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.

Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center.

BACKGROUND: The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints. METHODS: An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality. RESULTS: There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively. CONCLUSION: Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.

Role of AMPK-SREBP Signaling in Regulating Fatty Acid Binding-4 (FABP4) Expression following Ethanol Metabolism.

Fatty acid binding protein-4 (FABP4) is not normally expressed in the liver but is induced in alcohol-dependent liver disease (ALD)). This study sought to identify mechanisms whereby ethanol (EtOH) metabolism alters triglyceride accumulation and FABP4 production. Human hepatoma cells which were stably transfected to express alcohol dehydrogenase (ADH) or cytochrome P4502E1 (CYP2E1) were exposed to EtOH in the absence/presence of inhibitors of ADH (4-methylpyrazole) or CYP2E1 (chlormethiazole). Cells were analyzed for free fatty acid (FFA) content and FABP4 mRNA, then culture medium assayed for FABP4 levels. Cell lysates were analyzed for AMP-activated protein kinase-α (AMPKα), Acetyl-CoA carboxylase (ACC), sterol regulatory element binding protein-1c (SREBP-1c), and Lipin-1ß activity and localization in the absence/presence of EtOH and pharmacological inhibitors. CYP2E1-EtOH metabolism led to increased FABP4 mRNA/protein expression and FFA accumulation. Analysis of signaling pathway activity revealed decreased AMPKα activation and increased nuclear-SREBP-1c localization following CYP2E1-EtOH metabolism. The role of AMPKα-SREBP-1c in regulating CYP2E1-EtOH-dependent FFA accumulation and increased FABP4 was confirmed using pharmacological inhibitors and over-expression of AMPKα. Inhibition of ACC or Lipin-1ß failed to prevent FFA accumulation or changes in FABP4 mRNA expression or protein secretion. These data suggest that CYP2E1-EtOH metabolism inhibits AMPKα phosphorylation to stimulate FFA accumulation and FABP4 protein secretion via an SREBP-1c dependent mechanism.

Ectodysplasin-A mRNA in exosomes released from activated hepatic stellate cells stimulates macrophage response.

INTRODUCTION: The interaction between activated hepatic stellate cells (aHSCs) and macrophages is central to liver fibrosis development. The cargo contained within aHSC exosomes (aHSC-EXOs) and how aHSC-EXOs affect macrophage function is poorly understood. METHODS: RNA from aHSC-EXOs was separated into small (<200-basepairs) and large (≥200-basepairs) RNA species, transfected into macrophages, and macrophage IL-6 and TNFα mRNA expression and protein secretion measured. Next generation sequencing was performed on EXOs from rat quiescent and aHSCs and human aHSCs. aHSCs were transfected with siRNA against ectodysplasin-A (EDA), EXOs collected, and their effect on macrophage function analyzed. Human cirrhotic liver was analyzed for EDA mRNA expression and compared to non-tumor liver (NTL). RESULTS: Transfection with large RNA from aHSC-EXOs stimulated macrophage IL-6 and TNFα mRNA expression and protein secretion. EDA mRNA was highly expressed in aHSCs and transfection of aHSCs with EDA-siRNA decreased aHSC-EXO EDA mRNA and blunted the effect of aHSC-EXOs on macrophage function (IL-6/TNFα expression and macrophage migration). Human cirrhotic liver exhibited high EDA mRNA compared to NTL. CONCLUSIONS: HSC activation leads to altered EXO mRNA/miRNA profiles with aHSC-EXOs mRNAs exerting a dominant role in altering macrophage function. Ectodysplasin-A mRNA is an important component in aHSC-EXOs in regulating macrophage function.

Cytochrome P450 2E1-dependent hepatic ethanol metabolism induces fatty acid-binding protein 4 and steatosis.

BACKGROUND: Hepatic steatosis is an early pathology of alcohol-associated liver disease (ALD). Fatty acid-binding protein-4 (FABP4, a FABP not normally produced in the liver) is secreted by hepatocytes in ALD and stimulates hepatoma proliferation and migration. This study sought to investigate the mechanism[s] by which hepatic ethanol metabolism regulates FABP4 and steatosis. METHODS: Human hepatoma cells (HepG2/HuH7) and cells stably transfected to express cytochrome P450 2E1 (CYP2E1), were exposed to ethanol in the absence or presence of chlormethiazole (a CYP2E1-inhibitor; CMZ) and/or EX-527 (a sirtuin-1 [SIRT1] inhibitor). The culture medium was analyzed for ethanol metabolism and FABP4 protein abundance. Cells were analyzed for FABP4 mRNA expression, SIRT1 protein abundance, and neutral lipid accumulation. In parallel, cells were analyzed for forkhead box O1 [FOXO1], ß-catenin, peroxisome proliferator-activated receptor-α [PPARα], and lipin-1α protein abundance in the absence or presence of ethanol and pharmacological inhibitors of the respective target proteins. RESULTS: CYP2E1-dependent ethanol metabolism inhibited the amount of SIRT1 protein detected, concomitant with increased FABP4 mRNA expression, FABP4 protein secretion, and neutral lipid accumulation, effects abolished by CMZ. Analysis of pathways associated with lipid oxidation revealed increased FOXO1 nuclear localization and decreased ß-catenin, PPARα, and lipin-1α protein levels in CYP2E1-expressing cells in the presence of ethanol. Pharmacological inhibition of SIRT1 mimicked the effects of ethanol, while inhibition of FOXO1 abrogated the effect of ethanol on FABP4 mRNA expression, FABP4 protein secretion, and neutral lipid accumulation in CYP2E1-expressing cells. Pharmacological inhibition of ß-catenin, PPARα, or lipin-1α failed to alter the effects of ethanol on FABP4 or neutral lipid accumulation. CONCLUSION: CYP2E1-dependent ethanol metabolism inhibits SIRT1-FOXO1 signaling, which leads to increased FABP4 mRNA expression, FABP4 protein secretion, and neutral lipid accumulation. These data suggest that FABP4 released from steatotic hepatocytes could play a role in promoting tumor cell expansion in the setting of ALD and represents a potential target for therapeutic intervention.

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.

The introduction of wide-angle 270° laparoscopy through a novel laparoscopic camera system.

BACKGROUND: Laparoscopy has enjoyed improvements over the last three decades primarily in achieving high definition, but the 70° field of view (FOV) remains unchanged. Complications related to events that take place out of the FOV continue to be reported. Additional problems leading to poor visualization are fogging and smoke accumulation. A novel laparoscopic system (SurroundScope, 270Surgical) was developed and dramatically expands the FOV from the 70° to 270° by adding side cameras at the distal tip of the laparoscope, while LED illumination eliminates fogging and improves smoke effects. This study describes the initial clinical experience with SurroundScope and its potential advantages over traditional laparoscopy. METHODS: SurroundScope was studied at Bnai Zion Medical Center in Israel and the Minnesota Institute for Minimally Invasive Surgery in America. 27 laparoscopic surgeries were performed, and at the end of each procedure, evaluations were completed by all surgeons and camera holders. RESULTS: All 27 cases were completed successfully without adverse events. No injuries occurred as a result of surgical tool manipulation outside of the central frame while 133 potentially adverse events were identified on side frames. There was no fogging across the 27 cases. The impact of smoke was negligible in all cases, as laparoscope removal or venting was never necessary. Surgeon respondents indicated that tools could be followed from the port to the site of surgery without camera manipulation. Most surgeons strongly agreed that the potential to identify bleeding was improved. Camera holders strongly agreed that the ergonomics were improved and that they moved the camera less than with a standard laparoscope. CONCLUSIONS: Initial results demonstrate numerous advantages for SurroundScope as compared to traditional laparoscopy. The important benefits of expanded FOV, complete lack of fogging, and negligible smoke may improve patient safety, reduce adverse events and the duration of surgery. Further investigation to quantify these benefits is recommended.

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.

The technical aspects of ex vivo hepatectomy with autotransplantation: a systematic review and meta-analysis.

PURPOSE: Ex vivo hepatectomy is the incorporation of liver transplant techniques in the non-transplant setting, providing opportunity for locally advanced tumors found conventionally unresectable. Because the procedure is rare and reports in the literature are limited, we sought to perform a systematic review and meta-analysis investigating technical variations of ex vivo hepatectomies. METHODS: In the literature, there is a split in those performing the procedure between venovenous bypass (VVB) and temporary portacaval shunts (PCS). Of the 253 articles identified on the topic of ex vivo resection, 37 had sufficient data to be included in our review. RESULTS: The majority of these procedures were performed for hepatic alveolar echinococcosis (69%) followed by primary and secondary hepatic malignancies. In 18 series, VVB was used, and in 18, a temporary PCS was performed. Comparing these two groups, intraoperative variables and morbidity were not statistically different, with a cumulative trend in favor of PCS. Ninety-day mortality was significantly lower in the PCS group compared to the VVB group (p=0.03). CONCLUSION: In order to better elucidate these differences between technical approaches, a registry and consensus statement are needed.

Fatty acid binding protein-4 promotes alcohol-dependent hepatosteatosis and hepatocellular carcinoma progression.

Fatty liver disease (hepatosteatosis) is a common early pathology in alcohol-dependent and obese patients. Fatty acid binding protein-4 (FABP4) is normally expressed in adipocytes and macrophages and functions as a regulator of intracellular lipid movement/storage. This study sought to investigate hepatic FABP4 expression and function in alcoholic liver disease (ALD) and hepatocellular carcinoma (HCC). Using chronic ethanol fed mouse models and patient samples FABP4 expression was analyzed. Human HCC cells, and HCC cells transfected to express CYP2E1, were exposed to ethanol and analyzed for FABP4 expression, or exposed to rhFABP4 (in the absence/presence of ERK, p38-MAPK or JNK1/2 inhibitors) and cell proliferation and migration measured. Hepatosteatotic-ALD mouse models exhibited increased hepatic FABP4 mRNA and protein levels, with FABP4 expression confirmed in hepatocytes. In HCC cells, CYP2E1-dependent ethanol metabolism induced FABP4 expression in vitro and exogenous rhFABP4 stimulated proliferation and migration, effects abrogated by ERK and JNK1/2 inhibition. Increased FABP4 was also detected in ALD/ALD-HCC patients, but not patients with viral hepatitis/HCC. Collectively these data demonstrate ethanol metabolism induces hepatic FABP4 expression and FABP4 promotes hepatoma cell proliferation/migration. These data suggest liver-derived FABP4 may be an important paracrine-endocrine factor during hepatic foci expansion and/or hepatoma progression in the underlying setting of ALD.

The treatment sequence may matter in patients undergoing pancreatoduodenectomy for early stage pancreatic cancer in the era of modern chemotherapy.

BACKGROUND: The aim of this study was to investigate outcomes associated with neoadjuvant chemotherapy in patients undergoing pancreatoduodenectomy for early stage pancreatic adenocarcinoma in the era of modern chemotherapy. METHODS: The National Cancer Database (2010-2016) was queried for patients with clinical stage 0-2 pancreatic adenocarcinoma who underwent pancreatoduodenectomy. Patients who underwent up-front pancreatoduodenectomy were propensity matched to patients who received neoadjuvant chemotherapy. Postoperative outcomes, pathologic outcomes, and overall survival were compared. RESULTS: A total of 2036 patients were in each group. Neoadjuvant chemotherapy was associated with shorter length of stay, lower 30-day readmission rate, and lower 30 and 90-day mortality rates (all p < 0.05). Neoadjuvant chemotherapy was associated with lower rates of positives nodes and positive resection margins (all p < 0.0001). Neoadjuvant chemotherapy was associated with longer survival (26.8 vs. 22.1months, p < 0.0001). Patients who received neoadjuvant chemotherapy followed by surgery and adjuvant therapy had the longest OS, followed by neoadjuvant + surgery, surgery + adjuvant therapy, and surgery alone (29.8 vs. 25.6 vs. 23.9 vs. 13.1 months; p < 0.0001). CONCLUSIONS: Neoadjuvant chemotherapy is associated with improved postoperative outcomes, oncologic outcomes, and overall survival in patients with early stage pancreatic adenocarcinoma. Neoadjuvant chemotherapy should be considered in all patients with early stage pancreatic adenocarcinoma.

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.

Improved oncologic outcomes for minimally invasive left pancreatectomy: Propensity-score matched analysis of the National Cancer Database.

BACKGROUND AND OBJECTIVES: Minimally invasive (MIS) left pancreatectomy (LP) is increasingly used to treat pancreatic adenocarcinoma (PDAC). Despite improved short-term outcomes, no studies have demonstrated long-term benefits over open resection. METHODS: The National Cancer Database was queried between 2010 and 2016 for patients with PDAC, grouped by surgical approach (MIS vs open). Demographics, comorbidities, clinical staging, and pathologic staging were used for propensity-score matching. Perioperative, short-term oncologic, and survival outcomes were compared. RESULTS: After matching, both cohorts included 805 patients. There were no differences in baseline characteristics, staging, or preoperative therapy between cohorts. The MIS cohort had a shorter length of stay (6.8 ± 5.5 vs 8.5 ± 7.3 days; P < .0001) with the trend toward improved time to chemotherapy (53.9 ± 26.1 vs 57.9 ± 29.9 days; P = .0511) and margin-positive resection rate (15.3% vs 18.9%; P = .0605). Lymph node retrieval and receipt of chemotherapy were similar. The MIS cohort had higher median overall survival (28.0 vs 22.1 months; P = .0067). Subgroup analysis demonstrated the highest survival for robotic compared with laparoscopic and open LP (41.9 vs 26.6 vs 22.1 months; P < .0001). CONCLUSIONS: This study demonstrates the safety of MIS LP and favorable long-term oncologic outcomes. The improved survival after MIS LP warrants further study with prospective, randomized trials.

Examining the Hispanic paradox in bariatric surgery.

BACKGROUND: The obesity rate for the Hispanic population is significantly higher than that of white, non-Hispanic people in the United States, yet Hispanic people undergo disproportionately fewer metabolic and bariatric surgery procedures. This study used the Metabolic Bariatric Surgery Accreditation and Quality Improvement Program data registry to examine potential differences in preoperative co-morbidities and postoperative outcomes in Hispanic adults undergoing sleeve gastrectomy or Roux-en-Y gastric bypass procedures in the United States. OBJECTIVES: To study the presence of the Hispanic paradox in metabolic and bariatric surgery utilizing the MBSAQIP registry. SETTING: Academic Teaching Institution. METHODS: Participant User Files from the Metabolic Bariatric Surgery Accreditation and Quality Improvement Program were reviewed for patients undergoing sleeve gastrectomy or Roux-en-Y gastric bypass (2015-2017). Patients were grouped by race (Hispanic versus all other races) and primary procedure performed. Variables for major and minor postoperative complications were combined. A univariate analysis was performed on unmatched and propensity-matched cohorts. RESULTS: After applying exclusions, 53,353 (13.7%) Hispanic patients and 335,299 non-Hispanic patients remained. A univariate analysis demonstrated Hispanic patients had the lowest preoperative co-morbidity profile compared with all other races and decreased rates of major and minor postoperative complications. Using matched-cohort data, when complications were assessed and grouped as major/minor complications, rates of major and minor complications in Hispanic patients were lower in the Roux-en-Y gastric bypass group, despite Hispanic patients having higher leak rates. Similarly, there were no differences between Hispanic/non-Hispanic sleeve gastrectomy patients in overall major/minor complication rates despite Hispanic patients exhibiting higher venous thromboembolism and lower bleeding compared with non-Hispanic patients. CONCLUSION: Hispanic patients undergo disproportionately low rates of metabolic and bariatric surgery procedures and present with lower incidence of preoperative co-morbidities. Additionally, Hispanic patients have the same or decreased incidence of postoperative complications compared with non-Hispanic patients, thereby corroborating the Hispanic paradox.

Outcomes of adolescents compared with young adults after bariatric surgery: an analysis of 227,671 patients using the MBSAQIP data registry.

BACKGROUND: Obesity in the United States is increasingly prevalent in adolescents. Metabolic and bariatric surgery is offered at select sites to adolescents (<18 yr). Controversy exists regarding the safety of performing metabolic and bariatric surgery in adolescents. OBJECTIVES: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program registry was employed to compare outcomes of adolescents with adults (18-40 yr) undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). SETTING: Academic Teaching Institution. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant User Files were reviewed for patients undergoing SG or RYGB (2015-2018). Patients were stratified by age and outcomes for adolescents versus adults compared. A bivariate analysis was performed on propensity-matched data. RESULTS: After exclusion criteria were applied, 227,671 patients <40 years remained, of whom 1005 were adolescents. For those undergoing RYGB (13.8% adolescents, 25.3% adults), demographic characteristics were similar. Adolescent SG patients were more likely to be male and Hispanic, but less likely to be smokers or have preoperative co-morbidities. There were no differences in infection rates, mortality, major complications, reoperation, readmission, or other interventions for RYGB and SG groups. For both adult SG and adolescent SG, patients' operative times were less than adult and adolescent RYGB, respectively. However, operative times were shorter for adolescent RYGB versus adult RYGB patients, yet longer for adolescent SG patients versus adult SG patients. CONCLUSIONS: Metabolic and bariatric surgery is as safe for adolescents undergoing an SG or RYGB as adults. Currently, SG is more commonly performed in adolescents than RYGB, and adolescent SG patients have similar outcomes and shorter operating room times compared with adolescent RYGB patients.

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.