Insurance-mandated preoperative diet and outcomes after bariatric surgery.

BACKGROUND: Despite a lack of demonstrated patient benefit, many insurance providers mandate a physician-supervised diet before financial coverage for bariatric surgery. OBJECTIVES: To compare weight loss between patients with versus without insurance mandating a preoperative diet. SETTING: University hospital, United States. METHODS: Retrospective study of all patients who underwent laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy over a 5-year period, stratified based on whether an insurance-mandated physician-supervised diet was required. Weight loss outcomes at 6, 12, and 24 months postoperation were compared. Linear mixed-models and backward-stepwise selection were used. P<0.05 was considered significant. RESULTS: Of 284 patients, 225 (79%) were required and 59 (21%) were not required to complete a preoperative diet by their insurance provider. Patients without the requirement had a shorter time to operation from initial consultation (P = .04), were older (P<.01), and were more likely to have government-sponsored insurance (P<.01). There was no difference in preoperative weight or body mass index or co-morbidities. In unadjusted models, percent excess weight loss was superior in the group without an insurance-mandated diet at 12 (P = .050) and 24 (P = .045) months. In adjusted analyses, this group also had greater percent excess weight loss at 6 (P<.001), 12 (P<.001), and 24 (P<.001) months; percent total weight loss at 24 months (P = .004); and change in body mass index at 6 (P = .032) and 24 (P = .007) months. There was no difference in length of stay or complication rates. CONCLUSIONS: Insurance-mandated preoperative diets delay treatment and may lead to inferior weight loss.

Predictive factors of weight regain following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Strategies to address weight recidivism following Roux-en-Y gastric bypass (RYGB) could be developed if patients at risk were identified in advance. This study aimed to determine factors that predict weight regain. METHODS: Retrospective review was performed of patients who underwent laparoscopic RYGB at a single institution over 10 years. Group-based modeling was used to estimate trajectories of weight regain after nadir and stratify patients based on percent weight change (%WC). RESULTS: Three trajectories were identified from 586 patients: 121 had ongoing weight loss, 343 were weight stable, and 122 regained weight. Male sex (p = 0.020) and white race (p < 0.001) were associated with stable weight or weight regain. Being from a neighborhood of socioeconomic advantage (p = 0.035) was associated with weight regain. Patients with weight regain experienced improved percent weight loss (%WL) at nadir (p < 0.001) and ΔBMI (p = 0.002), yet they had higher weight and BMI and lower %WL and ΔBMI than the other two groups during long-term follow-up. On multivariate analyses, those who regained weight were more likely from socioeconomically advantaged neighborhoods (OR 1.82, CI 1.18-2.79). CONCLUSIONS: Several patient-related characteristics predicted an increased likelihood of weight regain. Further studies are needed to elucidate how these factors contribute to weight recidivism following bariatric surgery.

Comparison of outcomes following endovascular repair of abdominal aortic aneurysms based on size threshold.

INTRODUCTION: Size threshold for operative repair of abdominal aortic aneurysms (AAAs) has been determined based on risks and outcomes of open repair vs surveillance. The influence of endovascular aneurysm repair (EVAR) on this threshold is less established. The purpose of this study is to determine whether long-term outcomes following EVAR are affected by maximum diameter at the time of treatment. METHODS: Patients undergoing EVAR with modular stent grafts from 2000 to 2011 were identified from a prospectively maintained database and stratified by maximum aortic diameter at the time of repair: small (4.0-4.9 cm), medium (5.0-5.9 cm), and large (≥6.0 cm). Comparisons of demographics, indications for repair, perioperative complications, and long-term outcomes were made using analysis of variance, χ(2), and Kaplan-Meier plots. RESULTS: Seven hundred forty patients were identified: 157 (21.2%) small, 374 (50.5%) medium, and 209 (28.2%) large. Patients differed by mean age (69.3 ± 8.09, 71.7 ± 8.55, and 73.6 ± 8.77 years for small, medium, and large, respectively; P < .001), coronary artery disease (42% small, 57% medium, 51.2% large; P = .01), prior coronary angioplasty (14.6% small, 18.2% medium, 9.6% large; P = .02), congestive heart failure (5.7% small, 15.2% medium, 19.6% large; P = .01), prior vascular surgery (7% small, 15.8% medium, 10% large; P = .016), and chronic obstructive pulmonary disease (21% small, 27% medium, 33% large; P = .038). Small AAAs were more frequently symptomatic (19.7% small, 7.5% medium, 8.1% large; P < .001). There was no difference in perioperative complication rates (P = .399), expansion ≥5 mm (2.6% small, 5.6% medium, 7.2% large; P = .148), or all-type endoleak (40.8% small, 41.7% medium, 44.5% large; P = .73). Small AAAs developed fewer type I endoleaks (5.1% vs 6.95% medium and 14.8% large; P = .001). Compared with small AAAs, both medium (P = .39) and large (P < .001) required secondary intervention more frequently, with hazard ratios of 2.32 (95% confidence interval, 1.045-5.156) and 4.74 (95% confidence interval, 2.115-10.637), respectively. Ten-year survival was 72%, 63.1%, and 49.8% in the small, medium, and large groups, respectively (P < .001) with one rupture-related death after EVAR in the large group. All-cause mortality differed among the 75- to 84-year-old patients (30.4% small, 51.6% medium, 55.7% large; P = .017). CONCLUSIONS: EVAR for small AAAs shows improved long-term outcomes than for age-matched patients with larger aneurysms.

Protocol implementation of selective postoperative lumbar spinal drainage after thoracic aortic endograft.

BACKGROUND: Spinal cord ischemia (SCI) remains a significant concern in patients undergoing endovascular repair involving the thoracic aorta (thoracic endovascular aortic repair [TEVAR]). Perioperative lumbar spinal drainage has been widely practiced for open repair, but there is no consensus treatment protocol using lumbar drainage for SCI associated with TEVAR. This study analyzes the efficacy of an institutional protocol using selective lumbar drainage reserved for patients experiencing SCI following TEVAR. METHODS: A prospectively maintained registry was reviewed to identify all patients who underwent TEVAR from January 2000 through June 2010. Preoperative characteristics, intraoperative details, and outcomes, including neurologic deficit and mortality at 30 days and 1 year were determined based on reporting standards. Patients developing symptoms of SCI in the postoperative setting were compared with those without neurologic symptoms. SCI patients who received selective lumbar drainage were grouped based on resolution of neurologic function, with risk factors and outcomes of these subgroups analyzed with χ(2), t test, logistic regression, and analysis of variance (ANOVA). RESULTS: Two hundred seventy-eight TEVARs were performed on 251 patients. Twelve patients accounting for 12 TEVARs were excluded from analysis: 5 patients experienced SCI preoperatively, 4 patients were drained preoperatively, 2 expired intraoperatively, and 1 procedure was aborted. Of the remaining 266 procedures in 239 patients, 16 (6.0%) developed SCI within the 30-day postoperative period. Risk factors for SCI reaching statistical significance included length of aortic coverage (P = .036), existence of infrarenal aortic pathology (P = .026), and history of stroke (P = .043). Stent graft coverage of the left subclavian artery origin was required in 28.9% (n = 77) and was not associated with SCI (P = .52). Ten of 16 post-TEVAR SCI patients received selective postoperative lumbar drains and were categorized based on resolution of symptoms into complete resolution (n = 3; 30%), partial resolution (n = 4; 40%), and no resolution (n = 3; 30%). No patient characteristics or risk factors reached significance in comparison of lumbar drained patients and nondrained patients. All seven drained patients without complete resolution of SCI died within the first year after surgery, while all three of the complete responders survived (P = .017). In patients with SCI, increased all-cause mortality was observed at 1 year (56.3% vs 20.4%; P = .003). CONCLUSIONS: A protocol utilizing selective postoperative lumbar spinal drainage can be used safely for patients developing SCI after TEVAR with acceptably low permanent neurologic deficit, although overall survival of patients experiencing SCI after TEVAR is diminished relative to non-SCI patients.