reoperation and the pattern of subsequent procedures. Demographics and comorbidities were used in a multivariable logistic regression model to identify risk factors associated with reoperation after fundoplication. RESULTS:A total of 9462 patients were included. Overall, 430 (4.5%) patients underwent reoperation. Of those, 46 (10.7%) patients underwent RYGB at first reoperation, with the remainder having a redo fundoplication. An additional five patients were converted to RYGB after undergoing a redo fundoplication (51 total patients converted to RYGB at any point, 11.9%). Eighty-three percent of patients converted to RYGB were obese, as opposed to 8% for redo fundoplication. A single redo fundoplication was done in 81% of patients, while 35 patients (8.1%) underwent two or more revisional procedures. On average, any reoperation was performed 2.9 years after fundoplication, with redo fundoplication 2.5 years and RYGB 6.5 years later. Age 30-49 years (vs. >70 years; OR 2.01, p = 0.011) and 50-69 years (vs. >70 years; OR 1.61, p = 0.011), female gender (OR 1.56, p = < 0.0001), and chronic pulmonary disease (OR 1.40, p = 0.0044) were associated with revisional surgery. CONCLUSIONS:Fundoplication has a low reoperation rate within a mean 8.3 years of follow-up. Redo fundoplication is more commonly performed and at an earlier point than conversion to RYGB. Younger age, female gender, and chronic pulmonary disease are associated with reoperation after fundoplication.