Faculty Bibliography

IMPORTANCE/UNASSIGNED:In January 2023, the US Centers for Medicare & Medicaid Services (CMS) made major changes to reimbursement policy for abdominal wall hernia repairs, including removal of postoperative global periods. Similar changes have been proposed for other common surgical procedures (eg, colectomy). The role of this policy reform in spending remains unclear. OBJECTIVE/UNASSIGNED:To evaluate the association between the 2023 CMS ventral hernia repair reimbursement policy reform and changes in ventral hernia episode spending. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This retrospective cohort study used US national insurance claims data (Merative MarketScan) between January 1, 2022, and October 1, 2023. Data were analyzed from July to October 2025. Participants included commercially insured adult patients who underwent ventral or inguinal hernia repair. EXPOSURE/UNASSIGNED:January 2023 CMS ventral hernia repair reimbursement policy reform. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was total episode spending per surgical episode, broken down into professional and facility components as well as payer and patient sources. Utilization of billable postoperative care and component separation were also evaluated. A difference-in-differences approach was used to evaluate changes in spending associated with the January 2023 policy change, with inguinal hernia repair as the unaffected comparison group. RESULTS/UNASSIGNED:Among 58 069 surgical episodes (34 110 ventral, 23 959 inguinal; median patient age, 52 [IQR, 43-59] years; 28% female; 90% outpatients) per-episode spending for ventral hernia decreased following policy reform by -$492 (95% CI, -$496 to -$470) (7% relative reduction) compared with inguinal hernia. Professional reimbursements decreased by -$198 (95% CI, -$200 to -$197) (20% relative reduction). Facility reimbursements increased by $84 (1.4% relative increase) in absolute terms but decreased by -$260 (95% CI, -$263 to -$239) compared with inguinal hernia (4.6% relative decrease). Patient out-of-pocket costs decreased by -$83 (95% CI, -$87 to -$82) (10% relative decrease) compared with inguinal hernia repair. Of 7561 ventral hernia repair cases (52.3%) had 1 or more related postoperative visits in the 90 days after surgery, with the mean (SD) number of visits being 1.06 (2.7). There was no significant increase in component separation procedures. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this study, following the January 2023 CMS ventral hernia repair reimbursement policy reform, episode spending decreased, with the largest component of the decrease arising from professional fees. With CMS decreasing reimbursement for numerous surgical procedures, the outcomes for surgeon practices and patient costs warrant careful consideration.

BACKGROUND:Extended-course enoxaparin is increasingly used after bariatric surgery to prevent venous thromboembolism (VTE), the leading cause of death after bariatric surgery. Direct oral anticoagulants are widely used for extended thromboprophylaxis outside of bariatric surgery and offered to patients in our program who cannot tolerate or obtain enoxaparin. We evaluated the safety and efficacy of apixaban 2.5 mg twice daily relative to a weight-based dose of enoxaparin 40 mg or 60 mg twice daily for 30 days after discharge following sleeve gastrectomy. METHODS:Patients aged ≥18 years who underwent laparoscopic sleeve gastrectomy from 2019 to 2024 at a single high-volume urban academic center were included. Bleeding and thrombosis outcomes within 30 days were compared between patients receiving enoxaparin 40 mg twice daily or apixaban 2.5 mg twice daily. Weighted modified Poisson analyses were used to obtain covariate balance and assess differences in bleeding and thrombosis events. RESULTS:A total of 5921 patients were included for analysis (5274 enoxaparin 40 mg twice daily, 486 enoxaparin 60 mg twice daily, and 161 apixaban 2.5 mg twice daily). The 30-day thrombosis rate was significantly lower with enoxaparin versus apixaban (.1% versus 1.9%, P < .001). The composite outcome (VTE, portomesenteric venous thrombosis, and major/minor bleeding) was also significantly lower with enoxaparin versus apixaban (1.7% versus 5.6%, P < .01). In adjusted analyses, apixaban was associated with a relative risk of 12.09 for thrombosis (95% confidence interval [CI], 5.71-31.18), 1.93 for bleeding (95% CI, 1.27-3.00), and 2.59 (95% CI, 2.06-3.27) for any adverse outcome relative to enoxaparin. CONCLUSION/CONCLUSIONS:Enoxaparin is associated with both lower thrombosis and bleeding rates compared with apixaban for extended thromboprophylaxis after sleeve gastrectomy.

BACKGROUND:Bariatric surgery has long been established as an effective treatment option for obesity and diabetes [Kalainov et al. in J Am Acad Orthop Surg [32(10):427-438, 2025] and Ogden et al. in JAMA 311(8):806-806, 2025. 10.1001/jama.2014.732]. Recently, GLP-1 Receptor Agonists' (GLP-1RAs) use has expanded as an alternative therapy for weight loss and diabetes management. While GLP1RAs are known to be safe and effective, few have compared long term outcomes of GLP-1RAs versus the "gold standard" of bariatric surgery among Medicare/Medicaid patients, who make up the largest payer group in the U.S. [Kalainov et al. in J Am Acad Orthop Surg [32(10):427-438, 2025]. METHODS:This was a retrospective, multicenter study of obese, type-2 diabetic patients (T2D) ≥ 18 years old, who initiated weekly injectable semaglutide or tirzepatide or underwent bariatric surgery between January 1st, 2018 to July 31st, 2024. Patients with a baseline BMI ≤ 35, those with prior GLP1-RA use, or any prior bariatric procedure were excluded from analysis. The primary outcome of interest was % total body weight loss 3 months to 3 years post intervention among bariatrics surgery patients vs. GLP1-RA patients (any GLP1-RA prescription and 12 months continuous GLP1-RA prescription). RESULTS:7667 patients were included for analysis (7200 GLP1-RA, 467 bariatric surgery). Bariatric surgery patients were younger (median (IQR): 43 (34, 53) vs. 65 (54, 72); p < 0.001) and more likely to be female (67.5% vs. 60.8%; p < 0.01) and Hispanic (58.7% vs. 19.4%; p < 0.001) while GLP1-RA users were more likely to be white (58.5% vs. 10.7%; p < 0.001). In models adjusting for demographic and clinical characteristics, bariatric surgery was associated with a 22.9% total weight loss 3 years following surgery compared to 2.3% for patients with any GLP1-RA use, and 15.9% vs 2.4% for patients with 12 months consecutive GLP1-RA use (22.9 [21.0-24.8] vs 2.3 [0.5-4.1], 15.9 [6.9-24.9] vs. 2.4 [6.7-11.5]. CONCLUSIONS:Among obese, T2D, publicly insured patients, bariatric surgery was associated with greater weight loss than GLP1-RAs at all measured periods from 3 months to 3 years post op.

BACKGROUND:An estimated one in three adults is living with metabolic dysfunction-associated steatotic liver disease (MASLD) globally, among whom 20-25% progress to metabolic dysfunction-associated steatohepatitis (MASH). Despite their hepatic and extrahepatic burden, MASLD and MASH remain absent from the WHO non-communicable disease (NCD) global action plan and its so-called best buys. This study aimed to identify MASLD and MASH interventions that can be considered as WHO best buys and determine whether they can also be quick buys (ie, interventions that can have real public health impact within 5 years). METHODS:A core group developed 15 evidence-based intervention briefs following a literature review. These interventions were assessed for feasibility and potential impact, and whether they could also be considered as quick buys, by a global stakeholder panel in one Delphi round. Consensus was defined as 80% or higher combined agreement (ie, responses of agree plus somewhat agree). FINDINGS/RESULTS:A total of 321 experts who worked in 85 countries participated. All 15 proposed interventions reached consensus and garnered a combined agreement higher than 86%. For 12 of the interventions, fewer than 80% of panellists selected agree, leading to a higher reliance on responses of somewhat agree to reach a high combined agreement. The highest-rated best buy was "Manage overweight, obesity, and type 2 diabetes in people living with MASLD" (99% combined agreement). "Routine screening for liver fibrosis in people living with type 2 diabetes" was the most endorsed quick buy (88%). INTERPRETATION/CONCLUSIONS:This study shows a strong global consensus among experts that a range of interventions for MASLD and MASH meet the criteria for inclusion as WHO best buys. The high level of endorsement across the 15 interventions highlights the opportunity for global health systems to act on MASLD and MASH, providing a roadmap for policy makers to align liver health strategies with those of other NCDs. Immediate inclusion of prioritised interventions into the WHO NCD agenda could catalyse action, reduce health inequities, and strengthen the overall global response to chronic liver disease. FUNDING/BACKGROUND:Novo Nordisk and Echosens.

OBJECTIVE:Given frailty and comorbidities that occur with both aging and end-stage kidney disease (ESKD), it is unclear if older patients with ESKD derive the improved survival and kidney transplant (KT) access associated with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). METHODS:Using 2006-2021 USRDS data, we identified 876 patients with RYGB and 1508 patients with SG and compared 5-year mortality by age-group (18-29/30-39/40-49/50-59/60-69/≥ 70 years) to nonsurgical matched controls using 1:3 Mahalanobis distance matching, Kaplan-Meier, and Cox regression. We also compared age-stratified KT incidence between waitlisted patients and controls. RESULTS:) for patients with SG versus controls. CONCLUSIONS:RYGB in older patients with ESKD is associated with increased mortality and lower KT likelihood, whereas SG is associated with decreased mortality and higher KT likelihood compared to nonsurgical matched controls. Choice of bariatric surgery type may play a role in improving survival for older patients with ESKD.

BACKGROUND:Early postoperative small bowel obstruction (ESBO) following roux-en-Y gastric bypass (RYGB) is a feared complication, generally estimated to occur in 1-2% of cases. Most surgeons advocate for prompt surgical exploration for ESBO after RYGB. There is currently a paucity of literature regarding conservative management approaches to ESBO after RYGB. OBJECTIVES/OBJECTIVE:To determine the safety and efficacy of non-operative management of early small bowel obstruction following RYGB. SETTING/METHODS:Academic-affiliated municipal hospital. METHODS:We performed a retrospective review of all patients at a single institution who underwent RYGB between July 1, 2020 and April 30, 2024 and were readmitted within 30 days of the procedure due to a small bowel obstruction. Mesenteric defects were closed with permanent suture in 100% of cases. RESULTS:2430 RYGBs were performed, 54 patients (2.2%) developed ESBO. The average interval from time of surgery to diagnosis of ESBO was 7.3 days [range 2-26 days]. The vast majority of patients (n = 43; 80%) were successfully managed conservatively including nasogastric decompression (n = 20; 47%). Most (73%) of the patients requiring reoperation were found to have kinking at the anastomosis or dense adhesions from the cut end of the staple line. CONCLUSIONS:This study demonstrates that non-operative management may be a safe and effective treatment option for the majority of RYGB patients who develop ESBO. Clinical judgement is required to identify those who would benefit from early exploration.

BACKGROUND:Bariatric surgery (BS) is associated with improved cardiovascular (CV) outcomes in individuals with obesity. One proposed mechanism is reduced inflammation. S100A9, a pro-inflammatory cytokine, is elevated in obesity. S100A9, particularly expression in platelets, has been associated with CV risk. The impact of BS on circulating and platelet S100A9 in obesity is unknown. METHODS:We studied serum, plasma, and platelet supernatants from subjects with obesity pre- and post-BS (n = 23) and lean volunteers (n = 8). S100A9 levels were quantified using an S100A9 immunoassay. Wilcoxon, Mann-Whitney, and t-tests were performed to assess changes in S100A9 levels pre- and post-operatively and compare levels across sample and subject types. Spearman tests were used to assess correlations between S100A9 levels in different sample types and neutrophil/platelet counts. RESULTS:Serum and plasma S100A9 concentrations were elevated in individuals with obesity relative to lean individuals. Levels decreased to lean subject levels at 1-year post-BS, despite subjects with obesity remaining overweight. Circulating neutrophil counts also decreased post-BS, and post-BS differences in serum S100A9 were eliminated when calculated per-neutrophil. Platelet supernatant S100A9 levels were lower than in serum and plasma and did not change post-BS. Platelet supernatant S100A9 correlated with plasma, but not serum, levels. CONCLUSION/CONCLUSIONS:We found that S100A9 concentrations differ substantially between blood components, are elevated in obesity, and normalize post-BS. Reductions in circulating S100A9 may contribute to reduced inflammation and be largely driven by resolution of obesity-associated neutrophilia. Our data suggest minimal platelet contribution to circulating (or systemic) S100A9, but a local level inflammatory impact cannot be excluded.