Bariatric surgery: trends in utilization, complications, conversions and revisions.

BACKGROUND: Sleeve gastrectomy (SG) increased in popularity after 2010 but recent data suggest it has concerning rates of gastroesophageal reflux and need for conversions. This study aims to evaluate recent trends in the utilization of bariatric procedures, associated complications, and conversions using an administrative claims database in the United States. METHODS: We included adults who had bariatric procedures from 2000 to 2020 with continuous enrollment for at least 6 months in the MarketScan Commercial Claims and Encounters database. Index bariatric procedures and subsequent revisions or conversions were identified using CPT codes. Baseline comorbidities and postoperative complications were identified with ICD-9-CM and ICD-10 codes. Cumulative incidences of complications were estimated at 30-days, 6-months, and 1-year and compared with stabilized inverse probability of treatment weighted Kaplan-Meier analysis. RESULTS: We identified 349,411 bariatric procedures and 5521 conversions or revisions. The sampled SG volume appeared to begin declining in 2018 while Roux-en-Y gastric bypass (RYGB) remained steady. Compared to RYGB, SG was associated with lower 1-year incidence [aHR, (95% CIs)] for 30-days readmission [0.65, (0.64-0.68)], dehydration [0.75, (0.73-0.78)], nausea or vomiting [0.70, (0.69-0.72)], dysphagia [0.55, (0.53-0.57)], and gastrointestinal hemorrhage [0.43, (0.40-0.46)]. Compared to RYGB, SG was associated with higher 1-year incidence [aHR, (95% CIs)] of esophagogastroduodenoscopy [1.13, (1.11-1.15)], heartburn [1.38, (1.28-1.49)], gastritis [4.28, (4.14-4.44)], portal vein thrombosis [3.93, (2.82-5.48)], and hernias of all types [1.36, (1.34-1.39)]. There were more conversions from SG to RYGB than re-sleeving procedures. SG had a significantly lower 1-year incidence of other non-revisional surgical interventions when compared to RYGB. CONCLUSIONS: The overall volume of bariatric procedures within the claims database appeared to be declining over the last 10 years. The decreasing proportion of SG and the increasing proportion of RYGB suggest the specific complications of SG may be driving this trend. Clearly, RYGB should remain an important tool in the bariatric surgeon's armamentarium.

The antigenic landscape of human influenza N2 neuraminidases from 2009 until 2017.

Human H3N2 influenza viruses are subject to rapid antigenic evolution which translates into frequent updates of the composition of seasonal influenza vaccines. Despite these updates, the effectiveness of influenza vaccines against H3N2-associated disease is suboptimal. Seasonal influenza vaccines primarily induce hemagglutinin-specific antibody responses. However, antibodies directed against influenza neuraminidase (NA) also contribute to protection. Here, we analysed the antigenic diversity of a panel of N2 NAs derived from human H3N2 viruses that circulated between 2009 and 2017. The antigenic breadth of these NAs was determined based on the NA inhibition (NAI) of a broad panel of ferret and mouse immune sera that were raised by infection and recombinant N2 NA immunisation. This assessment allowed us to distinguish at least four antigenic groups in the N2 NAs derived from human H3N2 viruses that circulated between 2009 and 2017. Computational analysis further revealed that the amino acid residues in N2 NA that have a major impact on susceptibility to NAI by immune sera are in proximity of the catalytic site. Finally, a machine learning method was developed that allowed to accurately predict the impact of mutations that are present in our N2 NA panel on NAI. These findings have important implications for the renewed interest to develop improved influenza vaccines based on the inclusion of a protective NA antigen formulation.

Two proteins, the hemagglutinin and the neuraminidase, protrude from the surface of the influenza virus. Their detection by the immune system allows the host organism to mount defences against the viral threat. The virus evolves in response to this pressure, which manifests as changes in the appearance of its hemagglutinin and neuraminidase. This process, known as antigenic drift, leads to the proteins evading detection. It is also why flu vaccines require frequent updates, as they rely on 'training' the immune system to recognise the most important strains in circulation ­ primarily by exposing it to appropriate versions of hemagglutinin. While the antigenic drift of hemagglutinin has been extensively studied, much less is known about how the neuraminidase accumulates mutations, and how these affect the immune response. To investigate this question, Catani et al. selected 43 genetically distant neuraminidases from human viral samples isolated between 2009 and 2017. Statistical analyses were applied to define their relatedness, revealing that a group of closely related neuraminidases predominated from 2009 to 2015, before they were being taken over by a second group. A third group, which was identified in viruses isolated in 2013, was remarkably close to the neuraminidase of strains that circulated in the late 1990s. The fourth and final group of neuraminidases was derived from influenza viruses that normally circulate in pigs but can also occasionally infect humans. Next, Catani et al. examined the immune response that these 43 neuraminidases could elicit in mice, as well as in ferrets ­ the animal most traditionally used in influenza research. This allowed them to pinpoint which changes in the neuraminidase sequences were important to escape recognition by the host. Data obtained from the two model species were comparable, suggesting that these experiments could be conducted on mice going forward, which are easier to work with than ferrets. Finally, Catani et al. used machine learning to build a computational model that could predict how strongly the immune system would respond to a specific neuraminidase variant. These findings could help guide the development of new vaccines that include neuraminidases tailored to best prime and train the immune system against a larger variety of strains. This may aid the development of 'supra-seasonal' vaccines that protect against a broad range of influenza viruses, reducing the need for yearly updates.

Postpartum Ogilvie's Syndrome After a Vaginal Delivery.

Ogilvie's syndrome is a colonic pseudo-obstruction that results in colonic dilation without a mechanical obstruction. We discuss a 33-year-old, 36-week pregnant, G1P0L0A0 female who presented with severe pre-eclampsia. Less than 24 hours after induction by vaginal delivery, she developed significant abdominal pain and distention. On a CT scan of the abdomen and pelvis, she was diagnosed with Ogilvie's syndrome due to a finding of large bowel dilation with an abrupt transition point at the splenic flexure without a noted mass. She was initially treated conservatively with nasogastric tube decompression and IV fluid resuscitation. When these conservative measures failed, neostigmine was administered with transient improvement in symptoms. Despite the appropriate administration of neostigmine and initial relief of symptoms with stool output, the patient ultimately required surgical intervention with the creation of a transverse loop colostomy. The development of Ogilvie's syndrome in the postpartum period is a very rare finding, particularly after a vaginal delivery.

A Clinical Pharmacist-Led Transitions of Care Program for Veterans with Two Planned Care Transitions (Hospital to Skilled Care and Skilled Care to Home) amid the COVID-19 Pandemic.

Transitional care teams have been shown to improve patient safety. We describe a novel transitional care team with a clinical pharmacist as team leader initiated amid the COVID-19 pandemic. The program focused on Veterans with 2 planned transitions of care: hospital to skilled nursing facility (SNF) and from SNF to home. Ninety older Veterans were enrolled, and 79 medication errors and 80 appointment errors were identified. We conclude that a pharmacist-led program can improve safety in patients with 2 planned transitions of care.

Student Preferences for Virtual or In-Person Interprofessional Education Simulations.

The COVID-19 pandemic created a shift in interprofessional education (IPE) courses, causing programs to change pedagogical approaches. We sought to examine student preferences for taking IPE simulations. On post-simulation surveys from two courses (n=844 students, 2020-2022 academic years), we asked students if they preferred to take the simulation through a synchronous in-person or virtual format. More students preferred a virtual platform in academic year 2021-2022 than the previous year (p<0.001). Students who chose the virtual format believed it was more convenient, reduced COVID-19 transmission, and eased interprofessional collaboration. The downsides to in-person simulations included travel logistics and technical challenges in the simulation lab. Students suggested that in-person simulations more closely resembled 'real life' and that communication and body language are easier to convey in person.

Dying with dementia in nursing homes: A population-based study of decedents and their families.

BACKGROUND: Families play a critical role in end-of-life (EOL) care for nursing home (NH) residents with dementia. Despite the important role of family, little is known about the availability and characteristics of families of persons with dementia who die in NHs. METHODS: This is a retrospective cohort study of 18,339 individuals 65 years and older with dementia who died in a Utah NH between 1998 and 2016, linked to their first-degree family (FDF) members (n = 52,566; spouses = 11.3%; children = 58.3%; siblings = 30.3%). Descriptive statistics, chi-square tests, and t-tests were used to describe the study cohort and their FDF members and to compare sociodemographic and death characteristics of NH decedents with (n = 14,398; 78.5%) and without FDF (n = 3941; 21.5%). RESULTS: Compared with NH decedents with FDF, NH decedents with dementia without FDF members were more likely to be older (mean age 86.5 vs 85.5), female (70.5% vs 59.3%), non-White/Hispanic (9.9% vs 3.2%), divorced/separated/widowed (84.4% vs 61.1%), less educated (<12th grade; 42.2% vs 33.7%), have Medicare and Medicaid (20.8% vs 12.5%), and die in a rural/frontier NH (25.0% vs 23.4%). NH decedents who did not have FDF were also more likely to die from cancer (4.2% vs 3.9%), chronic obstructive pulmonary disease (COPD; 3.9% vs 2.5%), and dementia (40.5% vs 38.4%) and were less likely to have 2+ inpatient hospitalizations at EOL (13.9% vs 16.2%), compared with NH decedents with FDF. CONCLUSIONS: Findings highlight differences in social determinants of health (e.g., sex, race, marital status, education, insurance, rurality) between NH decedents with dementia who do and do not have FDF-factors that may influence equity in EOL care. Understanding the role of family availability and familial characteristics on EOL care outcomes for NH residents with dementia is an important next step to informing NH dementia care interventions and health policies.

Updates in Bariatric Surgery.

Bariatric surgery is currently the most effective long-term treatment for morbid obesity as well as type-2 diabetes mellitus. The field of metabolic and bariatric surgery has seen tremendous growth over the past decade with dramatically reduced risks. This article aims to provide an update on bariatric surgery, highlighting the latest outcomes, improvements, and challenges in the field. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) released a major update to the indications for bariatric surgery at BMI ≥35 kg/m2 regardless of co-morbidities and 30-34.9 kg/m2 with obesity-related comorbidities. Sleeve gastrectomy has emerged as the most popular bariatric procedure in the last 10 years with its remarkable efficacy and safety profile. The implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and Enhanced Recovery After Surgery (ERAS) protocols have significantly improved the quality of care for all bariatric patients. The recent introduction and FDA approval of Glucagon-Like Peptide-1 (GLP-1) agonists for chronic obesity has garnered significant media coverage and popularity, but no guidelines exist regarding its use in relation to bariatric surgery. This update underscores the need for tailored approaches, ongoing research, and the integration of evidence-based medicine and innovations to enhance patient care.

Co-Designing an Initiative to Increase Shared Access to Older Adults' Patient Portals: Stakeholder Engagement.

BACKGROUND: The patient portal is a widely available secure digital platform offered by care delivery organizations that enables patients to communicate electronically with clinicians and manage their care. Many organizations allow patients to authorize family members or friends-"care partners"-to share access to patient portal accounts, thus enabling care partners to receive their own identity credentials. Shared access facilitates trilateral information exchange among patients, clinicians, and care partners; however, uptake and awareness of this functionality are limited. OBJECTIVE: We partnered with 3 health care organizations to co-design an initiative that aimed to increase shared access registration and use and that can be implemented using existing patient portals. METHODS: In 2020, we undertook a rigorous selection process to identify 3 geographically diverse health care organizations that had engaged medical informatics teams and clinical champions within service delivery lines caring for older adults. We prioritized selecting organizations that serve racially and socioeconomically diverse populations and possess sophisticated reporting capabilities, a stable patient portal platform, a sufficient volume of older adult patients, and active patient and family advisory councils. Along with patients and care partners, clinicians, staff, and other stakeholders, the study team co-designed an initiative to increase the uptake of shared access guided by either an iterative, human-centered design process or rapid assessment procedures of stakeholders' inputs. RESULTS: Between February 2020 and April 2022, 73 stakeholder engagements were conducted with patients and care partners, clinicians and clinic staff, medical informatics teams, marketing and communications staff, and administrators, as well as with funders and thought leaders. We collected insights regarding (1) barriers to awareness, registration, and use of shared access; (2) features of consumer-facing educational materials to address identified barriers; (3) features of clinician- and staff-facing materials to address identified barriers; and (4) approaches to fit the initiative into current workflows. Using these inputs iteratively via a human-centered design process, we produced brochures and posters, co-designed organization-specific web pages detailing shared access registration processes, and developed clinician and staff talking points about shared access and staff tip sheets that outline shared access registration steps. Educational materials emphasized the slogan "People remember less than half of what their doctors say," which was selected from 9 candidate alternatives as resonating best with the full range of the initiative's stakeholders. The materials were accompanied by implementation toolkits specifying and reinforcing workflows involving both in-person and telehealth visits. CONCLUSIONS: Meaningful and authentic stakeholder engagement allowed our deliberate, iterative, and human-centered co-design aimed at increasing the use of shared access. Our initiative has been launched as a part of a 12-month demonstration that will include quantitative and qualitative analysis of registration and use of shared access. Educational materials are publicly available at Coalition for Care Partners.

Predicting readmission after bariatric surgery using machine learning.

BACKGROUND: While bariatric surgery is an effective method for achieving long-term weight loss, postoperative readmissions are associated with negative clinical outcomes and significant costs. OBJECTIVES: We aimed to use machine learning (ML) algorithms to predict readmissions and compare results to logistic regression. SETTING: Hospitals participating in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, United States. METHODS: Patients who underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch between 2016 and 2020 were selected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Patient variables reported by the MBSAQIP database were analyzed by ML algorithms random forest (RF), gradient boosting (XGB), and deep neural networks (NN), and the results of the predictive models were compared to logistic regression using area under the receiver operating characteristic curve (AUROC). RESULTS: Our study included 863,348 patients, of which 39,068 (4.52%) were readmitted. AUROC scores were XGB .785 (95% CI .784-.786), RF .785 (95% CI .784-.785), and NN .754 (95% CI .753-.754), compared with .62 (95% CI .62-.621) for logistic regression (LR) (P < .001). The sensitivity and specificity for XGB, the best performing model, were 73.81% and 70%, compared with 52.94% and 70% for logistic regression. The most important variables were intervention or reoperation prior to discharge, unplanned ICU admission, initial procedure, and the intraoperative transfusion. CONCLUSIONS: ML demonstrates significant advantages over logistic regression when predicting 30-day readmission following bariatric surgery. With external validation, models could identify the best candidates for early discharge or targeted postdischarge resources.

Application of machine learning to predict postoperative gastrointestinal bleed in bariatric surgery.

BACKGROUND: Postoperative gastrointestinal bleeding (GIB) is a rare but serious complication of bariatric surgery. The recent rise in extended venous thromboembolism regimens as well as outpatient bariatric surgery may increase the risk of postoperative GIB or lead to delay in diagnosis. This study seeks to use machine learning (ML) to create a model that predicts postoperative GIB to aid surgeon decision-making and improve patient counseling for postoperative bleeds. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was used to train and validate three types of ML methods: random forest (RF), gradient boosting (XGB), and deep neural networks (NN), and compare them with logistic regression (LR) regarding postoperative GIB. The dataset was split using fivefold cross-validation into training and validation sets, in an 80/20 ratio. The performance of the models was assessed using area under the receiver operating characteristic curve (AUROC) and compared with the DeLong test. Variables with the strongest effect were identified using Shapley additive explanations (SHAP). RESULTS: The study included 159,959 patients. Postoperative GIB was identified in 632 (0.4%) patients. The three ML methods, RF (AUROC 0.764), XGB (AUROC 0.746), and NN (AUROC 0.741) all outperformed LR (AUROC 0.709). The best ML method, RF, was able to predict postoperative GIB with a specificity and sensitivity of 70.0% and 75.4%, respectively. Using DeLong testing, the difference between RF and LR was determined to be significant with p < 0.01. Type of bariatric surgery, pre-op hematocrit, age, duration of procedure, and pre-op creatinine were the 5 most important features identified by ML retrospectively. CONCLUSIONS: We have developed a ML model that outperformed LR in predicting postoperative GIB. Using ML models for risk prediction can be a helpful tool for both surgeons and patients undergoing bariatric procedures but more interpretable models are needed.

Preferred Feedback Styles Among Different Groups in an Academic Medical Center.

INTRODUCTION: Feedback is an essential component in complex work environments. Different generations have been shown to have different sets of values, derived from societal and cultural changes. We hypothesize that generational differences may be associated with preferred feedback patterns among medical trainees and faculty in a large academic institution. METHODS: A survey was distributed to all students, residents/fellows, and faculty at a large academic medical institution from April 2020 through June 2020. Survey questions evaluated feedback methods for six domains: preparedness, performance, attitude, technical procedures, inpatient, and outpatient care. Participants selected a preferred feedback method for each category. Patient demographics and survey responses were described using frequency statistics. We compared differences in feedback preferences based on generation and field of practice. RESULTS: A total of 871 participants completed the survey. Preferred feedback patterns in the medical field do not seem to align with sociologic theories of generational gaps. Most participants preferred to receive direct feedback after an activity away from their team, irrespective of their age or medical specialty. Individuals preferred direct feedback during an activity in front of their team only for technical procedures. Compared to nonsurgeons, surgeons were more likely to prefer direct feedback in front of team members for preparedness, performance, and attitude. CONCLUSIONS: Generational membership is not significantly associated with preferred feedback patterns in this complex medical academic environment. Variations in feedback preferences are associated with field of practice that may be due to specialty-specific differences in culture and personality traits present within certain medical specialties, particularly surgery.

Adults Without Advocates and the Unrepresented: A Narrative Review of Terminology and Settings.

Socially isolated adults, including those with and without the ability to make medical decisions, are encountered in clinical practice and are at risk for adverse health outcomes. Consensus is lacking on appropriate terminology to describe subpopulations of these patients. In addition, little is known about the settings in which they present. These gaps prevent clinicians and policymakers from identifying and understanding these populations and deploying appropriate resources to meet their complex needs. We conducted a narrative review of literature on socially isolated adults aged 50 and older to assess and integrate the available evidence regarding the terminology used to describe unrepresented patients and adults without advocates to inform consensus on terminology. We also identified the settings in which unrepresented patients and adults without advocates are described in the literature, including both within and outside health care settings. Our results indicate that there is heterogeneity and inconsistency in the terminology used to describe socially isolated adults, as well as heterogeneity in the settings in which they are identified in the literature. Our findings suggest that future work should include achieving consensus on terminology and integrating proactive interdisciplinary interventions across health systems and communities to prevent adults without advocates from becoming unrepresented.

AF03 adjuvant improves anti-hemagglutinin and anti-neuraminidase immune responses induced by licensed seasonal quadrivalent influenza vaccines in mice.

Seasonal influenza remains a serious public health concern as the viral infection spreads easily from person to person and due to antigenic drift of neutralizing epitopes. Vaccination is the best method for disease prevention, however current seasonal influenza vaccines stimulate antibodies which are often effective against only antigenically similar strains. To boost the immune responses and increase vaccine effectiveness, adjuvants have been used for the past 20 years. The current study explores the use of oil-in-water adjuvant, AF03 to improve an immunogenicity of 2 licensed vaccines. A standard-dose inactivated quadrivalent influenza vaccine (IIV4-SD), containing both hemagglutinin (HA) and neuraminidase (NA) antigens, and recombinant quadrivalent influenza vaccine (RIV4), containing only HA-antigen were adjuvanted with AF03 in naïve BALB/c mouse model. Functional HA-specific antibody titers against all four homologous vaccine strains were enhanced by AF03, indicating potential increase in protective immunity. An increase in HA-specific total immunoglobulin G (IgG) binding titers were detected against homologous HAs, heterologous panel of 30 H3 HAs and seven Influenza B HAs. The neuraminidase inhibition (NAI) activity was significantly higher in IIV4-SD-AF03 group. Use of AF03 adjuvant improved the immune response to two influenza vaccines in a mouse model via an increase in functional and total antibodies against NA and a broad panel of HA-antigens.

Comparison of early post-operative complications in primary and revisional laparoscopic sleeve gastrectomy, gastric bypass, and duodenal switch MBSAQIP-reported cases from 2015 to 2019.

BACKGROUND: Sleeve gastrectomy (SG) is now the most performed bariatric surgery, though gastric bypass (GB) and duodenal switch (DS) remain common, especially as conversion/revision (C/R) procedures. This analysis compared early postoperative outcomes of primary and C/R laparoscopic SG to DS and GB; and primary procedures of each vs C/R counterparts. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) dataset was queried for SG, GB, and DS cases from 2015 to 2019. Multivariable logistic regression calculated crude and adjusted odds ratios for surgical site infection (SSI), reoperation, and readmission at 30 days in two initial comparisons: (1) primary SG vs DS or GB and (2) C/R SG vs DS or GB. A secondary analysis compared primary GS, GB, or DS with C/R counterparts. Models were adjusted for confounding demographics and comorbidities. RESULTS: Of 755,968 primary cases, most were SG (72.8%), followed by GB (26.3%), then DS (0.9%). Compared to SG, GB and DS demonstrated higher odds of SSI (aOR 3.02 [2.84, 3.2]), readmission (aOR 1.97 [1.92, 2.03]), and reoperation (aOR 2.74 [2.62, 2.86]), respectively. Of 68,716 C/R cases, SG was most common (43.2%), followed by GB (37.5%), then DS (19.2%). C/R GB and DS demonstrated greater risk of SSI (aOR 2.28 [1.98, 2.62]), readmission (aOR 2.10 [1.94, 2.27]), and reoperation (aOR 2.3 [2.04, 2.59]) vs SG, respectively. C/R SG and DS demonstrated greater risk of SSI (OR 2.09 [1.66, 2.63]; 1.63 [1.24, 2.14), readmission (OR 1.13 [1.02, 1.26]), and reoperation (OR 1.27 [1.06, 1.52]; 1.58 [1.24, 2.0]), vs primary procedures. C/R DS demonstrated greater risk of SSI (OR 1.23 [1.66, 2.63]). CONCLUSIONS: Early complications are comparable between GB and DS, and greater than SG. In C/R procedures, GB and DS demonstrate greater risk than SG. Overall, C/R procedures demonstrate greater risk of most, but not all, early postoperative complications.

Evaluating the Ergonomics of Surgical Residents During Laparoscopic Simulation: A Novel Computerized Approach.

BACKGROUND: Assessment of residents' body positioning during laparoscopy has not been adequately investigated. This study presents a novel computer vision technique to automate ergonomic evaluation and demonstrates this approach through simulated laparoscopy. METHODS: Surgical residents at a single academic institution were video recorded performing tasks from the Fundamentals of Laparoscopic Surgery (FLS). Ergonomics were assessed by 2 raters using the Rapid Upper Limb Assessment (RULA) tool. Additionally, a novel computer software program was used to measure ergonomics from the video recordings. All participants completed a survey on musculoskeletal complaints, which was graded by severity. RESULTS: Ten residents participated; all performed FLS in postures that exceeded acceptable ergonomic risks as determined by both the human and computerized RULA scores (P < .001). Lower-level residents scored worse than upper-level residents on the human-graded RULA assessment (P = .04). There was no difference in computer-graded RULA scores by resident level (P = .39) and computer-graded scores did not correlate with human scores (P = .75). Shoulder and wrist position were the greatest contributors to higher computer-graded scores (P < .001). Self-reported musculoskeletal complaints did not differ at resident level (P = .74); however, all residents reported having at least 1 form of musculoskeletal complaint occurring "often." CONCLUSIONS: Surgery residents demonstrated suboptimal ergonomics while performing simulated laparoscopic tasks. A novel computer program to measure ergonomics did not agree with the scores generated by the human raters, although it concluded that resident ergonomics remain a concern, especially regarding shoulder and wrist positioning.

Self-compassion training to improve well-being for surgical residents.

CONTEXT: Burnout remains prevalent among surgical residents. Self-compassion training may serve to improve their well-being. OBJECTIVE: To evaluate the impact on well-being of a self-compassion program modified for surgical residents. DESIGN: This is a 3-year, mixed-methods study using pre-post surveys and focus groups to identify areas for programmatic improvement and the subsequent impact of the modifications. SETTING: A single academic institution. PARTICIPANTS: Surgical residents participating in a self-compassion program. INTERVENTIONS: A self-compassion program adapted from a larger course to fit the needs of surgical residents. MAIN OUTCOME MEASURES: Themes relating to the program's strengths and weaknesses were identified through participant focus groups. Well-being was assessed through validated measurement tools, including The Maslach Burnout Inventory (MBI), Patient Health Questionnaire-9, Perceived Stress Scale, and Spielberger State-Trait Anxiety Inventory-6. RESULTS: 95 residents participated in the self-compassion program, of which 40 residents completed both surveys (total response rate: 42%). All participants demonstrated severe burnout pre-program, based on scores of at least one of the MBI subscales. Emotional exhaustion scores improved post-program, with larger improvements seen after program modifications (2018: 58% vs 2020: 71%). Focus group findings demonstrated that residents need a safe and distraction-free space to practice self-compassion, and program engagement improved following modifications.

Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: A Single-Institution Report.

Laparoscopic sleeve gastrectomy (LSG) is an effective weight-loss operation. Portomesenteric vein thrombosis (PMVT) is an important complication of LSG. We identified four cases of PMVT after LSG at our institution in women aged 36-47 with BMIs ranging from 44-48 kg/m2. All presented 8-19 days postoperatively. Common symptoms were nausea, vomiting, and abdominal pain. Thrombotic risk factors were previous deep vein thrombosis and oral contraceptive use. Management included therapeutic anti-coagulation, directed thrombolysis, and surgery. Complications were readmission, bowel resection, and bleeding. Discharge recommendations ranged from 3-6 months of anticoagulation using various anticoagulants. No consensus was reached on post-treatment hypercoagulable work up or imaging. All cases required multi-disciplinary approach with Surgery, Interventional Radiology, and Hematology. As PMVT is a rare but potentially morbid complication of LSG, further development of tools that quantify preoperative thrombotic risk and clear guidance regarding use of anticoagulants are needed for prevention and treatment of PMVT following LSG.

Comparison of robot-assisted sleeve gastrectomy outcomes in multiple staple line treatment modalities from 2015 to 2019: a 5-year propensity score-adjusted MBSAQIP® analysis.

BACKGROUND: Robot-assisted sleeve gastrectomy (RSG) is an increasingly common approach to sleeve gastrectomy (SG). Staple line reinforcement (SLR) is well-discussed in laparoscopic SG literature, but not RSG- likely due to the absence of dedicated robotic SLR devices. However, most RSG cases report SLR. This retrospective analysis compares outcomes in RSG cases reporting (1) any staple line treatment (SLT) vs none and (2) SLR vs oversewing. METHODS: MBSAQIP was queried for adults who underwent RSG from 2015 to 2019. Open procedures, Natural Orifice Transluminal Endoscopic Surgery, hand-assisted, single-incision, concurrent procedures, and illogical BMIs were excluded (n = 3444). Final sample included 52,354 patients. Two comparisons were made: SLT (n = 34,886) vs none (n = 17,468) and SLR (n = 22,217) vs oversew (n = 5620). We fitted multivariable regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) and performed propensity score analysis with inverse probability of treatment weight based on patient factors. RESULTS: Most RSG cases utilized SLT (66.6%). Cases with SLT had a reduced risk of organ space SSI (RR 0.68 [0.49, 0.94]), 30-day reoperation (RR 0.77 [0.64, 0.93]), 30-day re-intervention (RR 0.80 [0.67, 0.96]), sepsis (RR 0.58 [0.35, 0.96]), unplanned intubation (RR 0.59 [0.37, 0.93]), extended ventilator use (RR 0.46 [0.23, 0.91]), and renal failure (RR 0.40 [0.19, 0.82]) compared to no-treatment cases. In single-treatment cases (n = 27,837), most utilized SLR (79.8%). Cases with oversew had a higher risk of any SSI (RR 1.70 [1.19, 2.42]), superficial incisional SSI (RR 1.71 [1.06, 2.76]), septic shock (RR 6.47 [2.11, 19.87]), unplanned intubation (RR 2.18 [1.06, 4.47]), and extended ventilator use (> 48 h) (RR 4.55 [1.63, 12.71]) than SLR. CONCLUSIONS: Our data suggest SLT in RSG is associated with reduced risk of some adverse outcomes vs no-treatment. Among SLT, SLR demonstrated lower risk than oversewing. However, risk of all-cause mortality, cardiac arrest, and unplanned ICU admission were not significant.