Health Expenditures After Bariatric Surgery: A Retrospective Cohort Study.

OBJECTIVE: Bariatric surgery leads to substantial improvements in weight and weight-related conditions, but prior literature on post-surgical health expenditures is equivocal. In a retrospective cohort study, we compared expenditures between surgical and matched non-surgical patients. SUMMARY BACKGROUND DATA AND METHODS: In a retrospective study, total, outpatient, inpatient and medication expenditures 3 years before and 5.5 years after surgery were compared between 22,698 bariatric surgery (n=7,127 RYGB, 15,571 sleeve gastrectomy) patients from 2012-2019 and 66,769 matched non-surgical patients, using generalized estimating equations. We also compared expenditures between patients receiving the two leading surgical procedures in weighted analyses. RESULTS: Surgical and non-surgical cohorts were well matched, 80-81% female, with mean body mass index (BMI) of 44, and mean age of 47 (RYGB) and 44 (SG) years. Estimated total expenditures were similar between surgical and non-surgical groups 3 years before surgery ($27 difference, 95% confidence interval (CI): -42, 102)), increased 6 months prior to surgery for surgical patients, and decreased below pre-period levels for both groups after 3-5.5 years to become similar (difference at 5.5 y=-$61, 95% CI: -166, 52). Long-term outpatient expenditures were similar between groups. Surgical patients' lower long-term medication expenditures ($314 lower at 5.5 y, 95% CI: -419, -208) were offset by a higher risk of hospitalization. Total expenditures were similar between RYGB and SG patients 3.5 to 5.5 years after surgery. CONCLUSIONS: Bariatric surgery translated into lower medication expenditures than matched controls, but not lower overall long-term expenditures. Expenditure trends appear similar for the two leading bariatric operations.

Reduction in Long-term Mortality After Sleeve Gastrectomy and Gastric Bypass Compared to Nonsurgical Patients With Severe Obesity.

OBJECTIVE: To separately compare the long-term risk of mortality among bariatric surgical patients undergoing either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) to large, matched, population-based cohorts of patients with severe obesity who did not undergo surgery. BACKGROUND: Bariatric surgery has been associated with reduced long-term mortality compared to usual care for severe obesity which is particularly relevant in the COVID-19 era. Most prior studies involved the RYGB operation and there is less long-term data on the SG. METHODS: In this retrospective, matched cohort study, patients with a body mass index ≥35 kg/m 2 who underwent bariatric surgery from January 2005 to September 2015 in three integrated health systems in the United States were matched to nonsurgical patients on site, age, sex, body mass index, diabetes status, insulin use, race/ethnicity, combined Charlson/Elixhauser comorbidity score, and prior health care utilization, with follow-up through September 2015. Each procedure (RYGB, SG) was compared to its own control group and the two surgical procedures were not directly compared to each other. Multivariable-adjusted Cox regression analysis investigated time to all-cause mortality (primary outcome) comparing each of the bariatric procedures to usual care. Secondary outcomes separately examined the incidence of cardiovascular-related death, cancer related-death, and diabetes related-death. RESULTS: Among 13,900 SG, 17,258 RYGB, and 87,965 nonsurgical patients, the 5-year follow-up rate was 70.9%, 72.0%, and 64.5%, respectively. RYGB and SG were each associated with a significantly lower risk of all-cause mortality compared to nonsurgical patients at 5-years of follow-up (RYGB: HR = 0.43; 95% CI: 0.35,0.54; SG: HR = 0.28; 95% CI: 0.13,0.57) Similarly, RYGB was associated with a significantly lower 5-year risk of cardiovascular-(HR = 0.27; 95% CI: 0.20, 0.37), cancer- (HR = 0.54; 95% CI: 0.39, 0.76), and diabetes-related mortality (HR = 0.23; 95% CI:0.15, 0.36). There was not enough follow-up time to assess 5-year cause-specific mortality in SG patients, but at 3-years follow-up, there was significantly lower risk of cardiovascular- (HR = 0.33; 95% CI:0.19, 0.58), cancer- (HR = 0.26; 95% CI:0.11, 0.59), and diabetes-related (HR = 0.15; 95% CI:0.04, 0.53) mortality for SG patients. CONCLUSION: This study confirms and extends prior findings of an association with better survival following bariatric surgery in RYGB patients compared to controls and separately demonstrates that the SG operation also appears to be associated with lower mortality compared to matched control patients with severe obesity that received usual care. These results help to inform the tradeoffs between long-term benefits and risks of bariatric surgery.

Pregnancy after bariatric surgery in women with rheumatic diseases and association with adverse birth outcomes.

BACKGROUND: Autoimmune rheumatic diseases (ARDs) and bariatric surgery are each risk factors for adverse birth outcomes. To date, no study has investigated their combined impact on birth outcomes. OBJECTIVES: The objective of this study was to evaluate the impact of bariatric surgery on pregnancy outcomes in women with an ARD. As a secondary comparison, we assessed the risk of bariatric surgery on the same outcomes in women without an ARD. SETTING: Records maintained by the California Office of Statewide Health Planning and Development. METHODS: This cohort study included infants born between 20-44 weeks of gestation in California between 2011-2018. Risks of adverse pregnancy outcomes were evaluated for women with a history of bariatric surgery as compared to women without a history of bariatric surgery, stratified by ARD, using log-linear regression with a Poisson distribution. RESULTS: The study included 3,574,165 infants, of whom 10,823 (0.3%) were born to women who had an ARD and 13,529 (0.38%) to women with a history of bariatric surgery. There were 155 infants born to women (0.0043%) with both an ARD and a history of bariatric surgery. In women with an ARD and without bariatric surgery, the prevalence of preterm births was 18%, compared to 17.4% in women with both ARD and bariatric surgery; in women without ARD but with prior bariatric surgery, the prevalence of preterm births was 13.7%, compared to 8.2% in women without bariatric surgery. Except for neonatal intensive care unit (NICU) admissions, women with an ARD and history of bariatric surgery were not at a statistically increased risk of having other adverse pregnancy outcomes as compared to women with an ARD and no history of bariatric surgery. CONCLUSION: Our study shows that women with ARD already have a high occurrence of several adverse birth outcomes, and this was not further increased by a history of bariatric surgery. The infants born to women with a history of ARD and bariatric surgery were admitted to the NICU significantly more than the infants born to women with an ARD and no history of bariatric surgery.

Is Transdermal Multivitamin Patch Effective in Gastric Bypass Patients?

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) patients are recommended to take multiple oral vitamin supplements daily. Transdermal multivitamin patches are being advertised as an alternative for use in bariatric patients with no data to support their efficacy. The purpose of this study was to evaluate response to daily transdermal use of multivitamin patch after LRYGB and to compare them with a control group of similar patients who used oral supplements. METHODS: A retrospective review was carried out on patients who had LRYGB at a community hospital from February 2015 to February 2019. Patients who had completed preoperative and annual postoperative bariatric laboratory tests were included. They were divided into patch and pill (control) group. RESULTS: Seventeen patients were included in the patch and 27 in the pill group. Patients in each group used either patch or pills for 12 months and they were 1 year post LRYGB. Fourteen patients (82.35%) in patch group and 11 patients (40.74%) in pill group had at least 1 deficiency at annual postoperative blood work (P = .0116). Vitamin D deficiency was seen in 81% patients in patch group vs 36% in the pill group (P = .0092). Statistically significant lower postoperative serum concentrations of vitamin D, B1, and B12 were seen in the patch group. CONCLUSIONS: Multivitamin patch users are more likely to have vitamin D deficiency and lower serum concentration of various vitamins and minerals. Future large studies are needed on the efficacy of multivitamin patches before they can be recommended to bariatric patient population.

Is hyperkinetic gallbladder an indication for cholecystectomy?

BACKGROUND: The (99m) technetium-labelled hepato imino diacetic acid (HIDA) scan is widely used to evaluate patients with biliary colic with a normal trans-abdominal ultrasound scan. Most studies recommend cholecystectomy for patients with biliary dyskinesia, defined by gallbladder ejection fraction (GBEF) of less than 35-40% on HIDA scan. There are no recommendations regarding management of hyperkinetic gallbladder defined by GBEF of greater than 80% on HIDA scan. The aim of our study was to evaluate the outcomes following cholecystectomy on patients with biliary colic associated with hyperkinetic gallbladder. METHODS: We performed a retrospective chart review of all patients with biliary colic associated with hyperkinetic gallbladder that underwent cholecystectomy in our practice from July 2014 to February 2018. Data collection included age, gender, body mass index, preoperative symptoms, comorbidities, additional tests, ejection fraction, surgery, and histopathology of the gallbladder. Symptomatic improvement was assessed during routine 2-week postoperative visit and a follow-up phone interview. RESULTS: Thirty-two patients had undergone laparoscopic cholecystectomy during the study period for symptomatic hyperkinetic gallbladder. All the patients had abdominal pain related to food intake and 17 (53%) patients had worsening of symptoms with CCK infusion. The average GBEF was 92%. Chronic cholecystitis was seen in 29 (90%) patients on pathology. 23 (74%) patients had complete resolution of biliary symptoms, 5 (16%) had improved symptoms, and 3 (10%) had no change in symptoms. CONCLUSION: Patients with biliary colic and hyperkinetic gallbladder respond favorably to laparoscopic cholecystectomy. Our results suggest that patients with biliary colic in the setting of hyperkinetic gallbladder have symptomatic improvement following cholecystectomy.

Gastrointestinal stromal tumor: an incidental finding during laparoscopic bariatric surgery.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Lack of clinical symptoms and findings on preoperative upper endoscopy makes its diagnosis difficult in bariatric patients. A laparoscopic resection of the gastric GIST during bariatric surgery is associated with good long-term prognosis.

Biliopancreatic limb obstruction after laparoscopic Roux-en-Y gastric bypass: a rare and potentially fatal condition.

Biliopancreatic limb obstruction after laparoscopic Roux-en-Y gastric bypass is a challenging diagnosis as the symptoms are very nonspecific. CT scan is the optimal study for evaluation. Early diagnosis and treatment is essential in reducing the morbidity and mortality associated with this condition.

Scheduled intravenous acetaminophen reduces postoperative narcotic analgesic demand and requirement after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Intravenous (i.v.) acetaminophen has the potential to reduce postoperative narcotic analgesic requirement but this has not been reported in bariatric surgery. As lower dosages could reduce undesirable narcotic side effects, we investigated the opioid-sparing effect of concomitant i.v. acetaminophen in bariatric surgery. METHODS: We performed a retrospective review of our electronic medical records of laparoscopic Roux-en-Y gastric bypasses (LRYGB) performed for severe obesity between 2011 and 2013. We identified 183 patients that received scheduled i.v. acetaminophen in addition to morphine sulfate (MSO4) patient-controlled analgesia (PCA). A cohort of 229 patients from the preceding 2 years who were treated with MSO4 PCA but not acetaminophen was used as a historical control. Patient demographic characteristics and narcotic use data were extracted from electronic medical records. Student's t test or linear regression was used as appropriate (P< .05). RESULTS: During the first 24-hour postoperative period after LRYGB, narcotic analgesic demand (total PCA demand including nondelivery of narcotic due to lock-out) was reduced by 25% with the concomitant use of i.v. acetaminophen (40.5 versus 30.9 average pushes; P<.05). During the same period, narcotic analgesic dosage requirement was cut down by 20% in the study group (average of 29.9 versus 24.1 mg of MSO4; P<.05). Linear regression analysis confirmed that these changes were independent of age, gender, and body mass index distribution, or type 2 diabetes mellitus. CONCLUSION: Scheduled i.v. acetaminophen reduces the demand for and the requirement of narcotic analgesia after LRYGB. We provide new evidence in support of the routine use of multimodal analgesia that includes scheduled i.v. acetaminophen in the initial 24-hour period after bariatric surgery.

Takayasu's Arteritis and Crohn's Disease in a Young Hispanic Female.

Takayasu's arteritis (TA) and Crohn's disease (CD) are chronic inflammatory granulomatous disorders of undetermined etiology. TA is a large vessel vasculitis with a predilection for the aorta and its branches in young women of Asian descent; whereas CD has characteristic gastrointestinal manifestations more prevalent in young Caucasians. We describe a case of both diseases in a young Hispanic female, review the literature, and impart new insight on possible genetic linkage and the role of interleukin 12 B (IL-12B) as the common autoimmune mechanism and potential therapeutic target in this rare disease combination.

Role of robotic-assisted surgery in benign esophageal diseases.

Laparoscopic treatment of benign esophageal conditions is technically complex with several inherent limitations. Robotic-assisted surgery provides technical improvement and helps to overcome some of these limitations. We therefore report a single surgeon's experience in management of benign esophageal diseases by robotic-assisted surgery. Over a period of 8 consecutive years, a retrospective chart review was performed of 105 patients who underwent robotic-assisted surgery for benign esophageal diseases by a single surgeon. Demographic data and outcome measures were studied. The robotic-assisted procedures included 85 Nissen fundoplications with and without mesh repair, 12 Heller myotomies and eight para-esophageal hernia repairs. The mean total operating time was lowest for the Nissen group (94 min) and highest for the para-esophageal group (183 min). Operating time decreased from a mean of 105 min in the first 20 cases to 84 min in the last 20 cases for the Nissen group (P = 0.014). The mean length of stay was 1.3, 1.6, 1.5 and 4.8 days for the groups, respectively. Persistent symptoms of dysphagia/reflux/dysphonia requiring further investigation were seen in nine (8 %) of these patients. Two of these patients required repeat Nissen fundoplication in the mesh group. Our complication rate, total operating time and length of stay for robotic-assisted benign esophageal surgery are comparable to those reported in the literature. When performed by an experienced surgeon, robotic-assisted surgery is safe and effective in the management of benign esophageal diseases.

Robotic gastric electrical stimulator placement: technique and literature review.

Gastroparesis in a chronic setting is a disorder that results in diminished quality of life. Laparoscopic gastric electrical stimulator (GES) placement is now being performed in patients with medically refractory gastroparesis. During this procedure, a significant amount of suturing is required to anchor the electrodes to the gastric wall. Robotic surgery may provide surgeons with several technical and ergonomic advantages during this procedure, when compared with a standard laparoscopic approach. The aim of this study is to present a case and review the technique and literature for robotic placement of GES. This report demonstrates the safety and feasibility of robotic GES placement.

What is the diagnosis for this rash?

KEY CLINICAL MESSAGE: The etiology of rash in a given patient can be so varied. Good history-taking is very important to prevent unnecessary work-up. In this patient with Churg-Strauss syndrome, the rash was due to "coining," a traditional practice followed in Southeast Asian community and had no relation to her underlying disease.

Lower extremity mass.

KEY CLINICAL MESSAGE: Soft tissue sarcomas are rare tumors accounting for less than 1% of all malignancies. Multidisciplinary approach is used in the management of these patients.

Small bowel obstruction.

KEY CLINICAL MESSAGE: Gallstone ileus is a rare complication of cholelithiasis, but an established cause of mechanical small bowel obstruction in elderly patients. It is associated with high morbidity and mortality as most patients are elderly with multiple comorbidities. Surgery of choice is enterolithotomy.

Fitz-hugh-curtis syndrome in a male patient: a case report and literature review.

Fitz-Hugh-Curtis syndrome is a condition characterized by inflammation of the liver capsule with concomitant pelvic inflammation without involvement of liver parenchyma. It is classically seen in young women who present with sharp, pleuritic right upper quadrant pain, usually but not always accompanied by symptoms of pelvic inflammatory disease (PID), and is frequently confused with biliary tract disease. Rarely the syndrome has been reported in males, and hematogenous and lymphatic spread to liver is thought to be the underlying mechanism. Serological tests and computed tomography (CT) scan may aid in diagnosis of Fitz-Hugh-Curtis syndrome. Definitive diagnosis is made by laparoscopy, which provides both diagnostic and therapeutic benefits. We report a case of Fitz-Hugh-Curtis syndrome in a young male patient, which was diagnosed and treated by laparoscopy. We also include a review of the literature.