A Call to Action to Train Underrepresented Minorities in Surgical Subspecialties and Fellowships.

BACKGROUND: With each succession along the surgical career pathway, from medical school to faculty, the percentage of those who identify as underrepresented in medicine (URiM) decreases. We sought to evaluate the demographic trend of surgical fellowship applicants, matriculants, and graduates over time. STUDY DESIGN: The Electronic Residency Application Service and the Graduate Medical Education Survey for general surgery fellowships in colorectal surgery, surgical oncology, pediatric surgery, thoracic surgery, and vascular surgery were retrospectively analyzed (2005 to 2020). The data were stratified by race and gender, descriptive statistics were performed, and time series were evaluated. Race/ethnicity groups included White, Asian, other, and URiM, which is defined as Black/African American, Hispanic/Latino(a), Alaskan or Hawaiian Native, and Native American. RESULTS: From 2005 to 2020, there were 5,357 Electronic Residency Application Service applicants, 4,559 matriculants, and 4,178 graduates to surgery fellowships. Whites, followed by Asians, represented the highest percentage of applicants (62.7% and 22.3%, respectively), matriculants (65.4% and 23.8% respectively), and graduates (65.4% and 24.0%, respectively). For URiMs, the applicants (13.4%), matriculants (9.1%), and graduates (9.1%) remained significantly low (p < 0.001). When stratified by both race and gender, only 4.6% of the applicants, 2.7% of matriculants, and 2.4% of graduates identified as both URiM and female compared to White female applicants (20.0%), matriculants (17.9%), and graduates (16.5%, p < 0.001). CONCLUSIONS: Significant disparities exist for URiMs in general surgery subspecialty fellowships. These results serve as a call to action to re-examine and improve the existing processes to increase the number of URiMs in the surgery subspecialty fellowship training pathway.

Examination of Intersectionality and the Pipeline for Black Academic Surgeons.

IMPORTANCE: The lack of underrepresented in medicine physicians within US academic surgery continues, with Black surgeons representing a disproportionately low number. OBJECTIVE: To evaluate the trend of general surgery residency application, matriculation, and graduation rates for Black trainees compared with their racial and ethnic counterparts over time. DESIGN, SETTING, AND PARTICIPANTS: In this nationwide multicenter study, data from the Electronic Residency Application Service (ERAS) for the general surgery residency match and Graduate Medical Education (GME) surveys of graduating general surgery residents were retrospectively reviewed and stratified by race, ethnicity, and sex. Analyses consisted of descriptive statistics, time series plots, and simple linear regression for the rate of change over time. Medical students and general surgery residency trainees of Asian, Black, Hispanic or Latino of Spanish origin, White, and other races were included. Data for non-US citizens or nonpermanent residents were excluded. Data were collected from 2005 to 2018, and data were analyzed in March 2021. MAIN OUTCOMES AND MEASURES: Primary outcomes included the rates of application, matriculation, and graduation from general surgery residency programs. RESULTS: Over the study period, there were 71 687 applicants, 26 237 first-year matriculants, and 24 893 graduates. Of 71 687 applicants, 24 618 (34.3%) were women, 16 602 (23.2%) were Asian, 5968 (8.3%) were Black, 2455 (3.4%) were Latino, and 31 197 (43.5%) were White. Women applicants and graduates increased from 29.4% (1178 of 4003) to 37.1% (2293 of 6181) and 23.5% (463 of 1967) to 33.5% (719 of 2147), respectively. When stratified by race and ethnicity, applications from Black women increased from 2.2% (87 of 4003) to 3.5% (215 of 6181) (P < .001) while applications from Black men remained unchanged (3.7% [150 of 4003] to 4.6% [284 of 6181]). While the matriculation rate for Black women remained unchanged (2.4% [46 of 1919] to 2.3% [52 of 2264]), the matriculation rate for Black men significantly decreased (3.0% [57 of 1919] to 2.4% [54 of 2264]; P = .04). Among Black graduates, there was a significant decline in graduation for men (4.3% [85 of 1967] to 2.7% [57 of 2147]; P = .03) with the rate among women remaining unchanged (1.7% [33 of 1967] to 2.2% [47 of 2147]). CONCLUSIONS AND RELEVANCE: Findings of this study show that the underrepresentation of Black physicians at every stage in surgical training pipeline persists. Black men are especially affected. Identifying factors that address intersectionality and contribute to the successful recruitment and retention of Black trainees in general surgery residency is critical for achieving racial and ethnic as well as gender equity.

Association between time interval from bariatric surgery to pregnancy and maternal weight outcomes.

BACKGROUND: The majority of patients having bariatric surgery are reproductive-age women who are advised to delay pregnancy for at least 12 months after surgery. Many women become pregnant sooner and the association between gestational weight gain (GWG) and maternal long-term weight is unknown. OBJECTIVES: The primary objective of this study was to compare weight outcomes in pregnancies occurring < 12 months versus ≥ 12 months after bariatric surgery. The secondary objectives were to determine the association between time interval from bariatric surgery to pregnancy and maternal nutritional status and maternal and neonatal outcomes. STUDY DESIGN: This is a retrospective cohort study of women with singleton livebirths after bariatric surgery who received care at a single tertiary care center between 2009 and 2017. GWG was the difference in weight between the first prenatal visit and delivery. GWG adequacy was determined by the IOM 2009 guidelines according to prepregnancy BMI (inadequate, adequate, excessive). Postpartum weight retention was calculated as the difference between weight at first prenatal visit and measured postpartum weight. Weight outcomes along with maternal nutritional status and maternal and neonatal outcomes were compared between < 12 months versus ≥ 12 months after bariatric surgery with t-tests, Mann-Whitney U and chi-square tests, as appropriate. RESULTS: Of the 76 pregnancies that met inclusion criteria, 36.8% occurred < 12 months (median 7.2 months) and 63.2% occurred ≥ 12 months after surgery (median 26.9 months). Of those with pregnancies < 12 months from surgery, 34% had a restrictive procedure (adjustable gastric band or sleeve gastrectomy) while 66% had a combined restrictive-malabsorptive procedure (Roux-en-Y gastric bypass). In the ≥ 12 months group, 42.3% had a restrictive procedure while 57.7% had a combined restrictive-malabsorptive procedure. There were no significant differences in maternal age, ethnicity or nulliparity between groups, but there were more women with obesity in the < 12 months group (75 vs. 52%, p = .03). The mean prepregnancy BMI in the < 12 months group was 34.3 vs. 31.2 kg/m2 in the ≥ 12 months group. The < 12 months group had lower mean GWG (4.9 vs. 10.9 kg, p = .01) and higher frequency of weight loss during pregnancy (28.6 vs. 4.2%, p < .01) compared to the ≥ 12 months group. The < 12 months group had significantly less postpartum weight retention at 6 months compared to the ≥ 12 months group (-1.3 vs. 8.3 kg, p = .02). The < 12 months group had a higher prevalence of vitamin B12 deficiency (23.1 versus 4.9%, p = .05). There were no differences in hyperemesis, hypertensive disorders, gestational diabetes or delivery mode between groups (p > .05). There were no differences in gestational age at delivery, birth weight and small for gestational age infants between groups (p > .05). CONCLUSION: Pregnancy < 12 months after bariatric surgery is associated with significantly lower mean GWG and a higher frequency of weight loss during pregnancy as well as less postpartum weight retention at 6 months. Although there were no differences birthweight, weight loss during pregnancy and its accompanying metabolic changes are concerning for a developing fetus. Further study is needed to determine the optimal timing of pregnancy after bariatric surgery with respect to both maternal and infant short and long-term outcomes.

Hemobilia as a Complication of Transhepatic Percutaneous Biliary Drainage: a Rare Indication for Laparoscopic Common Bile Duct Exploration.

BACKGROUND: Hemobilia is the presence of blood in the biliary tree and is a frequent complication after percutaneous transhepatic biliary drainage (PTBD).1 Most of these episodes are self-limited; nevertheless, in less than 5% of cases, hemobilia is clinically significant, requiring an intervention (hepatic artery embolization, stenting, or percutaneous thrombin injection).2,3 Adequate treatment requires control of hemorrhage and restoration of bile flow. Surgery is the last resort and is indicated when the other modalities fail. METHODS: A 65-year-old man with multiple comorbidities was admitted with cholangitis. The patient underwent PTBD (Figure 1) but had persistent cholestasis. Thus, he underwent endoscopic cholangiopancreatography (ERCP), in which a plastic stent was misplaced within the common bile duct (CBD) and could not be removed (Figure 2). Afterwards, as the patient had persistently high bilirubin levels and the previously placed stent was malpositioned, the decision was made to proceed with laparoscopic cholecystectomy and CBD exploration. RESULTS: The operation was performed with choledocoscope guidance, and the CBD was closed over a T-tube. The operative time was 280 min. Postoperative course was uneventful; the T-tube was clamped 1 week after discharge. Four weeks postoperatively, the T-tube cholangiogram showed a patent extrahepatic biliary tree with no filling defects (Figure 3). The T-tube was then removed. CONCLUSIONS: Biliary obstruction secondary to hemobilia is a rare occurrence after PTBD. Surgical CBD exploration is required when conservative management and endoscopic treatment fail and can be done successfully through a minimally invasive approach.

Factor VIII elevation may contribute to portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy: a multicenter review of 40 patients.

BACKGROUND: Portomesenteric vein thrombosis (PMVT) has been increasingly reported after laparoscopic sleeve gastrectomy (LSG). Factor VIII (FVIII) is a plasma sialoglycoprotein that plays an essential role in hemostasis. There is increasing evidence that FVIII elevation constitutes a clinically important risk factor for venous thrombosis. OBJECTIVES: To report the prevalence of FVIII elevation as well as other clinical characteristics in a multicenter series of patients who developed PMVT after LSG. SETTING: University hospitals. METHODS: A retrospective review was conducted of all patients that developed PMVT after laparoscopic bariatric surgery from 2006 to 2016 at 6 high-volume bariatric surgery centers. RESULTS: Forty patients who developed PMVT postoperatively, all after LSG, were identified. During this timeframe, 25,569 laparoscopic bariatric surgery cases were performed, including 9749 LSG (PMVT incidence after LSG = .4%). Mean age and body mass index were 40 years (18-65) and 43.4 kg/m2 (35-59.7), respectively. Abdominal pain was the most common (98%) presenting symptom. Of patients, 92% had a hematologic abnormality identified, and of these, FVIII elevation was the most common (76%). The vast majority (90%) was successfully managed with therapeutic anticoagulation alone. A smaller number of patients required small bowel resection (n = 2) and surgical thrombectomy (n = 1). There were no mortalities. CONCLUSIONS: A high index of clinical suspicion and prompt diagnosis/treatment of PMVT usually leads to favorable outcomes. FVIII elevation was the most common (76%) hematologic abnormality identified in this patient cohort. Further studies are needed to determine the prevalence of FVIII elevation in patients seeking bariatric surgery.

Management of Pregnancy in Women Who Have Undergone Bariatric Surgery.

IMPORTANCE: As the problem of obesity continues to grow, more patients are choosing to undergo bariatric surgery to lose weight and treat comorbidities, such as diabetes. Of the more than 200,000 procedures performed each year, 80% are in women, many of reproductive age. Taking care of a pregnant woman who has undergone bariatric surgery requires understanding of the risks, the need for additional surveillance, and the limitations of our knowledge about how bariatric surgery affects pregnancy. OBJECTIVE: The aims of this study were to review the current literature on bariatric surgery and pregnancy and summarize the important evidence to help the obstetrician care for a pregnant woman after bariatric surgery. EVIDENCE ACQUISITION: Evidence for this review was acquired using PubMed. CONCLUSIONS: Pregnancy after bariatric surgery is safe and may be associated with improved pregnancy outcomes; however, more research is needed to better understand how to manage pregnant women with a history of bariatric surgery. RELEVANCE: Obstetricians will increasingly be caring for women who have undergone bariatric surgery and subsequently become pregnant.

Preoperative Endoscopy Prior to Bariatric Surgery: a Systematic Review and Meta-Analysis of the Literature.

BACKGROUND: There is debate regarding preoperative endoscopy (EGD) in patients undergoing bariatric surgery. Some centers perform EGD routinely in all patients; others perform EGD selectively. The objective of this study was to perform a systematic review and meta-analysis of the existing literature to estimate how frequently preoperative EGD changes management. METHODS: Our review yielded 28 studies encompassing 6616 patients. Baseline characteristics including age and body mass index (BMI) were included. Patients were grouped based on EGD findings into two groups: Group 1-findings which did not significantly change management (e.g., mild/moderate duodenitis, Grade A/B esophagitis, mild/moderate gastritis, H. pylori infection, hiatal hernia <2 cm); Group 2-findings which delayed, altered, or cancelled surgery (e.g., severe duodenitis, Grade C/D esophagitis, gastric varices, hiatal hernia >2 cm, mass/carcinoma). A general estimating equation (GEE) model accounting for the correlated data within each study was used to calculate confidence intervals around the estimate of how frequently surgery was delayed or altered. RESULTS: Mean age was 41.4 ± 2.9 years, the majority was women, and mean preoperative BMI was 47 ± 3.2 kg/m2. Overall 92.4 % (n = 6112) had a normal EGD or findings that did not change clinical management and 7.6 % (n = 504); 95 % CI [4.6, 12.4 %] had findings that delayed/altered surgery. The revised estimate was 20.6 %; 95%CI [14.5, 28.2 %] if all esophagitis (regardless of grade) were categorized into Group 2. The approximate incidence of Barrett's esophagus and carcinoma were 0.1 and 0.08 %, respectively. CONCLUSION: A selective approach to preoperative EGD may be considered, based on the patients' symptoms, risk factors, and type of procedure planned.

Insurance-mandated medical weight management before bariatric surgery.

BACKGROUND: Many insurance companies require a medical weight management (MWM) program as a prerequisite for approval for bariatric surgery. There is debate regarding the benefit of this requirement. The objective of this study is to assess the effect of insurance-mandated MWM programs on weight loss outcomes in our bariatric surgery population. OBJECTIVE: To assess the effect of insurance-mandated MWM programs on weight loss outcomes in our bariatric surgery population. SETTING: University. METHODS: A retrospective review of all bariatric surgery cases performed between 2009 and 2013 was conducted. Patients were stratified by payor mix based on whether the insurance company required MWM. To control for differences between groups, a bucket matching algorithm was used to match patients based on gender, age, body mass index (BMI), and surgery type (sleeve gastrectomy, gastric bypass, or gastric band). A repeated-measures regression model was created to estimate percent excess weight loss, percent excess BMI loss, and percent total weight loss. RESULTS: A total of 1432 bariatric surgery patients were reviewed. The bucket-matching algorithm resulted in 560 patients for final analysis. Mean age and BMI were 41 years and 43 kg/m(2), respectively, and 91% were female. The regression model found no significant differences in weight loss outcomes between the MWM group and the comparison group at 1 year and 2 years-percent total weight loss: 21.3% [95% confidence interval [CI] 20.6%-22.1%] versus 20.2% [95%CI 19.7%-20.6%) at 1 year and 23.4% [95%CI 22.6%-24.3%] versus 21.5% [95%CI 21.0%-22.0%] at 2 years. CONCLUSION: There was no difference in weight loss outcomes up to 2 years in patients who required insurance-mandated MWM programs. Longer-term studies are needed to determine the benefit of this insurance requirement.