Observational study of complex abdominal wall reconstruction using porcine dermal matrix: How have outcomes changed over 14 years?

BACKGROUND: Our center has adopted many evidence-based practices to improve outcomes for complex abdominal wall reconstruction with porcine dermal matrix. This study analyzed outcomes over time using porcine dermal matrix in complex abdominal wall reconstruction. METHODS: Prospective, tertiary hernia center data was examined for patients undergoing complex abdominal wall reconstruction with porcine dermal matrix. Early (2008-2014) and Recent (2015-2021) cohorts were defined by dividing the study interval in half. Multivariable analyses of wound complications and recurrence were performed. RESULTS: Comparing 117 Early vs 245 Recent patients, both groups had high rates of previously repaired hernias (76.1% vs 67.4%; P = .110), Centers for Disease Control and Prevention class 3 or 4 wounds (76.0% vs 66.6%; P = .002), and very large hernia defects (320 ± 317 vs 282 ± 164 cm2; P = .640). Recent patients had higher rates of preoperative botulinum injection (0% vs 21.2%; P < .001), posterior component separation (15.4% vs 35.5%; P < .001), and delayed primary closure (23.1% vs 38.8%; P < .001), but lower rates of concurrent panniculectomy (32.3% vs 27.8%; P = .027) and similar anterior component separation (29.1% vs 18.2%; P = .060). Most mesh was placed preperitoneal (74.4% vs 93.3%; P < .001). Recent patients had less inlay (9.4% vs 2.1%; P < .01) and other mesh locations as fascial closure rate increased (88.0% vs 95.5%; P < .001). Over time, there was a decrease in wound complications (42.1% vs 14.3%; P < .001), length of stay (median [interquartile range]:8 [6-13] vs 7 [6-9]; P = .003), and 30-day readmissions (32.7% vs 10.3%; P < .001). Hernia recurrence decreased (10.3% vs 3.7%; P = .016) with mean follow-up of 2.8 ± 3.2 and 1.7 ± 1.7 years, respectively. Respective multivariable models(odds ratio, 95% confidence interval) demonstrated an increased risk of wound complications with diabetes (2.65, 1.16-5.98; P = .020), panniculectomy (2.63, 1.21-5.73; P = .014), and anterior component separation (5.1, 1.98-12.9; P < .001), with recurrence risk increased by wound complication (3.8, 1.4-2-7.62; P = .032). CONCLUSION: Porcine dermal matrix in complex abdominal wall reconstruction performs well with low recurrence rates. Internal assessment and implementation of evidence-based practices improved outcomes such as length of stay, wound complications, and recurrence rate.

Predicting rare outcomes in abdominal wall reconstruction using image-based deep learning models.

BACKGROUND: Deep learning models with imbalanced data sets are a challenge in the fields of artificial intelligence and surgery. The aim of this study was to develop and compare deep learning models that predict rare but devastating postoperative complications after abdominal wall reconstruction. METHODS: A prospectively maintained institutional database was used to identify abdominal wall reconstruction patients with preoperative computed tomography scans. Conventional deep learning models were developed using an 8-layer convolutional neural network and a 2-class training system (ie, learns negative and positive outcomes). Conventional deep learning models were compared to deep learning models that were developed using a generative adversarial network anomaly framework, which uses image augmentation and anomaly detection. The primary outcomes were receiver operating characteristic values for predicting mesh infection and pulmonary failure. RESULTS: Computed tomography scans from 510 patients were used with a total of 10,004 images. Mesh infection and pulmonary failure occurred in 3.7% and 5.6% of patients, respectively. The conventional deep learning models were less effective than generative adversarial network anomaly for predicting mesh infection (receiver operating characteristic 0.61 vs 0.73, P < .01) and pulmonary failure (receiver operating characteristic 0.59 vs 0.70, P < .01). Although the conventional deep learning models had higher accuracies/specificities for predicting mesh infection (0.93 vs 0.78, P < .01/.96 vs .78, P < .01) and pulmonary failure (0.88 vs 0.68, P < .01/.92 vs .67, P < .01), they were substantially compromised by decreased model sensitivity (0.25 vs 0.68, P < .01/.27 vs .73, P < .01). CONCLUSION: Compared to conventional deep learning models, generative adversarial network anomaly deep learning models showed improved performance on imbalanced data sets, predominantly by increasing model sensitivity. Understanding patients who are at risk for rare but devastating postoperative complications can improve risk stratification, resource utilization, and the consent process.

Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study.

BACKGROUND: Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study. METHODS: A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated. RESULTS: Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm2 vs botulinum toxin A 289.7 ± 162.4 cm2; P = .73) (mean volume: 1,498.3 + 2,043.4 cm3 vs 2,914.7 + 6,539.4 cm3; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13). CONCLUSION: In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.

African American Patients Experience Worse Outcomes than Hispanic Patients Following Bariatric Surgery: an Analysis Using the MBSAQIP Data Registry.

BACKGROUND: Obesity rates in Hispanics and African Americans (AAs) are higher than in Caucasians in the USA, yet the rate of metabolic and bariatric surgery (MBS) for weight loss remains lower for both Hispanics and AAs. METHODS: Patient demographics and outcomes of adult AA and Hispanic patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) procedures were analyzed using the MBSAQIP dataset [2015-2018] using unmatched and propensity-matched data. RESULTS: In total, 173,157 patients were included, of whom 98,185 were AA [56.7%] [21,163-RYGB; 77,022-SG] and 74,972 were Hispanic [43.3%] [20,282-RYGB; 54,690-SG]). Preoperatively, the AA cohort was older, had more females, and higher BMIs with higher rates of all tracked obesity-related medical conditions except for diabetes, venous stasis, and prior foregut surgery. Intra- and postoperatively, AAs were more likely to experience major complications including unplanned ICU admission, 30-day readmission/reintervention, and mortality. After propensity matching, the differences in ED visits, treatment for dehydration, 30-day readmission, 30-day intervention, and pulmonary embolism remained for both SG and RYGB cohorts. Progressive renal insufficiency and ventilator use lost statistical significance in both cohorts. Conversely, 30-day reoperation, postoperative ventilator requirement, unplanned intubation, unplanned ICU admission, and mortality lost significance in the RYGB cohort, but not SG patients. CONCLUSION: Outcomes for AA patients were worse than for Hispanic patients, even after propensity matching. After matching, differences in major complications and mortality lost significance for RYGB, but not SG. These data suggest that outcomes for RYGB may be driven by the presence and severity of pre-existing patient-related factors.

Safety of biliopancreatic diversion with duodenal switch in patients with body mass index less than 50 kg/m2.

INTRODUCTION: Biliopancreatic diversion with duodenal switch (BPD-DS) has often been reserved for patients with BMI > 50 kg/m2. We aim to assess the safety of BPD-DS in patients with morbid obesity (BMI 335 kg/m2 and < 50 kg/m2) using a 150-cm common channel (CC), 150-cm Roux limb, and 60-fr bougie. METHODS: A retrospective review was performed on patients with a BMI < 50 mg/k2 who underwent a BPD-DS in 2016-2019 at a single institution. Limb lengths were measured with a laparoscopic instrument with minimal tension. Sleeve gastrectomy was created with 60-fr bougie. Variables were compared using paired t test, Chi-square analysis or repeated measures ANOVA where appropriate. RESULTS: Forty-five patients underwent BPD-DS. CC lengths and Roux limb lengths were 158 ± 20 cm and 154 ± 18 cm, respectively. Preoperative BMI was 44.9 ± 2.3 kg/m2 and follow-up was 2.7 ± 1.4 years. One patient required reoperation for bleeding and died from multiorgan failure and delayed sleeve leak. There was 1 (2.2%) readmission for contained anastomotic leak and 2 ED visits (4.5%) within 30 days. There were no marginal ulcers, limb length revisions, or need for parental nutrition. Percent excess weight loss was 67.2 ± 19.7%. 88.9% (N = 8), 86.6% (N = 13), and 55.5% (N = 5) of patients had resolution or improvement of their diabetes mellitus type II, hypertension, and hyperlipidemia, respectively. 40% (N = 4) of patients had resolution of their gastroesophageal reflux disease (GERD) and 11.4% (N = 5) developed de novo GERD. 32% (N = 14) of patients had vitamin D deficiency and 25% (N = 11) experienced zinc deficiency. CONCLUSION: BPD-DS may be considered in patients with BMI < 50 kg/m2 with 150-cm CC, 150-cm Roux limb, and a 60-fr bougie sleeve gastrectomy. There was sustained weight loss and no protein calorie malnutrition, but Vitamin D and zinc deficiency remained a challenge. Careful patient selection and proper counseling of the risks and benefits are necessary.

The role of total alimentary limb length in Roux-en-Y gastric bypass: a systematic review.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is an established surgical treatment for obesity. Variations in limb length during RYGB procedures have been investigated for optimizing weight loss while minimizing nutritional deficiencies. The role of the total alimentary limb length (TALL; Roux limb plus common channel [CC]), however, is poorly defined. OBJECTIVE: Compare TALL in RYGB procedures for weight loss outcomes and malnutrition. SETTING: Systematic review. METHODS: Ovid Medline and PubMed databases were searched for entries between 1993 and 2020. Search terms included "gastric bypass" and "TALL." Two independent reviewers screened the results. RESULTS: A total of 21 studies measured TALL in RYGB. Of these, 4 of 6 reported a relationship between TALL and weight loss. Additionally, 11 studies reported that when TALL was ≤400 cm and CC <200 cm, 3.4% to 63.6% of patients required limb lengthening for protein malnutrition. CONCLUSIONS: The majority of studies on RYGB do not report TALL length. There is some evidence that weight loss is affected by shortening TALL, while a TALL ≤400 cm with CC<200 should be avoided due to severe protein malnutrition. More studies on the effect of TALL are needed.

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database.

INTRODUCTION: For patients with super obesity (BMI > 50 kg/m2), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS. MATERIALS AND METHODS: The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18 years of age, BMI > 50 kg/m2, and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes. RESULTS: There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m2, p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019). CONCLUSIONS: Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.

Why Size Matters: an Evaluation of Gastric Pouch Size in Roux-en-Y Gastric Bypass Using CT Volumetric Analysis and its Effect on Marginal Ulceration.

PURPOSE: Marginal ulceration (MU) is a common long-term complication following Roux-en-Y gastric bypass (RYGB). The causes of MU after RYGB are multifactorial and include surgical technique of constructing the gastrojejunal anastomosis (GJA). The purpose of this study is to evaluate the relationship between gastric pouch size in RYGB and MU using CT volumetrics. MATERIAL AND METHODS: Patients were retrospectively identified who underwent esophagogastroduodenoscopy (EGD) following RYGB at a tertiary care teaching hospital. Measurement of gastric pouch size was performed using 3-D CT software. Standard statistical methods were used, a univariate comparison was performed between MU and non-MU patients followed by a propensity-matched comparison to control for factors known to affect MU, and a propensity-matched subgroup analysis was also performed. RESULTS: In total, 122 patients met criteria, 57 of which had MU on EGD and 65 who did not. The MU group had more smokers and patients with PPI use than the non-MU group, and the mean time from operation to CT scan was 26.6 months (range: 0-108 months). The MU group had a larger gastric pouch size than the non-MU group (34.1 ± 11.8 versus 20.1 ± 6.8 cm3). When analyzed for matched patient cohorts, this difference remained for the MU group that included smokers and PPI use. When stratified for pouch size, for each 5 cm3 increase in pouch size, patients had 2.4 times odds increase of MU formation. CONCLUSIONS: CT volumetric analysis demonstrated that a larger gastric pouch size was associated with MU following RYGB.

Gastrojejunal Anastomotic Stricture Following Roux-en-Y Gastric Bypass: an Analysis of Anastomotic Technique at a Single Institution.

PURPOSE: Patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) are at risk of developing strictures of the gastrojejunal anastomosis (GJA). Several variables can affect this, one of which may be the method of anastomosis. Between 2010 and 2014, our institution utilized three different anastomotic techniques for creating the GJA (25 mm end-to-end circular-stapled (CS), linear-stapled (LS), and robotic hand sewn (HS)). Our objectives were to compare the method of GJA relative to the subsequent development of anastomotic stricture. METHODS: We queried our electronic health record for all patients who underwent an upper endoscopy (EGD) after RYGB (2010-2014). Patient charts were retrospectively reviewed for type of GJA, weight loss, complications, interventions, and revisions of the GJA. RESULTS: In total, 1112 RYGB were performed at our institute, and 17.4% of patients (194/1112) had an upper endoscopy (EGD). Overall, 3.1% (34/1112) were found to have a stricture of the GJA. Patients undergoing a CS, LS, and HS anastomosis had GJA stricture rates of 4.9%, 0.5%, and 1.2% respectively (CS to LS (p < 0.05), p = NS among CS vs. HS, and LS vs. HS). The rate of GJA revision was 1.5%, 0.5%, and 0.1% (p = NS). In patients who had an EGD, excess BMI loss was 57.4%, 64.6%, and 59.2% (p = NS). In patients symptomatic from strictures, excess BMI loss was 69.4%, 83%, and 63.5% respectively (p = NS). CONCLUSION: The anastomotic technique for creating of the GJA may impact the formation of strictures. Based on our experience, gastrojejunostomies created with a 2-mm EEA-stapling technique are at higher risk of strictures.

Impacts of Gastrojejunal Anastomotic Technique on Rates of Marginal Ulcer Formation and Anastomotic Bleeding Following Roux-en-Y Gastric Bypass.

BACKGROUND: Marginal ulceration (MU) and bleeding are possible complications following laparoscopic Roux-en-Y gastric bypass (RYGB). Our institution utilizes three techniques for performing the gastrojejunal anastomosis (GJA), providing a means to compare postoperative MU and bleeding as it relates to GJA technique. OBJECTIVES: We sought to analyze the incidence of MU and bleeding between the 25-mm end-to-end anastomosis (EEA) stapler, linear stapler (LS), and robotic hand-sewn (RHS) GJA techniques. METHODS: Electronic health records for all patients who had an upper endoscopy (EGD) after RYGB were queried (2010-2014). Charts were retrospectively reviewed for type of GJA, complications, endoscopic interventions, and smoking and NSAID use. RESULTS: Out of 1112 RYGBs, the GJA was created using an EEA, LS, or RHS approach in 58.6%, 33.6%, and 7.7% of patients, respectively. 17.4% had an EGD (19.9% EEA, 13.9% LS, and 14.0% RHS). Incidence of MU was 7.3% (9.3% EEA, 4.8% LS, and 5.8% RHS). Rates of EGD and MU were significantly higher after EEA vs. LS GJA (p<0.05). The bleeding rate was 1.5%, [1.1% EEA, 2.1% LS, and 2.3% RHS (p=NS)]. MU within 90 days of RYGB occurred in 4.1%, 0.8%, and 4.7%, respectively (p<0.05 for EEA vs LS only). NSAID and cigarette use were identified in 29.3%, 38.9%, and 60% and 17.2%, 22.2%, and 20%, respectively, for the EEA, LS, and RHS GJA (p=NS). CONCLUSION: The method of GJA has an impact on rate of MU formation. A GJA fashioned with a 25-mm EEA stapler tends to have higher rates of EGD and MU.

Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion?

BACKGROUND: Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution. METHODS: A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed. RESULTS: 180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m2 (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m2 and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001). CONCLUSIONS: RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.

Preoperative patient opioid education, standardization of prescriptions, and their impact on overall patient satisfaction.

BACKGROUND: The opioid epidemic has reached a crisis level in America, and many institutions are implementing new guidelines to decrease opioid prescriptions. Although these may positively impact opioid addiction, its influence on patient satisfaction is inadequately described. The aim of the study was to evaluate the effect of standardized patient education and postoperative opioid regimens on patient satisfaction. METHODS: General surgery patients were counselled and given educational materials preoperatively regarding postoperative pain management. Inpatient discharge prescriptions were based on milligrams of oral narcotic required 24 hours before discharge. Outpatient procedure prescriptions were standardized. Postoperatively, patients received surveys regarding pain control and satisfaction. RESULTS: Of the 198 patients studied, 96% agreed or strongly agreed that they were satisfied with their pain control. 92% agreed or strongly agreed they received enough medication; 7% disagreed, and 1% strongly disagreed. Educational materials were evaluated with 97% agreeing or strongly agreeing they received appropriate information concerning when and what to take. Fifty-five patients (28%) refused opioids or did not take any. Only 10 (5%) requested a refill. CONCLUSION: Preoperative education and standardized postoperative narcotic prescribing can be highly effective while maintaining high patient satisfaction. Introduction across broad fields of surgery will allow uniformity for surgeons, trainees, nurses, pharmacists, and patients.

S146-Jejunojejunal intussusception after roux-En-Y gastric bypass: a case series of 34 patients.

INTRODUCTION: Jejunojejunal intussusception (JI) is a serious but rare complication that may occur following Roux-en-Y gastric bypass (RYGB) surgery. Causes of JI and best management strategy are not clearly defined. METHODS: Electronic health records were queried for ICD 9/10 codes for intussusception after RYGB surgery (2009-2019), and charts retrospectively reviewed. Patient demographics, operative technique, presentation, radiology, and JI management were analyzed. RESULTS: Of the 2,327 RYGB patients identified at our institute, 34 (1.5%) were treated for JI. The mean age was 45.0 ± 8.6 years, mean BMI (RYGB surgery) was 43.1 ± 8.2 kg/m2, mean BMI at JI was 28.3 ± 5.8 kg/m2, and 30/34 were female, The mean time between RYGB and JI was 5.5 ± 4.3 years (range 1-17 years). Of the JI patients identified, 9 had operative notes that did not include jejunojejunostomy linear stapler length (JJ-LSL). Of the remaining 25 JI patients, 9 had a 60-mm JJ-LSL and 16 had a 120-mm JJ-LSL. Rate of intussusception was higher in the 120-mm versus 60-mm JJ-LSL group (p < 0.05). Acute abdominal pain was present in all JI patients and 32/34 had radiologic findings (CT scan) that corroborated for JI. The majority of JI patients were managed operatively (26/34) with 22/26 using laparoscopy (2/22 were converted to open). Intraoperative findings included intussusception (15/26), and 9/26 had other pathologies (internal hernia (2/26), cholecystitis (4/26), marginal ulcer (3/26)). Operative management of JI was either reduction and enteropexy (7/15), reduction only (5/15), or JJ revision (3/15). Recurrence of JI occurred in 7/23 patients, of who 4/7 were managed operatively. CONCLUSIONS: In our experience, JI appears to be a relatively rare complication after RYGB surgery. However, for patients developing JI, the majority had a JJ length ≥ 120 mm, and most patients required operative management which was associated with a higher rate of conversion to open and risk of JI recurrence. Reduction only technique had the highest risk of JI recurrence and therefore is not recommended.

Ambulatory bariatric surgery: does it really lead to higher rates of adverse events?

BACKGROUND: Correlating patient outcomes with length of stay (LoS) is an important consideration in metabolic and bariatric surgery. At present, conflicting data exists regarding patient safety for ambulatory (AMB) metabolic and bariatric surgery. OBJECTIVE: Outcomes for AMB-metabolic and bariatric surgery patients (LoS <1 d) undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were compared with matched patients with LoS ≥1 day (non-AMB) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry. SETTING: MBSAQIP national database. METHODS: The MBSAQIP registry was queried for patients undergoing SG or RYGB (2015-2017) and patients grouped as AMB/non-AMB. Exclusion criteria included LoS >4 days, age <18 or >75 years, revision surgery, gastric banding, body mass index <35 kg/m2, and day of surgery mortality. Variables were combined into major/minor complications and 30-day mortality. Analysis was performed using univariate and multivariate logistic regression and propensity matching. RESULTS: After exclusions were applied 408,895 patients remained (9973 AMB). Overall, 111,279 patients underwent RYGB (1032 AMB) and 297,616 underwent SG (8941 AMB), with similar demographic characteristics and co-morbidities between groups. For AMB patients, there was no increase in 30-day mortality, reoperation, or readmission, and fewer drains were placed versus matched non-AMB patients. In AMB-SG patients more surgical site infections were reported versus non-AMB-SG, although AMB-SG patients had fewer intensive care unit admissions. For AMB-RYGB, no differences in complications were detected versus non-AMB-RYGB. CONCLUSION: Based on our analysis of the MBSAQIP database, patients undergoing laparoscopic RYGB or SG procedures can be safely discharged on the day of their procedure without increased incidence of mortality, reoperation, or readmission.

Outcomes of Bariatric Surgery in African Americans: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Data Registry.

BACKGROUND: The incidence of obesity is disproportionally high in African Americans (AA) in the United States. This study compared outcomes for AA patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with non-AA patients. METHODS: The MBSAQIP database was reviewed for RYGB and SG patients (2015-2017). Patients were identified as AA or non-AA and grouped to RYGB or SG. Combined and univariate analyses were performed on unmatched/propensity matched populations to assess outcomes. RESULTS: After applying exclusion criteria, 75,409 AA and 354,305 non-AA patients remained. Univariate analysis identified AA-RYGB and AA-SG patients were heavier and younger than non-AA patients. Overall, AA patients tended to have fewer preoperative comorbidities than non-AA patients with the majority of AA comorbidities related to hypertension and renal disease. Analysis of propensity matched data confirmed AA bariatric surgery patients had increased cardiovascular-related disease incidence compared with non-AA patients. Perioperatively, AA-RYGB patients had longer operative times, increased rates of major complications/ICU admission, and increased incidence of 30-day readmission, re-intervention, and reoperation, concomitant with lower rates of minor complications/superficial surgical site infection (SSI) compared with non-AA patients. For SG, AA patients had longer operative times and higher rates of major complications and 30-day readmission, re-intervention, and mortality, coupled with fewer minor complications, superficial/organ space SSI, and leak. CONCLUSION: African American patients undergoing bariatric surgery are younger and heavier than non-AA patients and present with different comorbidity profiles. Overall, AAs exhibit worse outcomes following RYGB or SG than non-AA patients, including increased mortality rates in AA-SG patients.

Male gender is an independent risk factor for patients undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass: an MBSAQIP® database analysis.

BACKGROUND: Male patients undergoing bariatric surgery have (historically) been considered higher risk than females. The aim of this study was to examine the disparity between genders undergoing laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) procedures and assess gender as an independent risk factor. METHODS: The MBSAQIP® Data Registry Participant User Files for 2015-2017 was reviewed for patients having primary SG and RYGB. Patients were divided into groups based on gender and procedure. Variables for major complications were grouped together, including but not limited to PE, stroke, and MI. Univariate and propensity matching analyses were performed. RESULTS: Of 429,664 cases, 20.58% were male. Univariate analysis demonstrated males were older (46.48 ± 11.96 vs. 43.71 ± 11.89 years, p < 0.0001), had higher BMI (46.58 ± 8.46 vs. 45.05 ± 7.75 kg/m2, p < 0.0001), and had higher incidence of comorbidities. Males had higher rates of major complications (1.72 vs. 1.05%; p < 0.0001) and 30-day mortality (0.18 vs. 0.07%, p < 0.0001). Significance was maintained after subgroup analysis of SG and RYGB. Propensity matched analysis demonstrated male gender was an independent risk factor for RYGB and SG, major complications [2.21 vs. 1.7%, p < 0.0001 (RYGB), 1.12 vs. 0.89%, p < 0.0001 (SG)], and mortality [0.23 vs. 0.12%, p < 0.0001 (RYGB), 0.10 vs. 0.05%; p < 0.0001 (SG)]. CONCLUSION: Males continue to represent a disproportionately small percentage of bariatric surgery patients despite having no difference in obesity rates compared to females. Male gender is an independent risk factor for major post-operative complications and 30-day mortality, even after controlling for comorbidities.

Correction to: Impact of age on morbidity and mortality following bariatric surgery.

This article was updated to correct the spelling of Nicholas Dugan's first name: it is correct as displayed here.

Impact of age on morbidity and mortality following bariatric surgery.

BACKGROUND: Bariatric surgery is the most effective modality to treat obesity and obesity-related comorbidities. This study sought to utilize the MBASQIP® Data Registry to analyze the impact of age at time of surgery on outcomes following sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) procedures. METHODS: The MBSAQIP® Data Registry for patients undergoing SG or RYGB procedures between 2015 and 2016 was reviewed. Patients were divided into 4 age groups [18-44; 45-54; 55-64; > 65 years]. Minimal exclusions for revisional and/or emergency surgery were selected and combination variables created to classify complications as major or minor. A comorbidity index was constructed to include diabetes, gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), and prior cardiac surgery. Univariate and multivariate logistic regression analyses were performed to compare age stratifications to the young adult (18-45 years) cohort. RESULTS: Of 301,605 cases, 279,419 cases (71.2% SG) remained after applying exclusion criteria (79.2% female, mean BMI 45.5 ± 8.1 kg/m2, 8.9% insulin-dependent diabetics). Mean age was 44.7 ± 12.0 years (51.3% 18-44 years; 26.9% 45-54 years; 16.3% 55-64 years; 5.5% > 65 years). A univariate analysis demonstrated preoperative differences of lower BMI with increasing age concomitant with increasing frequency of RYGB and a higher comorbidity index (p < 0.0001 vs. 18-45 years). At age > 45 years, major complications and 30-day mortality increased independent of procedure type (p < 0.0001). A multivariate analysis controlling for comorbidity indices demonstrated increasing age (> 45 years) increased risk for major complications and mortality. CONCLUSION: Overall, bariatric surgery (SG or RYGB) remains a low mortality risk procedure for all age groups. However, all age group classifications > 45 years had higher incidence of major complications and mortality compared to patients 18-45 years (despite older individuals having lower preoperative BMI) indicating delaying surgery is detrimental.

Twelve years of component separation technique in abdominal wall reconstruction.

BACKGROUND: Component separation technique involves incision of abdominal muscle and its aponeurosis, which generates a myofascial advancement flap to assist with fascial closure in abdominal wall reconstructions. This tissue mobilization allows for musculo-fascial approximation of much larger abdominal wall defects than would otherwise be possible. With extensive tissue mobilization, however, there is concern for significant wound and systemic complications. METHODS: A prospective, single institution hernia database was queried for patients undergoing component separation from January 2006 to May 2018. Emergency operations were excluded. Anterior component separation (external oblique release with posterior rectus sheath release) and posterior component separation (transversus abdominus release and posterior rectus sheath release) were examined. RESULTS: Of the 775 component separation, 33.4% included anterior component separation and 66.6% posterior component separation. Mean age was 58.8 ± 11.5 years, mean body mass index was 33.6 ± 7.1 (kg/m2), and 27.9% of patients were diabetic. Hernias were large (280.0 ± 220.9 cm2) and often complex (recurrent: 62.6%, incarcerated: 41.5%, concomitant panniculectomy: 39.1%, and contaminated: 37.0%). Defect size was larger in anterior component separation group compared with posterior component separation (379.5 ± 265.2 vs 230.0 ± 175.0 cm2, P < .001). There was a 35.1% wound complication rate with 32 recurrences (4.1%) during a mean follow-up of 23.3 ± 25.1 months. Complete fascial closure and lack of wound complications significantly improved outcomes (P < .01). Patients undergoing anterior component separation demonstrated more wound complications (42.9% vs 31.2%, P < .001) and recurrences (7.0% vs 2.7%, P = .005). In multivariate analysis, anterior component separation was associated with increased risk of wound complications (odds ratio 1.660; confidence interval, 1.125-2.450), but not recurrence (odds ratio 2.95; confidence interval, 0.72-12.19). Since 2013, prehabilitation and perforator sparing techniques reduced anterior component separation wound complications to 19.6% (P = .008). CONCLUSION: Both anterior component separation and posterior component separation are associated with low recurrence rates, but anterior component separation is associated with higher wound complications. Prehabilitation and operative techniques improve outcomes of component separation.