Metabolic and Bariatric Surgery Utilization Trends in the United States: Evidence from 2012-2021 National Electronic Medical Records Data

Objectives: Bariatric surgery has evolved over the past two decades yet assessing trends of bariatric surgery utilization in the growing eligible population is lacking.This study aimed to update the trends in bariatric surgery utilization, changes in types of procedures performed, and the characteristics of patients who underwent bariatric surgery in the US, using real-world data. Method(s): This cross-sectional study was conducted using the TriNetX, a federated electronic medical records network from 2012 to 2021, for adult patients 18 years old or older who had bariatric surgery. Descriptive statistical analysis was conducted to assess patients' demographics and characteristics. Annual secular trend analyses were conducted for the annual rate of bariatric surgery, and the specific procedural types and proportions of laparoscopic surgeries. Result(s): A steady increase in the number of procedures performed in the US over the first six years of the study, a plateau for the following two years, and then a decline in 2020 and 2021 (during the coronavirus-19 pandemic). The annual rate of bariatric surgery was lowest in 2012 at 59.2 and highest in 2018 at 79.6 surgeries per 100,000 adults. During the study period, 96.2% to 98.8% of procedures performed annually were conducted laparoscopically as opposed to the open technique. Beginning in 2012, the Roux-en-Y (RYGB) procedure fell to represent only 17.1% of cases in 2018, along with a sharp decline in the adjustable gastric band (AGB) procedure, replaced by a sharp increase in the sleeve gastrectomy (SG) procedure to represent over 74% of cases in 2018. Conclusion(s): Bariatric surgery utilization in the US showed a moderate decline in the number of RYGB procedures, which was offset by a substantial increase in the number of SG procedures and a precipitous drop in the annual number of AGB procedures.Copyright © 2023

The financial impact of the COVID-19 pandemic on sleeve gastrectomy at a major academic institution.

INTRODUCTION: The COVID-19- pandemic significantly impacted metabolic and bariatric surgery (MBS) practices due to large-scale surgery cancellations along with staff and supply shortages. We analyzed sleeve gastrectomy (SG) hospital-level financial metrics before and after the COVID-19 pandemic. METHODS: Hospital cost-accounting software (MicroStrategy, Tysons, VA) was reviewed for revenues, costs, and profits per SG at an academic hospital (2017-2022). Actual figures were obtained, not insurance charge estimates or hospital projections. Fixed costs were obtained through surgery-specific allocation of inpatient hospital and operating-room costs. Direct variable costs were analyzed with sub-components including: (1) labor and benefits, (2) implants, (3) drug costs, and 4) medical/surgical supplies. The pre-COVID-19 period (10/2017-2/2020) and post-COVID-19 period (5/2020-9/2022) financial metrics were compared with student's t-test. Data from 3/2020 to 4/2020 were excluded due to COVID-19-related changes. RESULTS: A total of 739 SG patients were included. Average length of stay (LOS), Center for Medicaid and Medicare Case Mix Index (CMI), and percentage of patients with commercial insurance were similar pre vs. post-COVID-19 (p > 0.05). There were more SG performed per quarter pre-COVID-19 than post-COVID-19 (36 vs. 22; p = 0.0056). Pre-COVID-19 and post-COVID-19 financial metrics per SG differed significantly for, respectively, revenues ($19,134 vs. $20,983) total variable cost ($9457 vs. $11,235), total fixed cost ($2036 vs. $4018), total profit ($7571 vs. $5442), and labor and benefits cost ($2535 vs. $3734; p < 0.05). CONCLUSIONS: The post-COVID-19 period was characterized by significantly increased SG fixed cost (i.e., building maintenance, equipment, overhead) and labor costs (increased contract labor), resulting in precipitous profit decline that crosses the break-even in calendar year quarter (CQ) 3, 2022. Potential solutions include minimizing contract labor cost and decreasing LOS.

Primary Care Physicians' Knowledge, Attitude and Practice towards Bariatric Operations in the Kingdom of Bahrain

Background: Obesity is an epidemic treatable disease. In Bahrain, the prevalence of obesity was 36.2%. Bariatric surgery should be considered for patients with BMI >= 40, or >= 30 with obesity-related comorbidities. Family physicians have a key role in identifying and counseling patients who may qualify for bariatric surgery. The most common reason for physicians' refusal of referral for bariatric surgeries is fear of complications followed by concern of ineffective weight loss following the surgery. Doctors are not comfortable providing post bariatric operation care. Aim(s): To study the PCPs' knowledge, attitude and practice towards bariatric surgeries in the kingdom of Bahrain. Method(s): this is a cross-sectional study of a convenient sample of physicians working in the Kingdom of Bahrain health centers, using an electronic and manual questionnaire to test the knowledge, attitude and practice towards bariatric surgery. Result(s): The sample included a total of 222 participants. 56.1% agreed that the BMI >= 40 without weight related comorbidities is an indication for bariatric surgery and 92.3% of them referred patients for bariatric surgery, with BMI (88.6%) as the most influential factor followed by presence of comorbidities (87.8%). On the other hand, lack of resources was the main cause for not referring patient for bariatric surgery (29.4%) followed by concerns with follow up (23.5%). 80.6% are comfortable to initiate conversations with their patients about bariatric surgery, while 36.1% feel comfortable explaining the procedural options to a patient. 83.8% agreed that additional medical education in bariatric surgical care would be useful. Conclusion(s): Primary care physicians showed well knowledge about the referral criteria to bariatric surgeries and that's reflected by the high referral rate (92.3%). But there is a gap in the knowledge mean score across different age groups and experience. Less than half of the physicians are not comfortable dealing with patients. Continuous medical education is essential to address the gap and to establish comprehensive obesity management guidelines for primary care physicians.Copyright © 2023, Bahrain Medical Bulletin. All rights reserved.

Post-Operative but Not Pre-Operative COVID-19 Predicts Serious Complications and Mortality Following Elective Bariatric Surgery.

PURPOSE: We sought to characterize the prevalence and subsequent impact of pre- and post-operative COVID-19 diagnosis on bariatric surgery outcomes. COVID-19 has transformed surgical delivery, yet little is known regarding its implications for bariatric surgery. MATERIALS AND METHODS: The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was evaluated with three cohorts described: those diagnosed with COVID-19 pre-operatively (PRE), post-operatively (POST), and those without a peri-operative COVID-19 (NO) diagnosis. Pre-operative COVID-19 was defined as COVID-19 within 14 days prior to the primary procedure while post-operative COVID-19 infection was defined as COVID-19 within 30 days after the primary procedure. RESULTS: A total of 176,738 patients were identified, of which 174,122 (98.5%) had no perioperative COVID-19, 1364 (0.8%) had pre-operative COVID-19, and 1252 (0.7%) had post-operative COVID-19. Patients who were diagnosed with COVID-19 post-operatively were younger than other groups (43.0 ± 11.6 years NO vs 43.1 ± 11.6 years PRE vs 41.5 ± 10.7 years POST; p < 0.001). Pre-operative COVID-19 was not associated with serious complications or mortality after adjusting for comorbidities. Post-operative COVID-19, however, was among the greatest independent predictors of serious complications (OR 3.5; 95% CI 2.8-4.2; p < 0.0001) and mortality (OR 5.1; 95% CI 1.8-14.1; p = 0.002). CONCLUSIONS: Pre-operative COVID-19 within 14 days of surgery was not significantly associated with either serious complications or mortality. This work provides evidence that a more liberal strategy which employs early surgery after COVID-19 infection is safe as we aim to reduce the current bariatric surgery case backlog.

Lessons from the COVID-19 pandemic: remote coaching in bariatric surgery.

BACKGROUND: The development of fast internet connection has stimulated different types of video-assisted teaching programs. However, a remote mentoring with the proctor not on site has never been reported in bariatric surgery. We described our experiences with remote telementoring for laparoscopic sleeve gastrectomy. METHODS: A qualified general surgeon at the beginning of his bariatric practice performed a series of 8 laparoscopic sleeve gastrectomies (LSG) while tutored by an experienced bariatric surgeon connected from a different city through a specific videoconferencing platform. Data on demographics at baseline, operative time, hospital stay, intraoperative early, and late complications were collected. RESULTS: Mean age and BMI of patients were 36.9 ± 9.6 years old and 41.8 ± 1.7 kg/m2. All procedures were carried out without conversion to open or complications. Mean operative time was 112.4 ± 21.9 min while the hospital stay was 3.5 ± 0.5 days. Operative time significantly decreased after the fourth operation. CONCLUSIONS: Remote coaching appears to be possible and safe for LSG.

[Impact of the COVID pandemic on treatment of bariatric patients in Germany-An analysis of the national StuDoQ/MBE register]. / Auswirkungen der COVID-Pandemie auf die Versorgung bariatrischer Patienten in Deutschland ­ eine Analyse des nationalen StuDoQ/MBE-Registers.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic the standard inpatient care of patients was restricted to increase overall and intensive care capacity reserves for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected persons. OBJECTIVE: This article presents the impact of the COVID-19 pandemic on the surgical and postoperative care of bariatric patients in Germany. MATERIAL AND METHODS: A statistical analysis of the national StuDoQ/MBE register data for the period from 1 May 2018 until 31 May 2022 was performed. RESULTS: Throughout the entire study period there was a continuous increase in documented operations, which continued even during the COVID-19 pandemic. A significant intermittent decline in surgery performed was observed only during the imposition of first lockdown in the months of March to May 2020, with a minimum number of 194 cases performed monthly in April 2020. The pandemic had no measurable effect on the surgically treated patient population, the type of surgical procedure, the perioperative and postoperative outcomes and follow-up care. CONCLUSION: Based on the results of the StuDoQ data and the current literature, it can be deduced that bariatric surgery can be carried out with no increased risk during the COVID-19 pandemic and the quality of postoperative care is not impaired.

Cancer, Covid and Control of Ra - a Toxic Combination?

Case report - Introduction: This case highlights the dilemma of keeping rheumatoid arthritis disease under control in active cancer cases and establishing a consistent multidisciplinary dialogue during a pandemic and staffing crises. During chemotherapy and active cancer treatment, disease-modifying therapies (conventional and biologic) are often stopped. In some cases, the potential benefits versus risks of restarting usual therapies have to be balanced against risks of suppressing disease activity with highdose steroids. Risks of infection (common and atypical) need to be considered. Case report - Case description: A is a 67-year-old female nonsmoker diagnosed with seropositive rheumatoid arthritis (RF, anti - CCP positive) in 2008. Other conditions include type 2 diabetes, atrial fibrillation (on warfarin), hypothyroidism and obstructive sleep apnoea. Due to active disease, despite triple therapy (methotrexate, sulphasalazine and hydroxychloroquine), anti-TNF therapy (etanercept) commenced in 2009 with primary non-response. However, she responded well to B-cell therapy (rituximab) in conjunction with oral methotrexate (25mg weekly) receiving annual infusions from 2010 to 2016. In 2017, an elective sleeve gastrectomy procedure for high BMI was abandoned after peritoneal deposits of concern were noted. Histology and CT imaging were consistent with a primary peritoneal malignancy (Stage 3c low-grade serous adenocarcinoma). Treatment involved debulking surgery (total abdominal hysterectomy, bilateral salpinoophorectomy, omentectomy) and tamoxifen. Treatment for rheumatoid arthritis stalled during this period but as frequent steroids were required for active joint inflammation, in agreement with the oncologists, she had a rituximab cycle in 2018. Unfortunately, in 2019 she had signs of cancer progression (elevated tumour markers, CT imaging) and has subsequently started carboplatin chemotherapy. She has been unable to continue methotrexate or rituximab pending completion of the chemotherapy cycles (ongoing). However, her arthritis is now uncontrolled without increased steroids. Due to recurrent flares, her maintenance dose has been increased from 5mg to 7.5-10mg prednisolone daily until we can establish if it is safe and appropriate to recommence her usual arthritis regime. Even without disease-modifying therapy like methotrexate and rituximab, risk of infection (including atypical ones) is still significant with the combination of chemotherapy and steroids. Risk of progressive joint damage and adverse quality of life with active arthritis also needs to be considered. Staffing crises, exacerbated by COVID pandemic issues, have added to complexity of decision making and coordination of regular multidisciplinary discussions regarding treatment. Case report - Discussion: Cancer is a known association in rheumatoid arthritis patients with a twofold higher risk of lymphoma compared to the general population. Whether condition or treatment affects risk remains unclear as immune dysregulation is relevant in both autoimmunity and cancer. Paraneoplastic, recent onset arthritis, chemotherapy- or immunotherapy-induced arthralgia/arthritis are also well documented. This case had a seropositive rheumatoid arthritis phenotype quite a few years prior to cancer diagnosis. Primary peritoneal cancer is uncommon, often presenting as in this case as an incidental finding. It is usually treated like ovarian cancer Whilst methotrexate has been implicated in lung cancer, melanoma and non-Hodgkin lymphoma, overall safety data suggest any risk is quite low (e.g., EBV-associated lymphoproliferative disorders usually resolve with drug discontinuation). It is also a known chemotherapeutic agent. Anti-TNF treatment algorithms generally exclude patients with recent cancer. Rituximab, originally developed as a cancer drug, is not thought to affect risk of cancer development or progression. Treatment with disease-modifying therapy (conventional and biologics) is often withheld in patients with active malignancy undergoing chemotherapy due to a theo etical risk of potentiated immunosuppression and toxicity, particularly cytopaenias. However, maintaining arthritis control with glucocorticoids also has short- and long-term risks. Combining chemotherapy agents like carboplatin with methotrexate has been used for urothelial carcinoma and can be well tolerated with close monitoring of haematological parameters. Thus, it could be argued this patient is at risk of infections whichever treatment approach is taken and regaining control of arthritis with recommencement of methotrexate and rituximab is much better for her quality of life. Regular multidisciplinary discussions are important to outline risks versus benefits of combined treatment. This may be difficult in practice during staffing crises. Covid risk in patients receiving rituximab and/or chemotherapy, timing and response to COVID vaccination are also important considerations. Case report - Key learning points: . Primary peritoneal cancer is uncommon and can present as an incidental finding . Whilst treatment for progressive cancer is important, withholding rheumatoid arthritis treatment can have a significant adverse impact on quality of life . Morbidity and mortality risks of stopping treatment versus combined treatment (cancer therapy and disease-modifying therapy) ideally needs to be fully discussed and agreed with the patient and all care providers - lack of "named" providers, restructuring, redeployment, multi-specialty care and a global pandemic can make coordination of this difficult.

Bariatric surgeon perceptions of the safety of same-day sleeve gastrectomy in the state of Massachusetts.

BACKGROUND: During the past 2.5 years, select bariatric surgeons in the Commonwealth of Massachusetts have been implementing same-day sleeve gastrectomy (SDSG). Key reasons for this change have been to reduce risks associated with hospitalization in the context of the COVID-19 pandemic and to comply with third-party payer preference to reduce costs. OBJECTIVE: We aimed to evaluate bariatric surgeons' attitudes about outcomes and morbidity between patients who are hospitalized after sleeve gastrectomy and patients who undergo SDSG. SETTING: Beth Israel Deaconess Medical Center in Boston, Massachusetts (teaching hospital of Harvard Medical School). METHODS: This prospective cohort study was conducted among bariatric surgeons practicing in the Commonwealth of Massachusetts. An anonymous web-based questionnaire was distributed using the Research Electronic Data Capture software. A total of 58 bariatric surgeons in Massachusetts were identified and successfully contacted based on registration with the Massachusetts Board of Registration in Medicine, membership in the American Society for Metabolic and Bariatric Surgery, and internet search. RESULTS: A total of 33 bariatric surgeons in Massachusetts completed the survey, yielding a response rate of 56.9%. Among the respondents, 75.76% have not performed SDSG, reporting patient safety as the major concern, and 24.24% had performed SDSG in the past. CONCLUSION: Survey responses showed no significant differences in surgeon perception between SDSG and hospitalization after surgery. Optimal patient selection was an important factor influencing surgeons' decisions with regard to performing SDSG. However, bariatric surgeons in Massachusetts are reluctant to perform SDSG.

Ehealth Intervention Via Line Social Media as an Adjunct for Postoperative Care after Bariatric-Metabolic Surgery - Single Institution Experience

Background/Introduction: Applying eHealth interventions via social media is common in modern medicine. LINE is a popular communication app in Taiwan that can deliver messages 24 hours a day. In addition to being free-of-charge, it also allows bariatric nurses (BNs) and patients to enjoy bidirectional communication via telecommunication services instead of direct, face-to-face contact for patients undergoing bariatric-metabolic surgery (BMS). Objective(s): We conducted this retrospective study to determine the frequency and reasons for early post-discharge of LINE messages/calls and investigate the relationship between this frequency and contents of these messages and postoperative outcomes after BMS. Method(s): A retrospective review of prospectively collected data was conducted in an Asian weight management center. The study period ran from August 2016 to December 2021, and a total of 143 native patients with severe obesity were enrolled. All patients were informed of the necessity of a postoperative dietitian consultation before bariatric surgery. The patterns of LINE communication with the BN and associated actions to resolve patients' needs within 180 days after index BMS were analyzed. Result(s): Among the 143 enrolled patients, 100 underwent laparoscopic sleeve gastrectomy and 43 underwent laparoscopic Roux-en-Y gastric bypass. A total of 1,205 messages/calls were analyzed concomitantly;most LINE communications focused on diet problems (47.97%;n = 578), weight problems (11.54%;n = 139), and medications (9.21%;n = 111). Most problems could be resolved by LINE communications directly, and only a small portion (5.6%) was directed to local clinics or emergency departments. During the COVID-19 pandemic, the usage of LINE communications significantly increased (12.2 +/- 10.4 vs. 6.4 +/- 4.9;p < 0.01);nonetheless, a higher frequency of LINE communications would not hinder the regular clinic visits (r = 0.359;p = 0.01). Conclusion(s): Based on our limited experience, the LINE consultation service operated by the BN could effectively address patients' problems. Moreover, it might reduce the need for emergency department visits or unexpected clinic appointments for patients after BMS.

Making lemonade with lemons: a multicenter effort to improve outpatient sleeve gastrectomy amid the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic impacted healthcare delivery worldwide. Resource limitations prompted a multicenter quality initiative to enhance outpatient sleeve gastrectomy workflow and reduce the inpatient hospital burden. OBJECTIVES: This study aimed to determine the efficacy of this initiative, as well as the safety of outpatient sleeve gastrectomy and potential risk factors for inpatient admission. SETTING: A retrospective analysis of sleeve gastrectomy patients was conducted from February 2020 to August 2021. METHODS: Inclusion criteria were adult patients discharged on postoperative day 0, 1, or 2. Exclusion criteria were body mass index ≥60 kg/m2 and age ≥65 years. Patients were divided into outpatient and inpatient cohorts. Demographic, operative, and postoperative variables were compared, as well as monthly trends in outpatient versus inpatient admission. Potential risk factors for inpatient admission were assessed, as well as early Clavien-Dindo complications. RESULTS: Analysis included 638 sleeve gastrectomy surgeries (427 outpatient, 211 inpatient). Significant differences between cohorts were age, co-morbidities, surgery date, facility, operative duration, and 30-day emergency department (ED) readmission. Monthly frequency of outpatient sleeve gastrectomy rose as high as 71% regionally. An increased number of 30-day ED readmissions was found for the inpatient cohort (P = .022). Potential risk factors for inpatient admission included age, diabetes, hypertension, obstructive sleep apnea, pre-COVID-19 surgery date, and operative duration. CONCLUSION: Outpatient sleeve gastrectomy is safe and efficacious. Administrative support for extended postanesthesia care unit recovery was critical to successful protocol implementation for outpatient sleeve gastrectomy within this large multicenter healthcare system, demonstrating potential applicability nationwide.

Can revision of RYGB to sleeve gastrectomy be a solution to inadequate weight loss treatment?

We aimed to discuss the weight loss success of the revision of RYGB to sleeve gastrectomy (SG). Between January 2019 and June 2020, four patients' files were analyzed retrospectively. Post-RYGB mean minimal BMI was 27.4 ± 9.47 kg/m², before SG the mean BMI was 43.41 ± 4.16 kg/m2. Post-operative gastric fistula developed in two patients. The mean follow-up time after revision surgery was 17.25 ± 6.89 months, mean excess weight loss (EWL) was 74.77 ± 8.94%, and mean BMI was 32.65 ± 2.9 kg/m2. Despite high rate of major complications, revision of RYGB to SG is successful in weight loss and resolving certain complications of RYGB.

Nuestro objetivo era discutir el éxito en la pérdida de peso de la revisión de BGYR a gastrectomía en manga (SG). Entre enero de 2019 y junio de 2020, se analizaron retrospectivamente los archivos de cuatro pacientes. El IMC mínimo medio post BGYR fue 27.4 ± 9.47 kg/m², antes de SG el IMC medio fue 43.41 ± 4.16 kg/m2. En dos pacientes se desarrolló una fístula gástrica posoperatoria. El tiempo medio de seguimiento después de la cirugía de revisión fue de 17.25 ± 6.89 meses, la pérdida media de exceso de peso (PEP) fue de 74.77 ± 8.94% y el IMC medio fue de 32.65 ± 2.9 kg/m2. A pesar de la alta tasa de complicaciones mayores, la revisión de BGYR a SG tiene éxito en la pérdida de peso y la resolución de ciertas complicaciones de BGYR.

Effect of COVID 19 Lockdown on Weight Change in Post-Surgical Bariatric Patients

Katarina Bade Hartford CT CT1, Richard Seip Hartford CT1, Tara McLaughlin Vernon Rockville CT1, Darren Tishler Glastonbury CT1, Ilene Staff Hartford CT2, Connie Santana Glastonbury CT1, Aziz Benbrahim MERIDEN CT3, Meagan Moskowitz Meriden CT3, Pavlos Papasavas Hartford CT1 Hartford Hospital1 Hartford Hospital2 Mid State Medical Center3 Introduction: Safe and effective weight loss immediately following bariatric surgery occurs in concert with both social and medical support. Interruption of support networks may threaten weight loss. During the COVID19 pandemic, a Connecticut state-mandated “lockdown” from 3/15 to 5/18/2020 suspended in-person services and interrupted social support. We investigated the effect of exposure to 63 days of COVID lockdown within 12 months of index sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) on weight loss. Methods: This single center, retrospective chart review identified 1057 patients with 1 year follow-up data who underwent SG or RYGB from 1/9/2016 to 12/30/20. Controls (Group C) (SG n750, RYGB n130) completed surgery and follow up from 1/9/2016 to 3/15/20, before lockdown. Lockdown patients (Group L) (SG n159, RYGB n18) completed surgery before 3/15/20, and follow up after the lockdown (5/20/20 to 12/31/2020). Weight loss (WL) was compared between C and L, within surgery types. Results: Within surgery type, pre-surgery characteristics differed little between L and C (Table 1, top). Days to follow-up, and absolute and relative weight changes did not differ between L and C. Within L, 16% of SG patients and 20% of RYGB patients experienced virtual (telemedicine) visits with bariatric clinicians during follow-up, compared to 0.6% in Group C. Conclusion: We detected no effect of 63 days of COVID lockdown on measures of weight change at 1 year post SG or RYGB. Telemedicine visits may be useful to maintain/improve clinical management of surgical weight loss during suspension of live health services.

Postoperative follow-up within the bariatric surgery practice is associated with improved one-year weight loss for telemedicine patients

Lee Ying New Haven CT1, Grace Chao New Haven CT1, Milot Thaqi New Haven CT1, Maija Cheung Branford CT1, Saber Ghiassi Fairfield CT1, Geoff Nadzam 1, Andrew Duffy New Haven CT1, John Morton MADISON CT2 Yale1 Yale University2 Background: When elective surgeries resumed during the COVID-19 pandemic of 2020, many in-person visits remained virtual. In this study we analyzed weight-loss outcomes for patients undergoing bariatric surgery during in 2020. Methods: This is a retrospective comparison of laparoscopic sleeve gastrectomies (LSG) from January to November at a large academic center in two separate calendar years (2020 and 2017). The average age, preoperative BMI, one-year postoperative percent total weight loss (%TWL), and postoperative follow-up was compared between patients who had surgery in 2020 and 2017. Results: There were 117 LSG cases in 2020, compared to 208 in 2017. There was no difference in the age of patients (years, 42.2 vs. 42), but patients in 2020 had a higher preoperative BMI (2020: 46.9, 2017: 43.5,;p<0.05). The one-year %TWL was lower for patients who underwent surgery in 2020 (2020: 17.9%, 2017: 22.1 %, p<0.05). Compared to outcomes in 2017, the average %TWL in 2020 was significantly lower for patients in 2020 who did not have one-year follow-up of any kind with bariatric surgery (22.1% versus 15.2%, p<0.01). There was no significant difference for those who did have one-year bariatric surgery follow-up (22.1% versus 22.4%, p=0.99). Patient satisfaction did not change. Conclusion: Compared to 2017, patients who underwent LSG during the COVID-19 pandemic tended to be similar in age but had a higher pre-operative BMI and lost less weight when they had no follow up. Ensuring follow-up within the bariatric surgery practice may improve weight loss in telemedicine patients.

Enhanced home health after bariatric surgery supports patient access and reduces length of stay and variable costs during COVID

Peter Ng Raleigh NC1, Afton Carducci Raleigh NC1, Lindsey Sharp Raleigh NC1, Dustin Bermudez Raleigh NC1, Linda Youngwirth Durham NC1, Tricia Burns Raleigh NC1, Erica McKearney Raleigh NC1, Lauren Massey Raleigh NC2 UNC Rex Bariatric Specialist1 UNC REX Hospital2 Introduction: The COVID-19 pandemic stressed inpatient hospital capacity and restricted elective surgery, limiting bariatric access. A novel outpatient home health program was introduced to support early discharge after bariatric surgery and preserve inpatient healthcare resources for COVID. This retrospective study evaluates the clinical/financial impact of enhanced home health in early post-operative bariatric recovery. Methods: Our program offered enhanced home health (EHH) to all bariatric patients with insurance inclusion. Patients were separated into 3 care tiers based on BMI and comorbidity with each tier adding complementary services. Tier 1 provided home intravenous hydration, anti-emetics x 3 days, and home nursing care. Tier 2 (BMI>50 kg/m2) added physical therapy. Tier 3 (plus comorbidity) added virtual primary care medical consultation. Patients were planned for scheduled discharge on post-operative day one by 10 am, if deemed medically appropriate. Results: From December to June 2021, 355 bariatric cases were performed, 158 non-EHH patients and 197 EHH patients with the following combined case mix: duodenal switch (54.6%), revision (17.2%), sleeve gastrectomy (16.6%), SADI-S (7.7%), and Roux-en-Y gastric bypass (3.9%). The prior year average hospital length of stay (LOS) was 2.0 days, non-EHH LOS of 2.0 days, versus EHH LOS of 1.5 days. A 6% reduction in direct variable costs per case was demonstrated, $9607 non-EHH versus $9036 EHH. Comparative readmission rates for nausea/vomiting/dehydration (NVD) equaled 3.8% for non-EHH and 1.5% for EHH patients. Conclusion: Enhanced home health preserved access to bariatric care while decreasing length of stay, variable costs, and reduced readmission for NVD.

The impact of COVID on bariatric surgery in Texas 2019-2020

Benjamin Clapp El Paso TX1, Jisoo Kim 1, Brittany Harper El Paso TX1, John Marr El Paso TX1, Hani Annabi El Paso TX1, Luis Alvarado 1, Brian Davis El Paso TX1 Texas Tech HSC Paul Foster School of Med1 Introduction: All fields of medicine were affected by the COVID pandemic including metabolic and bariatric surgery (MBS). Across the nation there was a moratorium on elective surgical cases that started in the second quarter of 2020 and continued on and off for the rest of the year. The negatively affected the health of bariatric patients who had their surgeries delayed. Our aim was to determine the decrease in the volume of MBS cases from 2019 to 2020. Methods: The Texas Inpatient and Outpatient Public Use Data File for the years 2019 and 2020 were evaluated. We searched for the Current Procedural Terminology (CPT) codes and International Classification of Diseases version 10 (ICD10) procedure codes for common bariatric operations in both databases. Descriptive statistics were applied and the data was separated by quarter. Results: There were 21,043 MBS cases performed in Texas in 2020. There was an 11% decrease in MBS in Texas from the year 2019 to 2020. The decrease was most noticeable in the 1st and 2nd quarter of 2020 with a subsequent rebound. There were 2,511 less cases in 2020. Sleeve gastrectomies remained the dominant procedure and the percentage of outpatient sleeves increased from 30% to 37% Conclusion: The COVID pandemic caused a 11% decrease in MBS in the year 2020 from the previous year. There was a shift toward performing more outpatient cases. There was a rebound in the second half of the year, with more cases being performed than in the previous 3rd and 4th quarter.

Making Lemonade with Lemons: A multi-institutional effort to improve same-day discharge for sleeve gastrectomy amid the COVID-19 pandemic

Theresa Jackson Sacramento CA1, Gary Grinberg Elk Grove CA1, Aaron Baggs Richmond CA2, Emily Siegler Elk Grove CA3, Panduranga Yenumula Sacramento CA1 Kaiser Permanente South Sacramento1 Kaiser Permanente Richmond2 California Northstate University3 Background: The COVID-19 pandemic impacted healthcare delivery worldwide. Resource limitations prompted a multi-institutional quality initiative to enhance same-day discharge workflow after sleeve gastrectomy to reduce the inpatient hospital burden. This study aims to determine the safety and efficacy of this initiative, as well as potential modifiable and non-modifiable risk factors for inpatient admission. Methods: A retrospective analysis of sleeve gastrectomy patients was conducted from January 2019 to August 2021. Inclusion criteria was discharge on postoperative day zero, one, or two. Patients were divided into same-day discharge (SD) and inpatient cohorts. Demographic, operative, and postoperative variables were compared, as well as monthly trends in same-day and inpatient care. Potential risk factors for inpatient admission were assessed. Results: Analysis included 2,209 sleeve gastrectomy surgeries (462 SD, 1,747 inpatient). Significant differences between cohorts were age, hypertension, obstructive sleep apnea, pre-/post-COVID, facility, and combination procedure (e.g. paraesophageal hernia). Monthly frequency of same-day discharge rose from 13% in June 2020 to 75% in August 2021. There was no difference in rates of inpatient readmission, reoperation, mortality, or 6-month excess weight loss. SD discharge patients had higher rates of 7-day emergency department readmission (9% vs 5%, p=0.004). Potential risk factors for inpatient admission include: age, BMI, diabetes mellitus, hypertension, obstructive sleep apnea, surgery date, facility, and combination case. Conclusion: Same-day discharge after sleeve gastrectomy is safe and efficacious. Administrative support for extended PACU (postanesthesia care unit) recovery was critical to successful protocol implementation for same-day discharge within this large multi-institutional healthcare system demonstrating potential applicability nationwide.

The Impact of COVID-19 Pandemic on Access to Bariatric Surgery

Katherine Ho Tucson AZ1, Chiu-Hsieh Hsu Tucson AZ1, Yazan Ashouri Tucson AZ1, Saad Ajmal Tucson AZ1, Iman Ghaderi Tucson AZ1 University of Arizona1 Introduction: The COVID-19 pandemic had affected the health systems across the world since early 2020 with a concern about access to medical care during the first wave of COVID-19 pandemic. The aim of this study was to examine the effect of COVID-19 on the patient selection for elective bariatric surgery using Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Methods: MBSAQIP data for 2016-2020 was queried. Log-normal regression was performed to evaluate patient characteristics. Comparison between cases performed in 2020 and previous years was derived using Wilcoxon rank-sum test for continuous variables and Fisher’s exact test for categorical variables for laparoscopic vs. robotic-assisted approaches. Results: A total of 822,558 patients underwent robotic (R) and laparoscopic (L) sleeve gastrectomy and Roux-en-Y gastric-bypass (R-SG, L-SG, R-RYGB, and L-RYGB, respectively). Comorbidities were lower in the cases performed in 2020 compared to pre-COVID years in both the laparoscopic and robotic approaches of SG and RYGB. Conclusion: Patients who underwent elective bariatric surgery during COVID-19 pandemic in 2020 tend to have less comorbidities comparing to the patients who had bariatric surgery prior to COVID-19. It is possible that bariatric centers decreased offering surgeries to high-risk patients.

The impact of COVID on revisional bariatric surgery trends: An analysis of the 2020 MBSAQIP database

Benjamin Clapp El Paso TX1, Omar Ghanem Rochester MN2, Pavlos Papasavas Hartford CT3, John Marr El Paso TX1, Jisoo Kim El Paso TX1, Wayne English Nashville TN4 Texas Tech HSC Paul Foster School of Med1 Mayo Clinic2 Hartford Hospital3 Vanderbilt University4 Background: Revisional bariatric surgery (RBS) is the third most common bariatric surgery performed in the United States. RBS is likely to increase with time and may soon surpass Roux-en-Y gastric bypass (RYGB) in volume. The Metabolic and Bariatric Surgery Quality Improvement and Accreditation Program (MBSAQIP) tracks bariatric cases. Our goal was to evaluate the MBSAQIP for revisional bariatric surgery trends. Methods: The 2020 MBSAQIP Participant Use File (PUF) was used to look at the number and type of RBS and compared to similar MBSAQIP data over the previous five years. All cases listed under the Revision tag were included in the analysis. Procedures considered included RYGB, sleeve gastrectomy (SG), adjustable gastric band (AGB), biliopancreatic diversion (BPD) and single anastomosis duodenoileal bypass (SADI). Descriptive statistics were used. Results: There were 197,812 cases reported in the PUF. Of these, 26,652 (13.5%) were revisions, conversions or reoperations. Stapled non emergent procedures dominated with 19,763. There were 4,291 SG conversions and 682 re-sleeves. There were 9,217 RYGB conversions and 3,221 revisions. There were 2,067 AGB revisions, 883 BPD revisions or conversions, and 424 SADI revisions or conversions. Conclusions: A 40.2% percent increase of RBS was seen from 2015 to 2019 but COVID was responsible for a 22.8% decrease in 2020. It is anticipated that RBS will resume its upward trend after the pandemic passes. AGB revisions have decreased, while SADI revisions have increased. The largest percentage of growth has been in SG conversions.

Laparoscopic Paraoesophageal Hernia, Gastric Bypass and Peroral Endoscopic Myotomy in a patient with Achalasia and Gastroesophageal reflux after Sleeve Gastrectomy

Daniel Slack Charlotte NC1, Paul Colavita Charlotte NC1, Abdelrahman Nimeri Charlotte NC1 Carolinas Medical Center, Atrium Health1 We present a 55-year-old female with class II obesity and a previous history of sleeve gastrectomy who developed significant gastroesophageal reflux disease refractory to medical management. After a covid infection in fall of 2020 she began to report new symptoms of dysphagia that progressed from solids to liquids. She underwent extensive workup including upper endoscopy, upper GI barium swallow, manometry, pH impedence and EndoFlip leading to a diagnosis of Achalasia type II as well as a paraesophageal hernia. Given these findings she underwent a combined paraesophageal hernia repair with conversion of sleeve gastrectomy to Roux-en-Y gastric diversion and an intra-operative Peroral Endoscopic Myotomy. Intra-operatively she was noted to have significant lower abdominal adhesions leading to performing the Roux-en-Y reconstruction through a supramesocolic defect in a retrocolic fashion. The patient tolerated the procedure well and recovered with improvement of both her reflux and achalasia.