Bariatric Patient Engagement in a Pre-surgery Virtual Patient Navigation Platform (VPNP).

BACKGROUND: This study analyzed patient engagement with a virtual patient navigation platform (VPNP) designed to help guide bariatric surgery candidates through the complex pre-operative workup for surgery. METHODS: Data on baseline sociodemographic and medical history was collected on patients enrolled in the bariatric program at a single academic institution between March and May 2021. The System Usability Scale (SUS) survey was administered to assess VPNP usability. Two groups emerged: "engaged" (ENG; n = 30) who activated their accounts and completed the SUS, and "not-engaged" (NEG; n = 35) who did not activate their accounts (n = 13) or did not use the app (n = 22) and were therefore ineligible for the SUS survey. RESULTS: Analyses demonstrated that only insurance status differed between groups (private insurance: 60% versus 34.3% for ENG versus NEG, respectively; p = 0.038). SUS survey analysis demonstrated high perceived usability (median score = 86.3), corresponding to the 97th percentile of usability. The top three reasons for disengagement included being too busy (22.9%), not being interested (20%), and being unsure about the purpose of the app (20%). CONCLUSIONS: The VPNP scored in the 97th percentile of usability. However, given a majority of patients did not engage with the app, and engagement was associated with completing pre-surgery requirements faster (unpublished), future work will focus on mitigating identified reasons for patients not engaging.

Robotic Enhanced-View Totally Extraperitoneal vs Intraperitoneal Onlay Mesh Evaluation: 1-Year Exploratory Outcomes of the REVEAL Randomized Clinical Trial.

BACKGROUND: Patients with small- to medium-sized ventral hernias randomized to robotic enhanced-view totally extraperitoneal (eTEP) or robotic intraperitoneal onlay mesh (rIPOM) previously demonstrated comparable 30-day patient-reported outcomes. Here we report 1-year exploratory outcomes for this multi-center, patient-blinded randomized clinical trial. STUDY DESIGN: Patients with midline ventral hernias 7 cm wide or less undergoing mesh repair were randomized to robotic eTEP or rIPOM. Planned exploratory outcomes at 1 year include pain intensity (using the Patient-Reported Outcomes Measurement Information System [PROMIS 3a]), Hernia-Related Quality of Life Survey (HerQLes) scores, pragmatic hernia recurrence, and reoperation. RESULTS: One hundred randomized patients (51 eTEP, 49 rIPOM) reached a median 12-month follow-up (interquartile range 11 to 13) with 7% lost. After regression analysis adjusting for baseline scores, there was no difference in postoperative pain intensity at 1-year for eTEP compared with rIPOM (odds ratio [OR] 2.1 [95% CI 0.85 to 5.1]; p = 0.11). HerQLes scores were 15 points lower on average (ie less improved) at 1 year after eTEP repairs compared with rIPOM, a difference maintained after regression analysis (OR 0.31 [95% CI 0.15 to 0.67]; p = 0.003). Pragmatic hernia recurrence was 12.2% (6 of 49) for eTEP and 15.9% (7 of 44) for rIPOM (p = 0.834). In the first year, 2 eTEP and 1 rIPOM patients required reoperations related to their index repair (p = 0.82). CONCLUSIONS: Exploratory analyses showed similar outcomes at 1 year in regard to pain, hernia recurrence, and reoperation. Abdominal wall quality of life at 1 year appears to favor rIPOM, and the possibility that an eTEP dissection is less advantageous in that regard should be the subject of future investigation.

Robotic eTEP versus IPOM evaluation: the REVEAL multicenter randomized clinical trial.

BACKGROUND: For small to medium-sized ventral hernias, robotic intraperitoneal onlay mesh (rIPOM) and enhanced-view totally extraperitoneal (eTEP) repair have emerged as acceptable approaches that each takes advantage of robotic instrumentation. We hypothesized that avoiding mesh fixation in a robotic eTEP repair offers an advantage in early postoperative pain compared to rIPOM. METHODS: This is a multi-center, randomized clinical trial for patients with midline ventral hernias ≤ 7 cm, who were randomized to rIPOM or robotic eTEP. The primary outcome was pain (0-10) on the first postoperative day. Secondary outcomes included same-day discharge, length of stay, opioid consumption, quality of life, surgeon workload, and cost. RESULTS: Between November 2019 and November 2021, 100 patients were randomized (49 rIPOM, 51 eTEP) among 5 surgeons. Pain on the first postoperative day [median (IQR): 5 (4-6) vs. 5 (3.5-7), p = 0.66] was similar for rIPOM and eTEP, respectively, a difference maintained following adjustments for surgeon, operative time, baseline pain, and patient co-morbidities (difference 0.28, 95% CI - 0.63 to 1.19, p = 0.56). No differences in pain on the day of surgery, 7, and 30 days after surgery were identified. Same-day discharge, length of stay, opioid consumption, and 30-day quality of life were also comparable, though rIPOM required less surgeon workload (p < 0.001), shorter operative time [107 (86-139) vs. 165 (129-212) min, p < 0.001], and resulted in fewer surgical site occurrences (0 vs. 8, p = 0.004). The total direct costs for rIPOM and eTEP were comparable [$8282 (6979-11835) vs. $8680 (7550-10282), p = 0.52] as the cost savings for eTEP attributable to mesh use [$442 (434-485) vs. $69 (62-76), p = < 0.0001] were offset by increased expenses for operative time [$669 (579-861) vs. $1075 (787-1367), p < 0.0001] and use of more robotic equipment [$760 (615-933) vs. $946 (798-1203), p = 0.001]. CONCLUSION: The avoidance of fixation in a robotic eTEP repair did not reveal a benefit in postoperative pain to offset the shorter operative time and surgeon workload offered by rIPOM.

Influence of sociodemographic variables on weight loss outcomes up to 3-years following primary bariatric surgery.

BACKGROUND: Our group has previously demonstrated that low socioeconomic status (SES) independently predicts ≤ 25th percentile weight-loss following bariatric surgery (BS). Given that sociodemographic metrics can be separated into income, education, and race, we sought to investigate how each metric independently impacted weight loss following BS. METHODS: Patients from a single academic institution who underwent bariatric surgery from 2014 to 2016 were retrospectively reviewed. Patients were stratified by income (low/high), education (≤ high school/ ≥ college), and race (black/white) then compared using univariate analysis. Variables significant on univariate analyses were subsequently used for a greedy 1:3 propensity score match with a caliper of 0.2. After matching, groups were balanced on demographics, social/medical/psychological history, and surgery type. Percent excess body weight loss for each post-operative time point was compared using appropriate univariate analyses. A p-value ≤ 0.05 was considered statistically significant. RESULTS: 571 patients were included. Unmatched race analysis demonstrated black patients were significantly younger (p = 0.05), single (p < 0.0001), in a lower income bracket (p < 0.0001), and experienced less weight loss at 2- (p = 0.01), 6- (p = 0.007), 12- (p = 0.008) and 24- (p = 0.007) months post-op. After matching, black patients continued to experience less weight loss at 2- (p = 0.01) and 6- (p = 0.03) months, which trended at 1 year (p = 0.06). Initial income analysis demonstrated patients in the low-income group (LIG) were more likely to be black (p < 0.0001), have ≤ high school education (p = 0.004), a higher preoperative BMI (p = 0.008), and lower postoperative weight loss at 2- (p = 0.001), 6- (p = 0.01), and 12- (p = 0.04) months after surgery. After matching, no differences were observed up to 3-years post-op. Analysis of education demonstrated no effect on weight loss in both unmatched and matched analyses. CONCLUSION: Unmatched analysis demonstrated that low income and race impact short-term weight loss after BS. After matching, however, race, not socioeconomic status, predicted weight loss outcomes up to 1-year.

Use of the MMPI-2 personality profile in predicting 30-day ED-visits and readmissions following primary bariatric surgery.

BACKGROUND: Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is used for psychological screening of bariatric surgery (BS) candidates. To date, no studies have analyzed the relationship between MMPI-2 and early returns to hospital. The aim of this study was to determine whether high T scores on the MMPI-2 clinical scales were associated with early return to hospital after primary bariatric surgery. METHODS: Patients who completed an MMPI-2 evaluation, undergoing primary BS from 2014 to 2016 were evaluated. T score for the tested scales were collected and stratified into a high T score (T > 65) vs not (T < 65). The optimal 'cut-point' (specific number of high T scores predicting likelihood for 30-day ED-visit/hospital readmission) was calculated using Youden's Index (J) = Max(c) [sensitivity (c) + specificity (c) - 1], where c = number of scales with a T score > 65. Patients were stratified based on the optimal cut-point which was determined to be ≥ 4 high T scores. Univariate and multivariate logistic regression analyses were used to identify differences between groups and predictors for early ED-visits and hospital readmissions. RESULTS: 375 patients had psychological evaluations available for review. Patients were divided into those with ≥ 4 high T scores (Scr(≥4); n = 86) versus not (Scr (<4); n = 289). Multivariate analysis showed Scr(≥ 4) (aOR 2.99, CI 1.20-7.47; p = 0.019), bipolar disorder (aOR 4.82, CI 1.25-18.83; p = 0.022), and urgent hospital complications (aOR 6.81, CI 2.02-22.91; p = 0.002), were significant independent predictors of 30-day readmissions. Early ED-visits were significantly predicted by public insurance (aOR 3.30, CI 1.22-8.91; p = 0.019), but the effect of the Scr(≥4) profile (aOR 2.42, CI 0.97-6.09; p = 0.06), while influential, did not reach significance. CONCLUSION: Differences in personality traits may be associated increased 30-day readmissions following primary bariatric surgery. Our study represents a novel application of the MMPI-2.