Bariatric and Foregut : Journal of the American College of Surgeons (2025)

Table of Contents
An Analysis of the Cost-Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Obesity Management Bariatric Surgery as a Safe and Effective Alternative for Managing Obesity in Individuals with Intellectual or Developmental Disorder: A Systematic Review and Meta-Analysis Bariatric Surgery Improves Female Fertility: Results of a Prospective Analysis on 287 Fertile Women Changes in Gastric Electrophysiology and Effect on Quality of Life after Laparoscopic Sleeve Gastrectomy Circulating Bile Acids Are Differentially Expressed after Gastric Bypass Compared with Sleeve Gastrectomy in Patients Undergoing Metabolic Surgery Comparative Cost-Effectiveness Analysis of Bariatric Surgery and GLP-1 Receptor Agonists for the Management of Obesity Digital Pathway to Recovery: Association Between Patient Engagement with a Customizable Mobile Platform and Readmission after Bariatric Surgery Evening the Score: Use of an Objective Scoring System to Capture Underdiagnosed Hypertension among Lower Socioeconomic Patients Undergoing Bariatric Surgery Factors Associated with GLP-1 Agonist Use after Bariatric Surgery Glucagon-Like Peptide-1 Receptor Agonists in the Management of Obesity: An Economics Meta-Analysis Hiatal Hernia Repair: A Single-Institution Experience and Risk Factors Associated with Symptomatic Recurrence at 1 Year How Does Payor Status Shape Postoperative Resource Use in Metabolic Surgery? A Multi-Institutional Study Improvement in Heart Failure Symptoms after Bariatric Surgery as Measured by a New Heart Failure-Specific Health-Related Quality of Life Instrument Intestinal Bypass as Metabolic Surgery Leads to More Significant Changes in Circulating Metabolites Compared with Restrictive Operation Laparoscopic Roux-en-Y Gastric Bypass Is Associated with Greater Change in Microbial Diversity Compared with Sleeve Gastrectomy in Morbidly Obese Patients Laparoscopic Surgery for Median Arcuate Ligament Syndrome: Clinical Outcomes and Recurrence Patterns Magnetic Duodeno-Ileostomy Side-to-Side without Gastrectomy for Type-2 Diabetes: Preliminary Results One Anastomosis Gastric Bypass: Indications and Results of Conversion to Roux-en-Y Gastric Bypass: A Mono-Centric Retrospective Study Overexpression of CDCA3 Relates to Tumor Malignant Potential and Outcomes of Gastric and Adenocarcinoma of the Esophagogastric Junction Postoperative Heartburn and Proton Pump Inhibitor Use after Peroral Endoscopic Myotomy vs Heller Myotomy with Dor Preoperative Semaglutide Use Does Not Improve Weight Loss or Safety of Bariatric Surgery Prior Surgical History and Psychiatric Conditions Can Increase Perioperative Opioid Use in Bariatric Surgery Prostate Cancer Screening Rate Improves after Bariatric Surgery Research on Glycocalyx-Related Molecules Glypican1 as a New Biomarker for Esophageal Cancer Roux-en-Y Gastric Bypass Jejunal-Jejunal Side-to-Side Anastomosis Using Self-Assembling Magnets and OTOLoc Safety of Same-Day Discharge after Sleeve Gastrectomy in Adults 65 Years and Older Should Laparoscopic Sleeve Gastrectomy Be Considered and Reimbursed as an Inpatient or an Outpatient Procedure? A Large Data Comparison of Health Care Use and Hospital Charges Surgical Approach to Pyloric Drainage for Gastroparesis: A Comparison of Laparoscopic Pyloroplasty and Gastric Peroral Endoscopic Myotomy Outcomes The Effect of Laparoscopic Vertical Sleeve Gastrectomy on Lower Esophageal Sphincter Pressure, Lower Esophageal Sphincter Length and GERD Using Functional Esophageal Test: A Systematic Review and Meta-Analysis The Impact of Barrett’s Esophagus on Nissen Fundoplication Outcomes: A Matched Case-Control Study The Impact of Preoperative Glucagon-Like Peptide-1 Receptor Agonist Use on Bariatric Surgery Outcomes The Role of pH Monitoring in Predicting Revisional Antireflux Surgery Outcome Use of Proton Pump Inhibitors after Laparoscopic Gastric Bypass and Sleeve Gastrectomy: A Nationwide Register-Based Cohort Study ePosters A Survey on Key Aspects of Hiatal Hernia Repair: Global Variations among Esophageal Surgeons Clinical Outcomes of Varying Age Groups Following Vertical Sleeve Gastrectomy: An MBSAQIP Study Community-Level Socioeconomic Disadvantage and Adverse Events after Metabolic Surgery Outcomes: A State-Wide Analysis from the Michigan Bariatric Surgery Collaborative Comparing Anastomotic Leak Rate between Robotic and Laparoscopic Bariatric Procedures: A Retrospective Analysis of MBSAQIP 2020-2022 Emergent Laparoscopic Paraesophageal Hernia Repairs Are Associated with Increased Risk of 30-Day Postoperative Complications: A NSQIP Analysis Enhancing Patient Safety and Outcomes in Bariatric Surgery: The Role of Resident Participation. A Systematic Review and Meta-Analysis Evaluating Outcomes after Metabolic-Bariatric Surgery among Middle Eastern and North African Patients in Michigan First Reported Clinical and Histopathologic Outcomes after Revisional Median Arcuate Ligament Surgery Helicobacter Pylori Testing: Is It Necessary in Bariatric Patients? Impact of Anti-Coagulation Therapy on Perioperative Outcomes in Patients Undergoing Minimally Invasive Metabolic and Bariatric Surgery: Propensity Score Matched Analysis Using the 2020-2021 MBSAQIP Improved Perioperative Outcomes and Reduced Adverse Events in Robotic Compared to Laparoscopic Hiatal Hernia Repair Is Bariatric Surgery at Risk Due to Ozempic? Lipid Trends in Patients Experiencing Weight Regain after Bariatric Surgery Metabolic Syndrome Is Associated with Increased Rate of Complications Following Minimally Invasive Esophagectomy for Esophageal Adenocarcinoma Outcomes after Anterior Gastropexy for Paraesophageal Hernia Repair? Per-Oral Pyloromyotomy Outcome Disparities in Gastroparesis Preoperative Determinants of Hernia Repair Pain among Females with Hernia at One Month Risk Factors for Early Bowel Obstruction Following Bariatric Surgery: A Comprehensive Analysis of MBSAQIP Database (2015-2021) Risk Factors for Postoperative Venous Thromboembolism in Patients with Previous Deep Vein Thrombosis or Pulmonary Emboli: Analysis of the MBSAQIP National Registry Robotic versus Laparoscopic Bariatric Surgery in Patients with Super Obesity: An Analysis of Outcomes of the MBSAQIP Data Registry Short- and Long-Term Outcomes of Laparoscopy and Endoscopy Cooperative Surgery and Endoscopic Submucosal Dissection for Duodenal Tumors Swallowing the Evidence: A Comparative Study of Postoperative Dysphagia in Anti-Reflux Surgery with Ineffective Esophageal Motility The Efficacy and Side Effects of Orbera 365 12 Months Intragastric Balloon: A Retrospective Analysis of a Prospectively Maintained Database The Impact of Area Deprivation Index on Bariatric Surgical Outcomes The Influence of Age on Weight Regain after Sleeve Gastrectomy & Roux-en-Y Gastric Bypass To Collis or Not to Collis: Robotic Surgery Predicts Needs for Collis Gastroplasty during Hiatal Hernia Repair Transforming Clinical Care: The Emergence of Ambulatory Bariatric Surgery for Patients with Obesity Trends in Open, Laparoscopic, and Robotic Bariatric Surgery Utilization in North America from 2015 to 2022

An Analysis of the Cost-Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Obesity Management

Marcus H Cunningham, BS, Grace C Bloomfield, MS, Yuan Chen, BMS, Sebastiano Bartoletti, MD, Dan E Azagury, MD, FACS, Nicholas Prindeze, MD, Yewande R Alimi, MD, FACS

Georgetown University School of Medicine, Washington, DC; Department of Surgery, Geneva University Hospitals, Geneva, Switzerland; Department of Surgery, Stanford University School of Medicine, Stanford, CA

Introduction: While the efficacy of bariatric surgery is well studied, the economics are less well characterized. With the emergence of new medical therapy options, this study aims to quantify the relative economic impact of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures.

Methods: A literature review and meta-analysis were performed using Ovid Medline. Of 135 total articles, 55 articles containing 18,789 patients met the inclusion criteria for this meta-analysis. Mean HbA1c, diabetes mellitus (DM) prevalence, and BMI were evaluated at baseline and annually. Annual cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were assessed postoperatively per Second Panel on Cost-Effectiveness in Health and Medicine recommendations.

Results: Bariatric surgery was associated with reduced DM prevalence when compared with medical regimens (11.4% vs 23.9% at 10 years). Analysis of annual population spending identified a point of cost neutralization observed at the 6-year postoperative mark, in which compounded cost of operation and medical intervention equated (Figure 1). Incremental QALY gains were appreciated after RYGB (0.15) and SG (0.13). Both RYGB ($83,066/QALY) and SG ($83,862/QALY) demonstrated a cost-effective ICER at 5-year follow-up.

Conclusion: The results of this analysis demonstrate that bariatric surgery is associated with higher rate of DM remission and fewer long-term expenditures when compared with medical therapy in patients with obesity. Additionally, ICER values of these procedures were determined to be cost-effective.

Bariatric Surgery as a Safe and Effective Alternative for Managing Obesity in Individuals with Intellectual or Developmental Disorder: A Systematic Review and Meta-Analysis

Stalin I Cañizares, MD, Patricia Marcolin, Jacob Nudel, MD, Heather A Ford, MD, Dmitry Nepomnayshy, MD, FACS, David M Brams, MD, FACS

Universidad San Francisco de Quito, Quito, Ecuador; Universidade Federal da Fronteira Sul, Sorriso, Brazil; Lahey Hospital and Medical Center, Burlington, MA

Introduction: Over 40 million people in the US have disabilities, and with rising obesity rates, it is imperative to consider the feasibility and effectiveness of surgical alternatives for this population. We aimed to systematically review the literature regarding people with intellectual disabilities undergoing bariatric surgery.

Methods: A systematic review using PubMed, Scopus, Cochrane and Web of Science was performed to compare weight loss outcomes after any bariatric procedure among obese patients with and without intellectual/developmental disabilities (DID/DD/CI). Two authors screened each record. We extracted study characteristics, demographics, and outcomes measures including percentage of total weight loss (%TWL) and percentage of BMI change (%BMIC). The effect size for each outcome was reported using pooled mean difference (PMD) [95CI].

Results: Of 1024 studies, 4 met inclusion criteria. Study characteristics can be found in Table 1. All patients underwent laparoscopic sleeve gastrectomy (LSG). The meta-analysis revealed a PMD of 0.91 [-0.73, 2.55], 0.50 [-2.49, 3.50] and 0.30 [-4.28, 4.87] for %TWL at 3, 6 and 12 months, and of 1.33 [-0.57, 3.22], -0.36 [-3.79, 3.06] and -0.81 [-6.20, 4.57] for %BMIC at 3, 6 and 12 months, indicating no statistical difference among groups. Studies showed low-moderate heterogeneity measured by I².

Table 1. - Characteristics of included studies. PWS: Prader-Willi Syndrome. AI: Average Intellectual Ability

Study. Exposed (n) vs Unexposed (n) Age at operation, mean (SD) Baseline BMI, mean (SD) Complications (n)/ Reoperation (n) Follow-up rate (follow-up time) according to last scheduled appointment
Aayed et al. 2015. PWS (24) vs Control (72). Overall 10.7 (range: 4.9 - 18) 46.4 ± 12.0 vs 46.4 ± 11.7 0 vs 0/ 0 vs 0 94.1% (5 years) vs 97% (5 years)
Wakamatsu et al. 2023. DID (14) vs AI (71) 43 ± 10.9 vs 45.1 ± 9.8 44.7 ± 7.8 vs 45.6 ± 10.1 1 vs 6/ 0 vs 0 42.9% (1 year) vs 53.5% (1 year)
Gillian et al. 2019. DD (10) vs Without DD (44) 19.3 ± 4.6 vs 17.0 ± 1.7 49.7 ± 7.3 vs 48.4 ± 5.4 1 vs 11/ 1 vs 1 100% (1 year) vs 100% (1 year)
Sarah et al. 2019. CI/DD (17) vs Without CI/DD (46) 17.7 ± 2.7 vs 17.6 ± 1.7 51.5 ± 10.5 vs 51.1 ± 7.9 N/A Overall 29.2% (2 years)

Conclusion: Both groups showed similar postoperative weight loss outcomes, emphasizing the safety and feasibility of LSG in this population. Discussions about surgical alternatives should be considered regardless of cognitive or communicative impairments; however, further research is needed to define eligibility criteria, particularly given the highly selected group of patients within these studies.

Bariatric Surgery Improves Female Fertility: Results of a Prospective Analysis on 287 Fertile Women

Filippo Carannante, MD, Francesco Belia, MD, Carmen Santise, MD, Ida F Gallo, MD, Giuseppe Spagnolo, MD, Carlo De Cicco Nardone, MD, Roberto Angioli, MD, Domenico Borzomati, MD, FACS

Campus Bio-Medico University of Rome, Rome, Italy; University of Bologna, Bologna, Italy

Introduction: Obesity is a significant global health concern associated with comorbidity, including gynecological issues and infertility. Bariatric surgery has emerged as an effective treatment, yet its impact on female fertility remains underexplored. The present study evaluated the impact of bariatric surgery on female fertility in a series of 287 women of childbearing age.

Methods: This prospective analysis included 287 women (aged 18-45 years) of the 844 who underwent bariatric surgery at 2 tertiary referral centers from January 2016 through December 2022. Standard preoperative and 1-year postoperative assessment included gynecological examination and fertility evaluation.

Results: Preoperatively, 97 (33.8%) of the 287 women showed gynecological disease; 217 (75.6%) attempted pregnancy, with a 90.8% success rate. Multivariate analysis revealed BMI and age as factors significantly affecting fertility, with a higher BMI associated with an increased risk of infertility (p < 0.05) and younger age inversely correlated with fertility (p < 0.05). At 1-year follow-up, improvement was observed in terms of BMI (p < 0.05), type II diabetes (p < 0.05), dyslipidemia (p < 0.05), systemic hypertension (p < 0.05), menstrual abnormality (p < 0.05) and polycystic ovarian syndrome (p < 0.05). Fertility rate increased after operation, with 52.9% of preoperatively infertile women achieving pregnancy.

Conclusion: To the best of our knowledge, our study is the first to demonstrate that bariatric surgery improves female fertility, with half of non-fertile obese women achieving pregnancy 1 year after operation. Our results pave the way for further studies focusing on lager series of obese women of childbearing age treated with bariatric surgery.

Changes in Gastric Electrophysiology and Effect on Quality of Life after Laparoscopic Sleeve Gastrectomy

Tim Hsu-Han Wang, MBChB, Chris Varghese, MBChB, Grant Beban, MBChB, Nicholas J Evennett, MBChB, Stefan S Calder, PhD, Greg O’Grady, MBChB, PhD

University of Auckland, Auckland, New Zealand; Auckland City Hospital, Auckland, New Zealand

Introduction: Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure. Unfortunately, 30% of patients may develop persistent gastric symptoms without a mechanical cause. Gastric motility is normally coordinated by a pacemaker located at the greater curvature, which is resected in LSG, with electrophysiological consequences still undefined. This study assessed the impact of LSG on gastric electrophysiology and correlation with symptoms and quality of life (QoL), using a novel noninvasive body surface gastric mapping (BSGM) technique.

Methods: Patients with previous LSG underwent BSGM (Gastric Alimetry, New Zealand), comprising 30-minute fasting baseline and 4-hour postprandial recordings. The analysis encompassed gastric frequency, amplitude, Gastric Alimetry Rhythm Index (GA-RI; a measure of gastric rhythm stability), compared with matched controls. Symptoms and QoL were evaluated using validated questionnaires.

Results: A total of 38 patients (median 36 months postoperative; range 6-119 months) and 38 controls were recruited. 37/38 patients had at least 1 abnormal gastric electrophysiology parameter, including reduced frequencies (2.4 ± 0.22 vs 3.09 ± 0.21 cycles per minute; p < 0.001) and amplitudes (28.2 ± 7.1 vs 38.8 ± 15.3 uV; p < 0.001). Patients showed higher symptom burdens and substantially reduced QoL (PAGI-SYM 20 vs 7, PAGI-QOL 27 vs 136, EQ-5D-5L 0.86 vs 0.96; p < 0.001). Worse symptom burdens and QoL were correlated with lower gastric frequency, GA-RI, and amplitude (p < 0.05).

Conclusion: Laparoscopic sleeve gastrectomy modifies gastric electrophysiology due to resection of the gastric pacemaker. Consistent reduction in gastric frequency and rhythm instability correlated with worse symptoms and poorer QoL. Gastric mapping now reveals a mechanism for symptoms after sleeve gastrectomy.

Circulating Bile Acids Are Differentially Expressed after Gastric Bypass Compared with Sleeve Gastrectomy in Patients Undergoing Metabolic Surgery

Andrew A Wheeler, MD, FACS, Nathan J May, DO, Samuel C Perez, BS, Charles C Cox, MD, Andrew Behrmann, BS

University of Missouri, Columbia, MO; University of South Alabama, Mobile, AL

Introduction: Bile acids have been shown to play an influential role in patients’ metabolic health. Understanding how metabolic surgery impacts levels of bile acids is thus of significant interest. We conducted a randomized controlled trial to investigate the impact of intestinal bypass on metabolic determinants of disease, including circulating bile acids.

Methods: A randomized controlled trial of variable biliopancreatic limb (BPL) lengths was performed with non-randomized vertical sleeve gastrectomy (VSG) patients used as a surgical control. Plasma was obtained from patients preoperatively and at 3, 6, and 12 months after operation. Gas chromatography/mass spectrometry was used to measure levels of bile acids in patients who underwent VSG and gastric bypass with 50 cm BPL and 100 cm BPL and 150 cm BPL lengths. Statistical analysis performed with Student’s t-test with significance at p < 0.05.

Results: Multiple bile acids were significantly different from baseline to 3, 6, and 12-months after operation. When comparing VSG and gastric bypass from preoperative to 3 months postoperative, glycochenodeoxycholic acid (GDCA) was significantly increased in gastric bypass (50 cm BPL) patients as compared with VSG patients.

Conclusion: Increased GDCA has been shown to improve insulin sensitivity and decrease hyperglycemia. Our data demonstrating a more pronounced effect on increasing GDCA after gastric bypass compared with VSG may provide insight into the more significant impact that bypassing intestine as part of metabolic surgery helps improve insulin sensitivity and diabetes. The extent to which increased BPL length leads to these changes will be determined as the clinical trial continues.

Comparative Cost-Effectiveness Analysis of Bariatric Surgery and GLP-1 Receptor Agonists for the Management of Obesity

Joseph Sanchez, MD, Alexander Lundberg, PhD, Whitney Jones, MD, MBA, Catherine S Valukas, MD, MS, Tara Lagu, MD, MPH, Ezra N Teitelbaum, MD, FACS, Anne Stey, MD, FACS

Northwestern University, Chicago, IL

Introduction: GLP-1 receptor agonists (GLP-1RA) is new, life-long medication for obesity management. However, cost analyses have yet to compare these with other obesity management options. This study aimed to quantify and compare cost-effectiveness of GLP-1RAs and bariatric surgery.

Methods: A Markov Model of wholesale cost was developed with 3 intervention arms: (1) Bariatric Surgery, (2) GLP-1RAs alone, (3) Bariatric Surgery + GLP-1RAs. Bariatric surgery procedures included were sleeve gastrectomy and Roux-en-Y gastric bypass. Medication included was Semaglutide and Liraglutide. Associated cost and health state utility data were abstracted from existing literature of US data sources. Incremental cost-effectiveness ratios (ICER) and quality-adjusted life years (QALY) were calculated between each arm. A total gross cost under $50,000 USD per QALY was considered cost-effective. A sensitivity analysis was conducted adjusting for yearly incremental GLP-1RA cost until patient expiration.

Results: Yearly cost for GLP-1RAs averaged $11,628 USD. Bariatric surgery was estimated at $18,581 USD. When compared with GLP-1RAs alone, bariatric surgery offered an incremental increase in QALY of +2.3, which dominated (ICER: -$9,094 USD). The combination of both bariatric surgery and GLP-1RAs offers an incremental increase of +5.3 QALYs and was cost-effective compared with bariatric surgery alone (ICER: +$7,239 USD). Sensitivity analysis revealed that bariatric surgery remained more cost-effective than GLP-1RAs at all adjusted costs of GLP-1RAs (Figure 1).

Conclusion: Bariatric surgery financially dominated GLP-1RAs with current price estimates. GLP-1RAs alone were not cost-effective. A combination of bariatric surgery and GLP-1RAs was cost-effective compared with bariatric surgery alone.

Digital Pathway to Recovery: Association Between Patient Engagement with a Customizable Mobile Platform and Readmission after Bariatric Surgery

Wendy Li, MD, Qais Abuhasan, MD, Charles Burney, MD, Tarik Yuce, MD, Dimitrios Stefanidis, MD, FACS

Indiana University School of Medicine, Indianapolis, IN

Introduction: The emergence of mobile applications that address patient-centered outcomes is promising to enhance postoperative bariatric care. Twistle is a customizable mobile platform that facilitates 2-way communication between patients and their care teams, potentially enabling early detection of patient struggles and appropriate interventions. We aimed to assess post-bariatric surgery patient engagement with Twistle and its impact on readmission rate.

Methods: A bariatric-specific pathway was developed within the Twistle app, incorporating patient-reported outcomes post-discharge. Bariatric surgery patients who interacted with the app between 2021 and 2023 were identified. Patient demographics, app engagement, and responses were analyzed. Association between app data and readmission was evaluated using multivariable logistic regression models.

Results: Of the 1,137 bariatric procedures performed between 2021 and 2023, 973 patients engaged with the platform for a median of 9 (interquartile range [IQR] 1, 37) active days and a total engagement period of a median of 11 (IQR 7, 12) months postoperatively. Among engaged patients, 156 (16%) experienced operation-related readmission. Engagement longer than 1 day was associated with higher readmission rate (18.9% vs 12.5%, adjusted odds ratio [aOR] 1.61, 95% CI 1.12, 2.31). Patients with fluid intake <48 oz over 24 hours were more likely to be readmitted compared with those with higher fluid intake (20.1% vs 13.3% aOR 1.56, 95% CI 1.05, 2.31). Similarly, protein intake <40 g over 24 hours and increased nausea symptoms were also associated with readmission.

Conclusion: Patients actively engaged with our platform up to 11 months postoperative, suggesting its potential as a tool for monitoring postoperative patient responses. Several patient-reported data (fluid and protein intake, and nausea) were found to correlate with readmission rate and provide potential targets for preventative intervention.

Evening the Score: Use of an Objective Scoring System to Capture Underdiagnosed Hypertension among Lower Socioeconomic Patients Undergoing Bariatric Surgery

Annie Wang, MD, Victoria Lyo, MD, MTM, FACS, Quincy C Jones, BS, Mohamed R Ali, MD, FASMBS, FACS, Shushmita M Ahmed, MD, DABOM, FACS

University of California, Davis, Sacramento, CA

Introduction: Previously, we showed increased capture of comorbidity severity using clinical and physiological data derived Assessment of Obesity-related Metabolic Comorbidities (AOMC) scores compared with purely clinically derived Assessment of Obesity-Related Comorbidities (AORC) scores. This study evaluates whether AOMC captures greater hypertension (HTN) severity among low-tier (LT) vs high-tier (HT) socioeconomic status (SES) bariatric patients.

Methods: Retrospective analysis was performed of patients undergoing primary metabolic/bariatric surgery. Groups were stratified into LT and HT using geocoded SES scores. AOMC and AORC scores were calculated and compared with t-tests and chi-square analyses.

Results: Of 1443 patients, 388 (26.9%) were LT and 1011 (70.0%) were HT. There were no differences in age, gender, and preoperative BMI between groups (p > 0.05). HTN AORC scores were similar between groups. HT patients were more likely to have controlled HTN by AOMC (26.0% LT vs 34.0% HT, p = 0.024). LT and HT had significantly different patterns of change from AORC to AOMC (p = 0.033). HT patients were more likely to have unchanged controlled HTN status between AORC and AOMC than LT (38.8% LT vs 49.2% HT), while more LT patients were upstaged from no HTN to any severity of HTN (26.6%LT vs 23.0%HT) and from controlled to uncontrolled HTN (20.7% LT vs 18.5% HT).

Conclusion: Despite similar clinical prevalence of HTN, LT patients were more likely to be upstaged into more severe categories than HT using AOMC. This suggests HTN underdiagnosis in LT patients. Thus, AOMC is useful in identifying greater HTN prevalence and greater high-risk patients in an already vulnerable patient subset.

Factors Associated with GLP-1 Agonist Use after Bariatric Surgery

Andrew Bain, MD, Robert Turer, MD, Vikas S Gupta, MD, Benjamin E Schneider, MD, FACS

University of Texas Southwestern Medical Center, Dallas, TX

Introduction: Weight regain after bariatric surgery is common, occurring in 15-30% of patients. To date, evaluation of GLP-1 agonist administration for postoperative weight regain is limited to single-center reviews. We sought to determine factors associated with postoperative GLP-1 agonist therapy in bariatric surgical population.

Methods: Cosmos, a community collaboration of health systems representing over 234,000,000 patient records from 1334 hospitals and 28,900 clinics, was queried. From 2018 to 2023, patients were identified using bariatric CPT codes with concurrent BMI greater than or equal to 30 kg/m2. Patients were stratified by prescription of anti-obesity dosed liraglutide or semaglutide, excluding patients prescribed preoperative GLP-1 agonists.

Results: A total of 186,658 patients underwent bariatric surgery (31% Roux-en-Y gastric bypass, 67% sleeve gastrectomy, 2% other). 3,520 patients (1.9%) were prescribed postoperative GLP-1 agonists. Average BMI was similar between those who were and were not prescribed GLP-1 agonists, 43.7 and 42.8 respectively (p = 0.9). Patients receiving postoperative GLP-1 agonists were more likely to be women (89% vs 83%, p < 0.01), Black (29% vs 26%, p < 0.01), have social vulnerability index in the bottom quartile (21% vs 17%, p < 0.01), and have undergone sleeve gastrectomy vs Roux-en-Y gastric bypass (75% vs 67%, p < 0.01) (Figure 1).

Conclusion: Leveraging large multi-institutional electronic health record data aggregation, we identified demographic differences in postoperative GLP-1 agonist use. Patients receiving GLP-1 agonists were more likely to have undergone sleeve gastrectomy and be Black, women, and have a lower social vulnerability index, mirroring disparity in postoperative weight regain. Considering international shortages, understanding the demographics of this population is critical to equitable care.

Glucagon-Like Peptide-1 Receptor Agonists in the Management of Obesity: An Economics Meta-Analysis

Grace C Bloomfield, MS, Yuan Chen, BS, Marcus H Cunningham, BS, Sebastiano Bartoletti, MD, Dan E Azagury, MD, FACS, Yewande R Alimi, MD, FACS, Nicholas Prindeze, MD

Georgetown University School of Medicine, Washington, DC; Geneva University Hospitals, Geneva, Switzerland; Stanford University School of Medicine, Stanford, CA

Introduction: GLP-1 receptor agonists (GLP-1RAs) are gaining significant popularity for the management of obesity and may have similar short-term outcomes to bariatric surgery in both glycemic control and weight loss. Considering the need for long-term use of this medication, little is known about its cost-effectiveness. This study examines the cost-to-benefit relationship of GLP-1RAs for obesity and diabetes.

Methods: A comprehensive literature review and meta-analysis were performed to compare the impact of various GLP-1RA regimens on BMI and hemoglobin A1c. The primary outcomes were the quality-adjusted life years (QALY) and the annual cost of diabetes management. From these data, the incremental cost-effectiveness ratio (ICER) was calculated for GLP-1RAs over placebo.

Results: After title and abstract screening, 176 articles were reviewed, and 35 articles met inclusion criteria. Among a pooled population of 7,308 patients treated with GLP-RAs, GLP augmentation reduced BMI by 2.2 kg/m2 points per year vs 1.1 kg/m2 among controls. Cost analysis for managing diabetes revealed an annual per-person cost of $11,545.73 without GLP-1RAs and $7,970.37 with GLP-1RAs at 1.3 years. Forecasting 2.5 years of GLP-1RA therapy yields $19,008.34 per person per year without GLP-1RAs vs $8,290.63 with GLP-1RAs (Figure 1). The ICER for using GLP-1RAs was $38,063.17 per QALY at 1.3 years and $43,025.56 per QALY at 2.5 years.

Conclusion: These findings demonstrate an overall positive utility of GLP-1RAs in the reduction of obesity-associated morbidity and overall healthcare cost savings. Future studies should be conducted to compare the long-term economic implications of GLP augmentation vs bariatric surgery.

Hiatal Hernia Repair: A Single-Institution Experience and Risk Factors Associated with Symptomatic Recurrence at 1 Year

Pauline Aeschbacher, MD, Patrick Strzempek, MS, Brett Weiss, MS, Elad Boaz, MD, Sameh H E Rizkalla, MBBCh, MD, FACS, Justin Dourado, MD, Peter Rogers, MD, Zoe Garoufalia, MD, Emanuele Lo Menzo, MD, FACS, Raul J Rosenthal, MD, FACS

Cleveland Clinic Florida, Weston, FL

Introduction: Symptomatic recurrence after hiatal hernia repair (HHR) poses challenges, given limited surgical options. Controversy around mesh involves its associated morbidity. Nevertheless, advocates argue mesh may reduce recurrence risk.

Methods: A retrospective analysis of HHR from 2011 to 2022 performed at our clinic was conducted. Hiatus defect was closed using barbed non-resorbable sutures. Univariate and multivariate logistic regression analyzed patient and operative characteristics for association with early symptomatic recurrence in patient with ≥12-month follow-up. Early symptomatic recurrence was defined as redo operation within 1 year post-primary repair. Kaplan-Meier estimator and log-rank test assessed recurrence-free interval.

Results: Of 1226 patients with HHR, 74.1% (n = 908) were women, median age was 65 years (interquartile range [IQR] 54, 72), and median BMI 28 g/m² (IQR 25, 33). 99.6% (n = 1221) of repairs were laparoscopic and 14.4% (n = 177) redo (43 with previous mesh placement). Thirty-day reoperation and mortality rate was 2.6% (n = 32) and 0.1% (n = 1), respectively. Median follow-up was 12 months (IQR 1, 44). A total of 47 (3.8%) symptomatic recurrences requiring reoperation were observed. In univariate and multivariate logistic regression of 610 patients with ≥12-month follow-up, 2.5% (n = 15) experienced symptomatic recurrence. Open repair (odds ratio [OR]: 5.37, p = 0.008) and redo with previous mesh (OR: 7.69, p = 0.013) were independent risk factors for early recurrence with an area under the curve of 0.64. Recurrence-free rate at 1-year was significantly impacted by mesh use in previous repair (93%) compared with no mesh (97%) or no previous repair (99%) (p = 0.024).

Conclusion: Barbed non-resorbable suture closure during HHR proves safe and effective. Open repair and redo with previous mesh placement were associated with higher 1-year recurrence rates, underscoring need for careful consideration in surgical planning.

How Does Payor Status Shape Postoperative Resource Use in Metabolic Surgery? A Multi-Institutional Study

Florina Corpodean, MD, Michael Kachmar, DO, Philip R Schauer, MD, FACS, Vance L Albaugh, MD, PhD, FACS, Michael W Cook, MD, FACS

Louisiana State University School of Medicine, New Orleans, LA; Metamor Institute, Pennington Biomedical Research Center, Baton Rouge, LA; University Medical Center, New Orleans, LA

Introduction: Postoperative emergency department (ED) use and readmission are critical quality outcomes metrics for MBSAQIP centers. With escalating cost, minimizing postoperative resource usage is imperative. This study aims to explore the impact of insurance payor status on postoperative resource use after metabolic surgery (MS).

Methods: Data from 2 MBSAQIP programs (2020-2023) were examined, and MS cases were identified and categorized based on primary payor status (n = 1678). Analyses included 30-day readmission, reintervention, reoperation, and ED use, while considering case characteristics and payor status.

Results: Medicaid beneficiaries were overall younger (40.4 years vs 46.5 years; p < 0.0001) than private insurance (PI) patients and more likely to be women. BMI was significantly higher for Medicaid compared with PI or Medicare (49.8 vs 47.8 vs 48.2; p < 0.05). Medicaid recipients had significantly higher average rate of ED use in 30 days (0.71 visits vs 0.28 vs 0.07; p < 0.0001) compared with PI and self-pay and longer operative time compared with PI and self-pay (144.8 min vs 126.7 vs 108.1 min; p < 0.0001). Medicaid status also had longer length of stay than PI (1.68 days vs 1.48 days, p < 0.0001); however, Medicaid status was not associated with increased composite complication, composite infection, length of stay >5 days, or readmission.

Conclusion: Postoperative ED use was notably higher in publicly insured patients (Medicaid) compared with those with PI or self-pay. This highlights the importance of implementing targeted quality improvement measures to reduce avoidable ED visits within this vulnerable population.

Improvement in Heart Failure Symptoms after Bariatric Surgery as Measured by a New Heart Failure-Specific Health-Related Quality of Life Instrument

Hila Zelicha, PhD, , MD, Yijun Chen, MD, Edward H Livingston, MD, FACS

University of California, Los Angeles, Los Angeles, CA

Introduction: There is a substantial overlap between heart failure (HF) symptoms and symptoms attributable to obesity itself. We aimed to evaluate changes in HF symptoms in patients with severe obesity 12 months after bariatric surgery using a new, validated HF health-related quality of life (HRQOL) instrument, PROMIS+HF-27.

Methods: PROMIS+HF-27 HRQOL surveys were administered to a cohort of patients before and 12 months after sleeve gastrectomy. HRQOL domain T-scores were calculated and centered on general population. For dyspnea, the reference population is patients with COPD.

Results: Of 106 patients at baseline, 90% had dyspnea when measured by PROMIS+HF, but only 1 patient had been diagnosed with dyspnea by their treating clinicians. No patients were diagnosed with HF. On the PROMIS+HF-27 survey, 1-year post-gastrectomy dyspnea, physical function, fatigue, sleep disorder, and pain T-scores were significantly improved (dyspnea: pre: 47.0 ± 7.5, post: 37.4 ± 6.4, p < 0.001; physical-function: pre: 46.8 ± 7.9, post: 52.5 ± 5.0, p < 0.001; fatigue: pre: 54.8 ± 8.4, post: 49.0 ± 9.2, p < 0.001; sleep-disturbances: pre: 52.2 ± 8.3, post: 48.4 ± 8.6, p = 0.004; pain: pre: 54.0 ± 9.1, post: 48.5 ± 8.0, p < 0.001). Depression, cognitive disturbance, and social T-scores did not significantly change (p > 0.05 for all). Summary scores (0-100 scale) for physical-function and the overall HRQOL total score were significantly improved after bariatric surgery (physical-score: pre: 67.6 ± 15.8, post: 82.3 ± 14.4, p < 0.001; Overall score: pre: 73.1 ± 14.7, post: 83.1 ± 14.8, p < 0.001). Social and mental health summary scores did not significantly change after bariatric surgery. Figure 1.

Conclusion: HF symptoms are common in patients with obesity and are frequently underdiagnosed in primary care. Bariatric surgery significantly improved HF symptoms and their impact on quality of life with 1-year weight loss. Dyspnea is major driver of reduced HRQOL in patients with obesity and is underdiagnosed in primary care. Dyspnea-related reduction in HRQOL is greatly improved by bariatric surgery.

Intestinal Bypass as Metabolic Surgery Leads to More Significant Changes in Circulating Metabolites Compared with Restrictive Operation

Andrew A Wheeler, MD, FACS, Andrew Behrmann*, BS, Samuel C Perez, BS

University of Missouri, Columbia, MO

*Excellence in Research Award recipient.

Introduction: Metabolic changes as expressed by circulating metabolites in the blood after metabolic surgery may serve as markers of not only procedure effectiveness, but also which metabolic pathways are impacted by different metabolic operations. We conducted a randomized controlled trial to investigate the impact of intestinal bypass on metabolic determinants of disease, including circulating metabolites.

Methods: A randomized controlled trial of variable biliopancreatic limb (BPL) lengths was performed with nonrandomized vertical sleeve gastrectomy (VSG) patients used as a surgical control. Plasma was obtained from patients preoperatively and at 3, 6, and 12 months after operation. Gas chromatography/mass spectrometry was used to measure levels of metabolites in patients who underwent VSG and gastric bypass with 50 cm BPL and 100 cm BPL and 150 cm BPL lengths. Statistical analysis performed with Student’s t-test with significance at p < 0.05.

Results: Multiple changes in circulating metabolites occurred after gastric bypass as well as sleeve gastrectomy. However, in most circumstances the gastric bypass, particularly longer length of bypass intestine through longer BPL lengths led to more significant changes. Table 1.

Conclusion: Intestinal bypass leads to more significant differences in metabolic pathways as compared with VSG. These differentially expressed pathways may provide mechanistic clues involved in clinical outcomes after operation.

Laparoscopic Roux-en-Y Gastric Bypass Is Associated with Greater Change in Microbial Diversity Compared with Sleeve Gastrectomy in Morbidly Obese Patients

Andrew A Wheeler, MD, FACS, Samuel C Perez, BS, Saeed Arefanian, MD, Aaron Ericsson, DVM, PhD

University of Missouri, Columbia, MO

Introduction: Dysbiosis of the gut microbiome has been shown to impact metabolic disease. The extent to which intestinal bypass influences microbial diversity after metabolic surgery is unknown. We conducted a randomized controlled trial to investigate the impact of intestinal bypass on metabolic determinants of disease, including the gut microbiome.

Methods: A randomized controlled trial of variable biliopancreatic limb (BPL) lengths was performed with nonrandomized vertical sleeve gastrectomy (VSG) patients used as a surgical control. Stool was obtained from patients preoperatively and at 3, 6, and 12 months after operation. DNA sequencing performed to investigate for microbial diversity in patients who had undergone VSG, bypass with 50 cm BPL and 100 cm BPL. Statistical analysis performed with PERMANOVA and Linear discriminant analysis effect size.

Results: No consistent effects of time or treatment on richness or alpha-diversity were detected. Significant differences in beta-diversity were found between preoperative and 3-month postoperative time points, particularly for patients undergoing intestinal bypass. VSG group had very little changes between baseline and 3-months postoperative but all groups of bypass patients experienced consistent postoperative changes including reduced relative abundance (RA) of families Lachnospiraceae and Ruminococcaceae, and increased RA of families Streptococcaceae and Enterobacteriaceae.

Conclusion: We have shown that intestinal bypass leads to greater changes in microbial diversity after metabolic surgery compared with restrictive procedures including loss of families involved in fiber degradation and gain in potentially inflammatory taxa. The extent to which increased BPL length leads to these changes will be determined as the clinical trial continues.

Laparoscopic Surgery for Median Arcuate Ligament Syndrome: Clinical Outcomes and Recurrence Patterns

Elad Boaz, MD, Pauline Aeschbacher, MD, Noam Kahana, MD, Patrick Strzempek, MS, Brett Weiss, MS, Felipe Okida, MD, Matthew D Kroh, MD, FACS, Samuel Szomstein, MD, FACS, Emanuele Lo Menzo, MD, FACS, Raul J Rosenthal, MD, FACS

Cleveland Clinic Florida, Weston, FL; Cleveland Clinic Florida, Wabern, Switzerland; Cleveland Clinic Florida, Downers Grove, IL; Cleveland Clinic Florida, Boca Raton, FL; Cleveland Clinic Florida, Sunrise, FL; Cleveland Clinic, Cleveland Heights, OH; Cleveland Clinic Florida, North Miami Beach, FL

Introduction: Median arcuate ligament syndrome (MALS) is a rare condition characterized by the compression of the celiac artery by the median arcuate ligament. Despite its rarity, MALS presents with variable symptom severity and unpredictable treatment responses, rendering it a controversial diagnosis.

Methods: A retrospective analysis was conducted on patients treated for MALS within our healthcare system between March 2015 and May 2021. Data including demographics, presenting symptoms, treatment modalities, surgical outcomes, and follow-up results were collected and analyzed.

Results: A total of 162 patients (130 women) with MALS underwent laparoscopic release of the median arcuate ligament. The median age was 38.5 years, with a mean BMI of 25.1 kg/m2. Median duration of symptoms was 24 months (range 2-300). Preoperative celiac ganglion block was performed in 126 patients (77.7%). The median operative time was 77 minutes (range 32-287), with a conversion rate to open operation of 4.3%, primarily due to bleeding. Patients had a median hospital stay of 2 days. At a median follow-up of 13 months, 86.4% of patients reported partial or complete resolution of symptoms after operation. However, symptom recurrence occurred in 63 patients (40%), frequently within 3 months postoperatively. Notably, only 33 of these cases showed evidence of recurrence on postoperative imaging.

Conclusion: Laparoscopic surgery for MALS offers favorable outcomes in terms of symptom relief, with most patients experiencing initial improvement. However, symptom recurrence remains a challenge, often without evident radiographic evidence, highlighting the need for further research into long-term management strategies for this complex condition.

Magnetic Duodeno-Ileostomy Side-to-Side without Gastrectomy for Type-2 Diabetes: Preliminary Results

Michel Gagner, MD, FACS, FRCSC, FASMBS, FICS, AFC(Hon), MD, Levan Koiava, MD, David Abuladze, MD

Westmount Square Surgical Center, Montreal, QC, Canada; Innova Medical Center, Tbilisi, Georgia

Introduction: Linear magnets (swallowable) were developed to create a side-to-side duodenal-ileal (DI) anastomosis using magnetic compression without enterotomy. This study aimed to determine safety and efficacy.

Methods: Side-to-side DI was performed by swallowing the first distal 39 mm linear magnet to the ileum (250 cm from the caecum) and by endoscopic delivery of a proximal magnet to the duodenum; magnets were aligned with laparoscopic assistance. This is without enterotomy or gastrectomy. After gradual anastomosis, magnets were expelled naturally.

Results: A total of 9 subjects with type-2 diabetes (T2DM) with a mean age of 53 years, a weight of (mean ± SEM) 97.6 ± 3.9 kg, a BMI of 33.0 ± 0.4 kg/m2, serum glycemia of 186.0 ± 16.4 mg/dL, and HbA1c of 7.8 ± 0.4% were followed. There was 100% successful patency with magnet pair expulsions at a mean of 24.3 ± 1.2 days. At 12 months, the mean weight and BMI had decreased to 78.3 ± 5.8 kg and 28.5 ± 1.8 kg/m2. This represented a total weight loss of 11.8 ± 3.8% and an excess weight loss of 56 ± 21%. The serum glycemia went down to 131.4 ± 5.5 mg/dL and HbA1c to 6.3 ± 0.2%. Within 12 months, 15 adverse events were noted (Clavien-Dindo: 87% Grade I and II, 13% Grade III, no Grade IV or V). No adverse events were related to the magnets. There was no anastomotic bleed, leak, infection, or death.

Conclusion: The creation of an anastomosis using linear magnets to achieve side-to-side DI diversion in adults with T2DM appeared safe and efficacious. Further, preliminary weight loss results, and improvement in diabetes profiles, in the short term are encouraging.

One Anastomosis Gastric Bypass: Indications and Results of Conversion to Roux-en-Y Gastric Bypass: A Mono-Centric Retrospective Study

Elena Belloni, MD, Lionel Rebibo, MD, Evangelia Triantafyllou, MD

Univeristà La Sapienza di Roma, Ospedale Sant’Andrea, Rome, Italy; Hospital European Georges Pompidou, Paris, France

Introduction: Long-term results of one anastomosis gastric bypass (OAGB) have shown the occurrence of a symptomatic gastroesophageal reflux (RGO), requiring conversion from OAGB to RYGB. Our aim is to evaluate the principal’s indications of conversion and to the results in terms of morbidity and mortality and weight loss.

Methods: It is a monocentric retrospective analysis including 92 patients undergoing an elective conversion operation between April 2015 and October 2023 in an expert center.

Results: Of the 92 patients, 82 met the criteria to be included in the analysis. The median age was 44 years. The median delay between the OAGB and the conversion was 181.5 months. A total of 92.7% of patients had a preoperative endoscopy, the main abnormalities being gastritis/gastropathy (28%), biliary reflux (18.3%), gastro-jejunal ulcer (18.3%), gastro-jejunal stenosis (11%) and Barrett’s esophagus (6%). 96.3% of operations were laparoscopic with a morbidity rate of 17%. 9% of patients underwent a reoperation, the main reason being anastomotic complication (hematoma on the jejuno-jejunal anastomose or stenose). 73% of patients underwent conversion operation due to reflux problems, while 19.5% for anomaly in the gastro-jejunal anastomose. BMI at the moment of conversion was 34.3 kg/m2 in the reflux group and 23.5 kg/m2 in the other, and it remained stable at 2-year follow-up in the reflux group, while it increased progressively in the second group. Figure 1.

Conclusion: The conversion of OAGB to RYGB is feasible and effective on refractory RGO. It allows maintenance of weight loss, without increasing morbimortality.

Overexpression of CDCA3 Relates to Tumor Malignant Potential and Outcomes of Gastric and Adenocarcinoma of the Esophagogastric Junction

Hiroshi Arakawa, MD, Shuhei Komatsu, MD, PhD, FACS, Takuma Kishimoto, MD, Ryo Ishida, MD, Rie Shibata, MD, Yudai Nakabayashi, MD, Keiji Nishibeppu, MD, PhD, Jun Kiuchi, MD, PhD, FACS, Taisuke Imamura, MD, PhD, FACS, Eigo Otsuji, MD, PhD

Kyoto Prefectural University of Medicine, Kyoto, Japan

Introduction: Cell Division Cycle Associated 3 (CDCA3) is known to have functions as a constituent part of the SCF ubiquitin ligase (E3) complex to degrade the endogenous cell cycle inhibitor. In this study, we investigated the oncological functions of CDCA3 in gastric carcinoma (GC) and adenocarcinoma of the esophagogastric junction (AEJ).

Methods: We retrospectively analyzed the clinical data and tissue samples of 189 primary GC patients and 102 primary AEJ patients. Seven GC cell lines are used in vitro analyses.

Results: Overexpression of the CDCA3 protein was frequently detected in 66 primary GC specimens (34.9%) and 54 primary AEJ specimens (52.9%). Overexpression of CDCA3 was significantly correlated with more advanced pT and pN stages, and a higher recurrence rate. Moreover, CDCA3 positivity was an independent factor predicting worse patient outcomes (GC patients: p = 0.001, hazard ratio 2.72, AEJ patients: p < 0.0001, hazard ratio 2.58). Overexpression of CDCA3 was observed in all GC cell lines. Among those cell lines, we selected MKN45, a wild type TP53 cell line, and MKN74, a mutant type TP53 cell line, for in vitro analyses. Overexpression of CDCA3 facilitated cell proliferation of GC cells, and knockdown of CDCA3 inhibited cell proliferation, migration and invasion, of GC cells through the Akt pathway and increased cell apoptosis in a TP53 mutation-independent manner.

Conclusion: CDCA3 plays a crucial role in tumor-malignant potential through overexpression, highlighting its utility as a prognostic factor and a potential therapeutic target in GC and AEJ.

Postoperative Heartburn and Proton Pump Inhibitor Use after Peroral Endoscopic Myotomy vs Heller Myotomy with Dor

Shubha Vasisht, BA, Aarush Sahni, BSE, Vivek K Singh, BA, BS, Alexandra L Strauss, MD, Gregory G Ginsberg, MD, Daniel T Dempsey, MD, FACS, Monica Saumoy, MD, MS, Victoria M Gershuni, MD, MS, MTR, Daniel Hashimoto, MD, MTR

Department of Surgery, University of Pennsylvania, Philadelphia, PA; Department of Medicine, Division of Gastroenterology, Penn Medicine Princeton Medical Center, Plainsboro, NJ

Introduction: Achalasia can be managed with endoscopic or surgical treatment options, peroral endoscopic myotomy (POEM) or Heller myotomy with Dor fundoplication (HM), respectively. Prior institutional practice was to counsel patients that HM should be considered if patients wanted to reduce risk of heartburn and long-term proton pump inhibitor (PPI) use. We assessed our institutional experience with these two procedures to determine whether there were significant differences in patient-reported heartburn or PPI use.

Methods: Patients who underwent POEM or HM between 2016 and 2023 at a large academic medical center or its affiliated hospitals. Manometry, esophagogastroduodenoscopy (EGD) reports, and Eckardt scores were included in the analysis.

Results: A total of 210 patients were identified, of whom 199 patients (153 POEM and 46 HM) were eligible for inclusion (39 POEM and 8 HM lost to follow-up). There were no significant differences in age, sex, distance traveled, BMI, Charlson Comorbidity Index, achalasia type, or integrated relaxation pressure. POEM was associated with longer length of myotomy. Unintentional mucosal injury was higher in POEM patients but did not lead to significant increase in leak. POEM and HM resulted in similar rate of postoperative PPI use and heartburn symptoms (Table 1).

Table 1: - Results

Outcomes POEM (n = 153) Heller Myotomy (n = 46) p Value
Achalasia Subtype (I, II, III) 22 (14.4%), 90 (58.8%), 15 (9.8%) 11 (23.9%), 31 (67.4%), 2 (4.0%)
Eckhardt Score Delta (Median) -5 -7 0.001267 *
Length of myotomy (cm): Type I & II, Type III 8: 7.77 (n = 112), 10.20 (n = 15) 6: 5.60 (n = 42), 6.50 (n = 2) 6.196e-10 *: 3.567e-12 *, 0.0956
Unintentional mucosal injury (n) 14/153 (9.2%) 0/46 (0%) 0.03163 *
Incidence Rate of Leak (%) 2/114 (1.75%) 0/38 (0%) 0.4188
Mean ± SD LOS (days) 1.26 ± 0.84 1.57 ± 1.48 0.002714 *
Clavien-Dindo Complications: I, II, IIIa, IIIb 5, 0, 0, 1 0, 0, 0, 0
Postop Heartburn 7/114 (6.1%) 2/38 (5.3%) 0.8473
Frequency of PPI Usage at First Follow-Up (%) 75/114 (65.8%) 29/38 (76.3%) 0.2548

Conclusion: While study power was limited by the single health system nature of the study, both POEM and HM are viable treatment options for achalasia with comparable results. Similar rate of postoperative heartburn and PPI use suggests that HM with Dor fundoplication does not necessarily prevent postoperative heartburn. Larger, multi-institutional studies with long-term follow-up are warranted to further explore questions on postoperative PPI use and heartburn.

Preoperative Semaglutide Use Does Not Improve Weight Loss or Safety of Bariatric Surgery

Vasundhara Mathur, MBBS, Katherine Wasden, MD, Thomas Shin, MD, Pourya Medhati, MD, Abdelrahman A Nimeri, MBBCh, FACS, Ali Tavakkoli, MBBS, FACS, Eric G Sheu, MD, FACS

Laboratory for Surgical and Metabolic Research, Brigham and Women’s Hospital, Boston, MA

Introduction: Semaglutide has been shown to cause significant weight loss. However, little is known about the impact of preoperative Semaglutide use on outcomes of metabolic/bariatric surgery (MBS).

Methods: A retrospective study between 2019 and 2023 at a tertiary care hospital was undertaken. Patients who had Semaglutide before operation (Group 1, n = 36) were matched 1:2 to patients who had no preoperative Semaglutide (Group 2, n = 72) based on age, weight and BMI at operation, sex, race, ethnicity, diabetic status, and type of operation. Postoperative weight loss (%TWL) at 3, 6, 12 months (T3, T6, T12), post-Semaglutide weight loss, and 30-day postoperative complication data was noted. The cumulative %TWL was calculated by adding %TWL from Semaglutide to postoperative %TWL at that time-point. Mann-Whitney t-tests were used for analysis and p < 0.05 was considered significant.

Results: After matching, MBS patients with and without preoperative Semaglutide had similar age, demographics, comorbidity, and preoperative BMI (44.3 ± 8.7 kg/m2, Group1; 43 ± 7.3 kg/m2, Group2). After MBS, patients with prior Semaglutide use had lower surgical %TWL than patients without prior Semaglutide use at all time points in the first year (Figure 1). Even after including preoperative medical TWL on Semaglutide, cumulative 1 year %TWL in those who received preoperative Semaglutide + MBS (27.7 ± 2) and those undergoing MBS alone (25.3 ± 1.3) was no different (p = 0.3). The incidence of 30-day postoperative complication also did not differ between those with preoperative Semaglutide use and those without (8.3% vs 9.7%, p = 0.8).

Conclusion: Our results suggest that Semaglutide therapy before metabolic bariatric surgery does not improve overall weight loss outcomes or reduce postoperative complication.

Prior Surgical History and Psychiatric Conditions Can Increase Perioperative Opioid Use in Bariatric Surgery

Maryam Hassanesfahani, MD, Ruby Zhao, DO, Patrick Kiarie, DO, Hiranya S, Armon Farhani, Benjamin Hershfeld, Martine A Louis, MD, FACS, Noman Khan, FACS, Darshak Shah, MBBS, FACS

Flushing Hospital Medical Center, New York, NY; American University of the Caribbean School of Medicine, Cupecoy, Sint Maartin; St. George’s University, School of Medicine, Queens, NY; New York Institute of Technology College of Osteopathic Medicine, Long Island City, NY; New York Institute of Technology College of Osteopathic Medicine, Roslyn Harbor, NY

Introduction: The opioid epidemic is among the most concerning public health crises. Minimally invasive operation leads to decreased opioid requirement in the perioperative period. This study explores differences in opioid requirement between robotic and laparoscopic bariatric surgery.

Methods: A retrospective chart review of minimally invasive bariatric operations from March 2021 to March 2023 was conducted. Patients were divided into 2 groups: robotic and laparoscopic surgery. Opioid use was expressed as morphine milligram equivalents (MME) in 6, 24, and 48 hours postoperatively.

Results: The total sample size was 505 patients. Age range 18 to 76 years (M = 42.07) and the majority were women (n = 421, 83.53%). 67 patients (13.54%) had a history of bariatric surgery, and 140 patients (27.72%) underwent concomitant hiatal hernia repair. The sample included 225 laparoscopic procedures (45.55%) and 280 robotic procedures (54.45%). Among laparoscopic group, 190 patients (85.20%) underwent sleeve gastrectomy and 14 (6.28%) gastric bypass. Patients with psychiatric conditions and those with prior operation were noted to have increased opioid use (p = 0.034). Robotic procedures (mean = 13.32, SD = 13.19) were associated with a greater opioid use than laparoscopic procedures (mean = 10.12, SD = 11.18) (p = 0.03).

Conclusion: A history of psychiatric conditions or prior surgical history increased the perioperative use of rescue opioid in minimally invasive bariatric procedures, and robotic procedures can be associated with greater opioid use. Preoperative counseling regarding expectations for pain and pain management may help improve patient satisfaction.

Prostate Cancer Screening Rate Improves after Bariatric Surgery

Noah Brown, MD, Abigail Alexander, MD, Joshua Horns, PhD, Sheetal Hardikar, PhD, MBBS, Rupam Das, MS, MBA, Mary Playdon, PhD, MPH, Anna R Ibele, MD, FACS

University of Utah, Salt Lake City, UT; Huntsman Cancer Institute, Salt Lake City, UT

Introduction: Patients with obesity are at a greater risk of developing more aggressive forms of prostate cancer. Bariatric surgery has been demonstrated to reduce that risk; however, the exact mechanism of this protective effect is not known. We examined the relationship between bariatric surgery and prostate cancer screening rate using a national insurance database.

Methods: Using the MarketScan database, 74,710 men aged 50 years and older who underwent bariatric surgery were identified and compared with 3 control groups who did not undergo bariatric surgery stratified by obesity according to ICD codes. Multivariable Poisson regression analyzed the rate of prostate cancer screening, adjusting for demographics and comorbidity.

Results: The rate of screening pre-bariatric surgery was 0.04 tests per person-year and post-bariatric surgery was 0.13 (p < 0.001). For control groups, screening rate was 0.08, 0.09, and 0.08 tests per person-year for the non-obese group, obesity and morbid obesity groups respectively. The incidence rate ratio relative to the non-obese control group (95% CI) was 0.52 (0.48-0.55) for the preoperative group, 1.91 (1.80-2.02) for the postoperative group, 1.07 (1.03-1.12) and 1.00 (0.95-1.04) for the obesity and morbid obesity groups respectively.

Conclusion: The rate of patients undergoing prostate cancer screening significantly increased after bariatric surgery. Relative to their counterparts in all control groups, the preoperative group was significantly under-screened. After their operation, the same patients became the most screened group. This significant increase in screening rate after bariatric surgery suggests that bariatric surgery serves as an impetus for engaging with the healthcare system across other areas of healthcare.

Research on Glycocalyx-Related Molecules Glypican1 as a New Biomarker for Esophageal Cancer

Rie Shibata, MD, Hirotaka Konishi, MD, PhD, Tomohiro Arita, MD, PhD, Yusuke Yamamoto, MD, PhD, Hiroki Shimizu, MD, PhD, Shuhei Komatsu, MD, PhD, FACS, Atsushi Shiozaki, MD, PhD, Eigo Otsuji, MD, PhD, Taiga Yamamoto, MD, Hayato Matsuda, MD

Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan

Introduction: The surface of cells is covered with a layer of glycans that is referred to as the glycocalyx. It has been reported that the formation of glycocalyx on cancer cells is associated with tumor growth or metastasis. The purpose of the present study is to develop a new biomarker related to glycocalyx that reflects therapeutic effect and prognosis of esophageal cancer.

Methods: Based on previous reports, GPC1, which expressed in esophageal cancer, was selected as candidate glycocalyx. Concentration of GPC1 protein in preoperative plasma of advanced esophageal cancer patients was measured by ELISA and its relationships with clinicopathological factors or prognosis were examined. The effects of extracellular rhGPC1 on esophageal squamous cell carcinoma (ESCC) cells were examined.

Results: Prognostic analysis revealed that high GPC1 plasma level was significantly related to advanced stage and distant metastatic recurrence and was an independent poor prognostic factor in ESCC patients (p = 0.010, hazard ratio = 4.22). In patients with NAC, high histological response (Grade 2/3) was correlated with low plasma GPC1 concentration (p = 0.035). Proliferation ability of ESCC cell lines was not changed by the addition of extracellular rhGPC1 (200 ng/mL). In contrast, both migration and invasion abilities were markedly promoted by extracellular rhGPC1. In drug susceptibility assay, resistance to CDDP slightly increased with the addition of extracellular rhGPC1.

Conclusion: Plasma GPC1 is a useful less invasive biomarker of clinicopathological features, prognosis, and treatment efficacy in ESCC patients. Furthermore, extracellular GPC1 affects tumor cell motility.

Roux-en-Y Gastric Bypass Jejunal-Jejunal Side-to-Side Anastomosis Using Self-Assembling Magnets and OTOLoc

Juan E Contreras, MD, FACS

Clinica Colonial, Santiago, Chile.

Introduction: In previously bi-partition studies, a magnetic anastomosis has demonstrated the ability to reduce anastomosis complication such as leak and bleeding, however, previous delivery methods required the creation an enterotomy with delayed anastomosis creation. We report the procedure feasibility and 30-day results of a first-ever use in humans of a novel surgical technique that eliminates the need to close the enterotomies via conventional methods after creating the anastomosis and facilitates an immediate lumen opening between 2 new coupled self-forming magnets (SFM) in RYGB patients.

Methods: A prospective non-randomized single-center trial was conducted. The operation consisted of creating an immediate communication in a side-to-side jejunal-jejunal anastomosis intraluminally, through a novel temporary enterotomy control and capture (ECC) device. All devices were deployed and delivered laparoscopically.

Results: A total of 5 patients were recruited, with a mean age of 35.8 (27-43) years, sex-ratio (60% women) and initial BMI of 44.8 ± 7.6 kg/m2. All procedures were performed laparoscopically. There was no conversion or perioperative mortality. All ECCs and SFMs were delivered and connected with no delivery malfunctions, completed in an anastomosis creation time of 10 minutes (enterotomy to magnet coupling). All ECC and SFMs passed with no retention. Adverse events (AE) occurred in a total of 1 procedure due to poor tolerance to oral intake from gastro-jejunal anastomosis inflammation. No AE occurred during the 30-day follow up period.

Conclusion: Preliminary and procedure feasibility data of these new surgical techniques and devices suggest the procedures are both feasible and safe in Roux-en-Y gastric bypass operation. Further and longer studies are warranted.

Safety of Same-Day Discharge after Sleeve Gastrectomy in Adults 65 Years and Older

Sarah Suh, MD, Nabeel R Obeid, MD, FACS, Oliver A Varban, MD, FACS, Sabrena F Noria, MD, FACS, Anthony T Petrick, MD, FACS, Michael Edwards, MD, FACS, Tammy Kindel, MD, FACS

Medical College of Wisconsin, Milwaukee, WI; University of Michigan, Chelsea, MI; Henry Ford Health, Ann Arbor, MI; Ohio State University, Columbus, OH; Geisinger College of Health Sciences, Danville, PA; Mayo Clinic, Ponte Vedra Beach, FL

Introduction: The purpose of this study was to compare outcomes between same-day vs next-day discharge after undergoing minimally invasive sleeve gastrectomy (SG) in adults 65 years and older.

Methods: This study was a retrospective analysis of patients 65 years and older discharged on postoperative day (POD) 0 vs POD 1 after undergoing SG in 2022. Data was received from MBSAQIP. Univariate analyses were performed to compare demographics, comorbidity, and 30-day outcomes between patients discharged on POD 0 and 1. Data is presented as frequency and mean ± SD with significance determined by a t-test with p < 0.05.

Results: A total of 4,609 patients were included in the study. Of these, 310 (6.7%) were discharged on POD 0 and 4,299 (93%) on POD 1 after SG. POD 0 patients were of similar age, more likely women, and had a lower BMI compared with POD 1 patients (41.4 ± 6.5 vs 42.6 ± 6.4 kg/m2, p = 0.039). Despite a significantly lower rate of hypertension, obstructive sleep apnea, and chronic obstructive pulmonary disease in POD 0 patients, they were more likely to experience wound disruption (p < 0.001), acute renal failure requiring dialysis (p = 0.015), and administration of outpatient intravenous fluids (p = 0.008) (Table 1).

Table 1. - Perioperative Outcomes in SG Patients 65+ Years Discharged on POD 0 and POD 1

Outcomes LOS 0 n = 310 LOS 1 n = 4,299 p Value
Superficial incisional surgical site infection 2 (0.6%) 7 (0.2%) 0.063
Wound disruption 1 (0.3%) 0 (0%) <0.001*
Acute renal failure requiring dialysis 1 (0.3%) 1 (0%) 0.015*
Intensive care unit admission within 30 days 0 (0%) 12 (0.3%) 0.352
Bowel obstruction 0 (0%) 3 (0.1%) 0.642
Reoperation 1 (0.35%) 21 (0.5%) 0.682
Readmission 7 (2.3%) 98 (2.3%) 0.98
Administration of outpatient intravenous fluids 15 (4.8%) 102 (2.4%) 0.008*
Emergency department visit 16 (5.2%) 199 (4.6%) 0.668

Conclusion: Same-day discharge SG for patients 65 years and older is associated with increased 30-day complication rate despite fewer preoperative obesity-associated comorbidities. Older patients may be more sensitive to dehydration events, and consideration should be given to continue inpatient monitoring after SG for these patients.

Should Laparoscopic Sleeve Gastrectomy Be Considered and Reimbursed as an Inpatient or an Outpatient Procedure? A Large Data Comparison of Health Care Use and Hospital Charges

Ioannis Raftopoulos, MD, FACS, Conner W Pike, MD, Gavin Hui, PhD, Ioanna Pagani, PhD

Holyoke Medical Center, West Hartford, CT; Atropos Health, New York, NY

Introduction: There is no consensus as to whether laparoscopic sleeve gastrectomy (LSG) should be considered an inpatient or outpatient procedure. This debate exists between surgeons practicing under different healthcare circumstances and is reinforced by insurance carriers which prefer reimbursement to be according to an outpatient status.

Methods: This retrospective cohort study compared the healthcare resource use (HRU) of LSG (n = 9919) with inpatient laparoscopic colectomy with ileocolostomy (ILC, n = 2464) and outpatient procedures ((OP): mastectomy, laparoscopic cholecystectomy and laparoscopic inguinal hernia repair, n = 25,000) using unmatched data from a nationally representative electronic health records (EHR) dataset (2010 to 2023) from Eversana Life Sciences (ELS). HRU was assessed by 6-month emergency room (ER) visits, interventional radiology procedures (IR), 30-day readmission/reintervention and readmission hospital stay (LOS). Data from our hospital was used for cost approximation.

Results: Compared with LSG, ILC had a higher 30-day readmission, 6-month IR and 30-day reintervention (3.7% vs 1.2%, ratio: 3.1:1, p < 0.0001), but not 6-month ER visits and readmission LOS. Compared with OP, LSG had a higher 30-day readmission, 6-month ER visits, 6-month IR, readmission LOS (0.048 vs 0.007, p = 0.24) and 30-day reintervention. There was a significant difference in median hospital charges between LSG and outpatient procedures or ILC. The proportional cumulative mean HRU and median charges ratio of LSG to outpatient procedures and ILC was 2:1 and 1.9:1, respectively. Table 1.

Table 1. - HRU and Charges of LSG, Laparoscopic Colectomy and Outpatient Procedures

Variable LSG Outpatient or Colectomy Ratio p Value
30-day readmission LSG vs outpatient 6% 0.9% 6.8:1 <0.0001
6-mth ER visits LSG vs outpatient 5.7% 2.6% 2.2:1 <0.0001
6-mth radiology interventions LSG vs outpatient 1.8% 0.6% 3:1 <0.0001
30-day intervention LSG vs outpatient 3.6% 1.2% 3:1 <0.0001
Median charges LSG vs outpatient $31,814 $12,946 2.5:1 <0.0001
30-day readmission LSG vs Colectomy 6.4% 18.8% 1:2.9 <0.0001
6-mth radiology intervention LSG vs Colectomy 1.8% 2.9% 1:1.6 0.001
30-day reintervention LSG vs Colectomy 1.2% 3.7% 1:3.1 <0.0001
Median charges LSG vs Colectomy $31,814 $42,671 1:1.3 <0.0001

Conclusion: HRU and cost of LSG resemble ILC by a ratio of 2:1 compared with common outpatient procedures. Outpatient LSG status should not determine reimbursement.

Surgical Approach to Pyloric Drainage for Gastroparesis: A Comparison of Laparoscopic Pyloroplasty and Gastric Peroral Endoscopic Myotomy Outcomes

Sven Eriksson, MD, Mostafa Abdelhalim, BS, Inanc Samil Sarici, MD, Johnathan Nguyen, BS, Ping Zheng, MD, Blair A Jobe, MD, FACS, Shahin Ayazi, MD, FACS

Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA

Introduction: The endoscopic approach to the surgical management of gastroparesis is gaining popularity. However, data comparing endoscopic myotomy with traditional laparoscopic pyloroplasty are limited. This study aimed to compare outcomes between gastric peroral endoscopic myotomy (G-POEM) and pyloroplasty.

Methods: Gastroparesis patients who underwent pyloroplasty or G-POEM from 2016 through 2022 at our institution were reviewed. Pre-/postoperative gastroparesis cardinal symptom index (GCSI) and gastric emptying scintigraphy (GES) were assessed. Favorable outcome was defined as resolution of predominant gastroparesis symptoms.

Results: There were 314 patients who underwent surgical myotomy. Median (interquartile range [IQR]) age was 51.9 (40-62) years and 84.1% were women. Of these, 81 underwent G-POEM and 233 underwent pyloroplasty. Age and sex were similar between surgical approaches (p > 0.05). Gastroparesis etiology was 61.8% idiopathic, 21.3% diabetic and 16.9% postoperative. Postoperative etiology was more likely to undergo G-POEM (25.9% vs 13.7%, p = 0.046). At a mean (SD) of 7.4 (9) months, favorable outcomes were achieved by 70.0% after G-POEM and 76.3% after pyloroplasty (p = 0.297). The GCSI improved after G-POEM [3.11 (2.6-3.4) to 2.42 (1.1-3.0), p = 0.014] and pyloroplasty [3.13 (2.5-3.9) to 1.93 (1.2-3.2), p < 0.0001]. There was no difference in postoperative GCSI (p = 0.920) or percent GCSI improvement (p = 0.976) between groups. In the 96 patients with pre- and postoperative GES, 4-hour retention decreased for G-POEM from 33.7% (17-53) to 11% (5-26) (p = 0.0012) and for pyloroplasty from 28.0% (28-55) to 5.0% (1-21) (p < 0.001). Pyloroplasty showed a trend toward better emptying (p = 0.0719) with more patients achieving ≥50% improvement (70.3% vs 50%, p = 0.086).

Conclusion: Gastroparesis symptom improvement is similar after pyloroplasty and G-POEM; however, there is a trend toward better improvement in gastric emptying after pyloroplasty.

The Effect of Laparoscopic Vertical Sleeve Gastrectomy on Lower Esophageal Sphincter Pressure, Lower Esophageal Sphincter Length and GERD Using Functional Esophageal Test: A Systematic Review and Meta-Analysis

Muhammed A Memon, MBBS, FRACS, FRCSI, FRCSEd, FRCSEng, FACS, Rossita M Yunus, PhD, Khorshed Alam, PhD, Zahirul Hoque, PhD, Shahjahan Khan, PhD

University of Southern Queensland, Toowoomba, Australia; Universiti Malaya, Kuala Lumpur, Malaysia

Introduction: The importance of esophageal manometry ±24-hour pH study pre- and post-laparoscopic vertical sleeve gastrectomy (LVSG) was evaluated to determine its impact of on the lower esophageal sphincter (LES) anatomy and physiology in morbidly obese patients.

Methods: Articles analyzing conventional or high-resolution manometry ± 24-hours pH-study pre- and post-LVSG between 1999 and 2023 were identified using various electronic databases. The Critical Appraisal Skills Programme (CASP) Checklist for Cohort Study was used as a critical appraisal tool. The DerSimonian and Laird’s random effects model was used to calculate the effect size of both dichotomous and continuous data. Heterogeneity was determined by the Cochran Q statistic and I2 index.

Results: Eighteen publications satisfied the inclusion criteria. Nine studies each performed conventional manometry and high-resolution manometry. Significant manometric reduction in lower esophageal sphincter pressure (LESP) of 3.94 mmHg post LVSG was observed based on 15 studies (weighted mean difference [WMD] 3.94, 95% CI 1.76 to 6.11; p < 0.0001, I2 = 89.3%). LESL did not alter significantly pre- and post-LVSG based on 9 studies (WMD 0.05, 95% CI -0.15 to 0.26; p = 0.625, I2 = 83.1%). DeMeester Score (DMS) was significantly increased, 10.42 post LVSG vs pre LVSG based on 11 studies (WMD -10.42, 95% CI -15.73 to -5.11; p = 0.001, I2 = 90.9%).

Conclusion: LVSG is associated with significant decrease in LESP and significantly increased in DMS post-LVSG cohort leading to the development and/or worsening of GERD symptoms. These findings should be integrated into clinical practice for introducing routine esophageal physiological testing to implement a comprehensive protocol for the selection of bariatric procedures.

The Impact of Barrett’s Esophagus on Nissen Fundoplication Outcomes: A Matched Case-Control Study

William C Maclellan, MD, Sven Eriksson, MD, MS, Naveed Chaudhry, BS, MS, Inanc Samil Sarici, MD, Johnathan Nguyen, BS, Ping Zheng, MD, Blair A Jobe, MD, FACS, Shahin Ayazi, MD, FACS

Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA

Introduction: Barrett’s esophagus (BE) represents a unique patient population requiring antireflux operation. However, there is a paucity of data on the impact of BE on antireflux outcomes. This case-control study aimed to compare Nissen fundoplication outcomes in patients with and without BE.

Methods: Patients with BE who underwent Nissen fundoplication over 7 years at our institution were selected. An age, sex, and BMI-matched non-BE control group was constructed in a 1:1 ratio to the number of cases. GERD-health-related quality of life (HRQL) questionnaires and pH-monitoring were completed before and 1-year after operation. Demographic, clinical characteristics and surgical outcomes were compared between groups.

Results: There were 202 patients with BE (53% women), with a mean (SD) age of 61.6 (13) years and BMI of 28.4 (5) kg/m2. The control group had 202 non-BE patients. Preoperative DeMeester score was higher in patients with BE [61.9 (57) vs 46.6 (41), p = 0.022). They also had more Los Angeles grade C/D esophagitis (24.3% vs 13.9%, p = 0.011). The hiatal hernia rate was 85.8%, and similar between groups (p = 0.771). At 10.5 (9) months after operation, the GERD-HRQL total score for BE patients improved from 31.0 (23) to 8.2 (13), p < 0.0001, with 95.4% freedom from PPIs, and 67.6% DeMeester score normalization (<14.7). The control group had similar GERD-HRQL (p = 0.832), freedom from PPIs (p = 0.723), and DeMeester score normalization (p = 0.261) outcomes. GERD-HRQL score was similar between ultrashort (<1 cm), short (1-3 cm) and long (>3 cm) segment BE groups (p = 0.461).

Conclusion: Patients with BE present with more severe distal esophageal acid exposure. Nevertheless, antireflux operation is effective in these patients, with significant improvement in subjective and objective outcomes, comparable to patients without BE.

The Impact of Preoperative Glucagon-Like Peptide-1 Receptor Agonist Use on Bariatric Surgery Outcomes

Qais Abuhasan, MD, Wendy Li, MD, Charles Burney, MD, Luke M Funk, MD, FACS, Jane Holl, MD, MPH, Don Selzer, MD, FACS, Dimitrios Stefanidis, MD, PhD, FACS, Tarik Yuce, MD, MS

Indiana University School of Medicine, Indianapolis, IN; University of Wisconsin - Madison, Madison, WI; University of Chicago, Chicago, IL

Introduction: The efficacy of glucagon-like peptide-1 receptor agonists (GLP1RA) for the treatment of obesity has led to increased demand for GLP1RA. GLP1RA use before bariatric surgery may represent a novel approach to treating obesity. The objectives of this study were to describe trends in pre-bariatric GLP1RA use, and to evaluate differences in clinical outcomes based on preoperative GLP1RA use.

Methods: Patients who underwent bariatric surgery at 3 Indiana hospitals from 2018 to 2023, were identified. Patients who used GLP1RA in the year preceding operation were compared with those who did not. Outcomes included rate of GLP1RA use, 30-day postoperative readmission, emergency department (ED) visits, and percent excess weight loss (%EWL) at 1 year. Association between preoperative GLP1RA use and outcomes was evaluated using multivariable logistic regression (categorical variables) and Wilcoxon rank sum test (continuous variables).

Results: Of 2,185 patients who underwent operation, 323 (14.8%) used GLP1RA preoperatively. The rate of GLP1RA use increased threefold from 2018 to 2023 (Figure 1). Men were more likely to receive preoperative GLP1RA (21.3% vs 13.6%, p < 0.001). There were no significant differences in 30-day postoperative outcomes between patients who did and did not use GLP1RA preoperatively. Similarly, there was no significant difference in %EWL at 1 year postoperatively between groups (median 56.8% vs 60.8%, p = 0.278).

Conclusion: Use of GLP1RA in the year before bariatric surgery has significantly increased. Preoperative GLP1RA use is not associated with worse 30-day outcomes or differences in %EWL at 1 year postoperatively. Further work is needed to evaluate whether GLP1RA dosing and duration of treatment impact postoperative outcomes.

The Role of pH Monitoring in Predicting Revisional Antireflux Surgery Outcome

Inanc Samil Sarici, MD, Sven Eriksson, MD, Naveed Chaudhry, BS, MS, Ping Zheng, MD, Johnathan Nguyen, BS, Mostafa Abdelhalim, BS, Blair A Jobe, MD, FACS, Shahin Ayazi, MD, FACS

Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA

Introduction: Patients often undergo pH monitoring before revisional antireflux surgery (ARS); however, there is limited data whether pH monitoring has a role in predicting outcome. This study aimed to assess the role of pH monitoring in predicting revisional ARS outcomes.

Methods: Records of patients who completed pH-monitoring before undergoing revisional ARS over 8 years were reviewed. Favorable outcome was defined as freedom from proton pump inhibitor (PPI) and patient satisfaction at 1-year after revisional ARS. Patient satisfaction, GERD-health-related quality of life (HRQL) scores, and PPI use were compared between patients with and without abnormal DeMeester score (>14.7) before revision.

Results: The final study population consisted of 160 patients (69% women) with mean (SD) age of 51 (13) years. Abnormal DeMeester score (≥14.7) was found in 91 (57%) patients. At a mean follow-up of 14 (3) months after revisional ARS, 61.2% achieved favorable outcome. The strongest predictors of favorable outcome on multivariable analysis was found to be abnormal DeMeester score [odds ratio (OR) = 3.8 (1.4-8.3), p = 0.007].Patients with abnormal DeMeester score had a lower GERD-HRQL total score [7 (2-22) vs 14 (6-32), p = 0.002], and higher patient satisfaction (83% vs 65%, p = 0.026) and freedom from PPIs (78% vs 60%, p = 0.036) after revision. In subgroup analyses, abnormal DeMeester predicted favorable outcomes in recurrent reflux symptom (p = 0.018) and ≥2 cm hiatal hernia (p = 0.026) subgroups. Outcome was independent of pH-monitoring in dysphagia as indication for revisional operation (p = 0.612), <2 cm hiatal hernia (p = 0.194) and <1 year time to failure (p = 0.659) subgroups.

Conclusion: Abnormal DeMeester score is the strongest predictor of revisional ARS outcome. However, in patients with dysphagia, small hernia, or early failure after index ARS, pH-monitoring has no role in predicting outcome after revision.

Use of Proton Pump Inhibitors after Laparoscopic Gastric Bypass and Sleeve Gastrectomy: A Nationwide Register-Based Cohort Study

Johanne Gormsen, MD, Frederik Helgstrand, MD, FACS

Department of Surgery, Zealand University Hospital, Køge, Denmark; Koege, Denmark

Introduction: Laparoscopic Roux-en-Y gastric bypass (L-RYGB) and sleeve gastrectomy (L-SG) are the dominant bariatric procedures worldwide. While L-RYGB is an effective treatment for coexisting GERD, L-SG is associated with an increased risk of de-novo or worsening of GERD. The study aimed to evaluate the long-term use of proton pump inhibitors (PPI) after L-RYGB and L-SG.

Methods: This nationwide register-based study included all patients undergoing L-RYGB or L-SG in Denmark between 2008 and 2018. In total, 17,740 patients were included in the study, with 16,096 and 1,671 undergoing L-RYGB and L-SG, respectively. The median follow up was 11 years after L-RYGB and 4 years after L-SG. Data were collected through Danish nationwide health registries. The development in PPI use was assessed through postoperative redeemed prescriptions. GERD development was defined by a relevant diagnosis code associated with gastroscopy, 24-hour pH measurement, revisional operation, or antireflux operation. The risk of initiation of PPI treatment or GERD diagnosis was evaluated using Kaplan Meier plots and Cox regression models.

Results: The risk of initiating PPI treatment was significantly higher after L-SG compared with L-RYGB (hazard ratio [HR] 7.06, 95% CI 6.42-7.77, p < 0.0001). The use of PPI consistently increased after both procedures. The risk of GERD diagnosis was also significantly higher after L-SG compared with L-RYGB (HR 1.93, 95% CI 1.27-2.93, p < 0.0001).

Conclusion: The risk of initiation of PPI treatment was significantly higher after L-SG compared with L-RYGB, and a continuous increase in the use of PPI was observed after both procedures.

ePosters

A Survey on Key Aspects of Hiatal Hernia Repair: Global Variations among Esophageal Surgeons

John Campbell, MD, Peter T White, MD, Adam J Bograd, MD, Alexander S Farivar, MD, Brian E Louie, MD

Swedish Medical Center, Cancer and Digestive Health Institutes, Seattle, WA

Introduction: Aspects of hiatal hernia repair (HHR), such as diaphragmatic reconstruction and use of relaxing incisions or mesh, are variably employed. We surveyed surgeons globally to determine the current utilization of these techniques in primary minimally invasive HHR.

Methods: We conducted an online survey targeting esophageal surgeons via international professional societies. The survey included questions regarding diaphragmatic reconstruction and adjunct interventions use/indications.

Results: There were 280 responses across five continents with representation of differing training backgrounds and surgical specialties working in academic, community, and private practice settings. Generally, crural repair was initiated posteriorly with simple interrupted (152, 54%), figure of 8 (48, 17%), or running (38, 14%) sutures. Anterior sutures were used by 207 (83%). Closure completion was evaluated with endoscopy by 59 (24%), bougie by 54 (22%), and both by 38 (16%) surgeons. Visual inspection alone was sufficient for 75 (31%). Mesh was used by 157 (64%), with tissue quality (116, 87%), hernia size (99, 74%), and tension (95, 71%) cited as indications. Mesh material and configuration varied. Relaxing incisions were used by 151 (61%) with tension (145, 96%) as its indication. Pledgets were used by 125 (51%) with tissue quality (83, 89%) being the indication.

Conclusion: This global survey amongst a diverse group of surgeons demonstrated variation in key aspects of HHR. Surgeons were mixed in their method of assessing hiatal closure and split on mesh, pledget, and relaxing incision use. However, there was agreement upon adjunct’s indications for use. These variations highlight the diverse perspectives in HHR.

Clinical Outcomes of Varying Age Groups Following Vertical Sleeve Gastrectomy: An MBSAQIP Study

Zoltan H Nemeth, MD, PhD, Satyam K Ghodasara, BS, Tyler T Oe, MD, Hyo J Yang, MD, Ashish Padnani, MD, FACS, Rolando H Rolandelli, MD, FACS

Morristown Medical Center, Department of Surgery, Morristown, NJ

Introduction: Rising rates of obesity across the United States, especially among pediatric patients, have led to more bariatric surgeries. Previous studies have compared the outcomes amongst Pediatric or Elderly patients and Non-Elderly patients, but none have studied all groups together. Therefore, we compared the three age groups for outcomes following a vertical sleeve gastrectomy.

Methods: The 2022 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) was utilized to identify Pediatric (<18 years; n = 333), Middle-Aged (18-65 years; n = 118,444), and Elderly (>65 years; n = 5,646) patients. Analyses were performed with the Middle-Aged cohort serving as the reference group.

Results: Postoperatively, the Elderly cohort experienced higher rates of mortality and complications, including sepsis, reoperations, and readmissions. Preoperatively, the Elderly cohort also had higher rates of comorbidities, including sleep apnea, gastroesophageal reflux disease, and hypertension. After controlling for all variables, the multivariate logistic regression revealed that being pediatric, male, or having a preoperative body mass index (BMI) ≥ 45 increases a patient’s odds of a BMI decrease ≥2.5 postoperatively within the 30-day follow-up period. Moreover, Elderly age, preoperative BMI ≥ 45, and sleep apnea were found to have greater odds of mortality, while female sex was associated with lower odds.

Conclusion: These findings highlight the varying clinical outcomes among age groups of patients undergoing bariatric surgery. The Pediatric cohort saw the most significant decrease in postoperative BMI with minimal complications, while the Elderly cohort saw the opposite trend.

Community-Level Socioeconomic Disadvantage and Adverse Events after Metabolic Surgery Outcomes: A State-Wide Analysis from the Michigan Bariatric Surgery Collaborative

Rebecca L Ferguson, MD, Sarah Petersen, MPH, Renuka Tipirneni, MD, Ahmad Hider, MPhil, Jonathan F Finks, MD, FACS, Nabeel R Obeid, MD, FACS, Arthur Carlin, MD, FACS, Oliver A Varban, MD, FACS

Henry Ford Hospital, Ferndale, MI; University of Michigan, Ann Arbor, MI; Ann Arbor, MI; Chelsea, MI; Clinton Township, MI

Introduction: Patients from socioeconomically disadvantaged communities have been shown to have poorer health-care outcomes. The area deprivation index (ADI) is a validated, composite index that uses zip codes to identify neighborhood-level social disparities. A higher ADI indicates a greater degree of disadvantage. To date, metabolic surgery outcomes according to ADI have not been evaluated.

Methods: Using a state-wide bariatric-specific data registry, we obtained state-level ADI (Percentile Rank: 1-10) on all patients who underwent primary metabolic surgery (n = 79,311). Patient characteristics and 30-day risk-adjusted outcomes were compared between patients in the highest and lowest quartile for ADI.

Results: Patients in the highest quartile for ADI (mean ADI 9.1) were younger (43.8 years vs 46.5 years, p < 0.0001), had a higher preoperative body mass index (BMI) (49.3 kg/m2 vs 46.6 kg/m2, p < 0.0001) and were more likely to be female (84.4% vs 76.8%, p < 0.0001), non-White (53.9% vs 23.1%, p < 0.0001) and have diabetes (33.6% vs. 30.8%, p < 0.0001) when compared to patients in the lowest quartile (mean ADI 2.2). The highest quartile experienced similar complication rates, emergency room visit rates and readmission rates for both sleeve gastrectomy (5.3% vs 5.5% p = 0.859, 7.6 vs 7.5, p = 0.1071 and 2.7% vs 2.9%, p = 0.7583, respectively) and gastric bypass (12.3% vs 11.2%, p = 0.0637, 11.2% vs 11.1%, p = 0.3013 and 5.5% vs 5.6%, p = 0.6459, respectively).

Conclusion: Within the context of a state-wide quality improvement collaborative, adverse events after metabolic surgery are similar between patients living in neighborhoods with high and low ADI in Michigan. Long-term outcomes require further investigation.

Comparing Anastomotic Leak Rate between Robotic and Laparoscopic Bariatric Procedures: A Retrospective Analysis of MBSAQIP 2020-2022

Alexandria Jones, BS, Alexander G Hall, MS, Kalyana C Nandipati, MBBS, FACS

Creighton University School of Medicine, Omaha, NE; Creighton University, Omaha, NE

Introduction: Within bariatric surgery, robotic approaches have become common. Postoperative bleeding and anastomotic-related complications, especially leaks, are the most common reasons for unplanned reoperations and morbidity. The objective of this study is to compare the rate of anastomotic leak in robotic-versus-laparoscopic approaches within the three most common bariatric procedures: sleeve gastrectomy (SG), Roux-en-Y (RYGB), Duodenal Switch (DS).

Methods: Utilizing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we evaluated patient-surgeries between 2020-2022. Separate log-binomial regression models are estimated for each procedure to quantify the adjusted risk for 30-day anastomotic leak between robotic-assisted and laparoscopic approaches. Adjusted risk ratios alongside 95% confidence intervals are presented.

Results: Our analyses included 563,051 total surgeries and 1,185 recorded leaks (0.21%). Within SG, robotic approach was associated with an estimated 31% higher adjusted risk of leak compared to laparoscopic approach (RR 1.31, CI 1.10-1.57, p = .0030). Within DS and RYGB, robotic approach was also associated with a higher yet non-statistically significant estimated risk of leak. Additionally, in all three procedures, drain placement and previous foregut surgery were significant predictors of greater leak risk.

Conclusion: Our findings suggest that, while overall risk of leak is low, robotic-assisted bariatric procedures may have a higher risk of anastomotic leaks. This estimated difference was statistically significant for SG which had the highest event rate (and largest number of associated surgeries) but not for DS or RYGB. Future studies should continue to compare robotic-versus-laparoscopic risks as training in robotic-assisted surgeries intensifies and efficiency in both approaches improves.

Emergent Laparoscopic Paraesophageal Hernia Repairs Are Associated with Increased Risk of 30-Day Postoperative Complications: A NSQIP Analysis

Victoria Haney, MD, Hope T Jackson, MD, FACS, Ben Mcsweeney, MD, Romtin Nadjafi, BS, Seyedeh Azadeh Miran, MS, Juliet Lee, MD, FACS, Khashayar Vaziri, MD, FACS

The George Washington University Hospital, Washington, DC; The GW Medical Faculty Associates, Washington, DC

Introduction: Paraesophageal hernias (PEH) exhibit diverse anatomical variations, and while elective repair is standard for symptomatic cases, larger Types II-IV can necessitate emergent intervention. Despite a recognized demographic trend in emergent cases, a consensus on postoperative outcomes is lacking. This study aimed to assess the 30-day postoperative outcomes of laparoscopic elective versus emergent PEH repair.

Methods: This analysis queried the ACS-NSQIP database from 2011-2020, focusing on elective and emergent laparoscopic PEH repairs. Procedures resulting in any resection or conversion to open were excluded. Regression analyses, employing Firth’s Logistic Regression, multiple linear regressions, ordinal logistic regressions, and multinomial logistic regressions were applied to assess 30-day postoperative outcomes.

Results: Patients undergoing emergent laparoscopic PEH repair, compared to elective repair, were significantly older with lower BMI (p < 0.0001; p < 0.0001). Controlling for demographics and medical comorbidities, emergent cases were associated with significantly higher risks of sepsis, infection, transfusion, venous thrombosis, readmission, reoperation, longer operative time, longer length of stay, pulmonary complications, and renal complications (all p < 0.0001, except p = 0.0011 for venous thrombosis).

Conclusion: Despite the existing literature’s discordant findings, our study, controlling for demographics and medical comorbidities, showed that emergent laparoscopic PEH repairs are associated with significantly worse 30-day outcomes compared to elective laparoscopic PEH repairs. The higher rates of postoperative complications in emergent cases emphasize the need for careful consideration with respect to emergent repair or temporizing laparoscopic gastropexy with delayed definitive repair.

Enhancing Patient Safety and Outcomes in Bariatric Surgery: The Role of Resident Participation. A Systematic Review and Meta-Analysis

Diana Nguyen, Raquel Nogueira, MD, Joao P Goncalves Kasakewitch, MD, Carlos André B D Silveira, MD, Rachel C Santana Felipes, Aisulu J Jessup, MD, PhD, Saad Ahmed, Diego L Lima, MD, Diego R Camacho, MD, FACS

Albert Einstein College of Medicine, Bronx, NY; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Beth Israel Deaconess Medical Center, Boston, MA; Bahiana School of Medicine and Public Health, Salvador, Brazil; Albert Einstein College of Medicine, Yonkers, NY; Keio University, Tokyo, Japan

Introduction: Amidst concerns about surgical training’s impact on patient care, this study aims to evaluate the outcomes and safety of bariatric surgeries, including robotic and laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), with resident participation.

Methods: Cochrane, PubMed/MEDLINE, and Embase databases were searched on studies that compared outcomes of bariatric surgeries performed with resident involvement against those conducted by attending surgeons alone. The selection process was carried out by three independent reviewers, with any disagreements being adjudicated by a fourth reviewer.

Results: From 750 records, 25 studies were included, encompassing 1,818,940 patients, of whom 382,661 (21.0%) underwent bariatric surgery with resident participation. Our findings indicate that surgeries involving residents were associated with a reduced risk of postoperative bleeding (RR 0.68; 95% CI 0.49-0.96) compared to those performed by attending surgeons alone. Conversely, surgeries without resident involvement showed a higher risk of small bowel obstruction (SBO) and large bowel obstruction (LBO) (RR 1.56; 95% CI 1.31-1.85). No significant differences were observed in ICU admissions, anastomotic leakage, mortality, readmission rates, reoperations, or SSI.

Conclusion: Resident participation in bariatric surgeries does not compromise patient safety and may enhance certain postoperative outcomes. This supports the integration of residents in bariatric surgical teams, emphasizing the importance of hands-on training in surgical education without adversely affecting patient care.

Evaluating Outcomes after Metabolic-Bariatric Surgery among Middle Eastern and North African Patients in Michigan

Ahmad Hider, MPhil, Sarah Petersen, BS, MPH, Arthur Carlin, MD, FACS, Annie Ehlers, MD, FACS, Jonathan F Finks, MD, FACS, Oliver A Varban, MD, FACS, Nabeel R Obeid, MD, FACS

University of Michigan, Ann Arbor, MI; Henry Ford Health, Clinton Township, MI; University of Michigan, Ann Arbor, MI; Henry Ford Health, Detroit, MI; University of Michigan, Chelsea, MI

Introduction: The Middle Eastern and North African population (MENA) in the US comprises 3.8 million individuals. This study aims to elucidate healthcare outcomes for MENA patients compared to non-MENA patients undergoing bariatric surgery in Michigan.

Methods: This retrospective cohort study utilized 2017 - present data from the Michigan Bariatric Surgery Collaborative (MBSC) database. The self identified MENA group comprised 839 patients (1.5% of the total cohort). Data included demographics, comorbidities, procedure performed, 30-day complications, and 1-year postoperative outcomes including weight loss and changes in comorbid status. The analysis included adjusted outcomes using logistic regression and comparisons using chi square or Fisher’s exact test were indicated.

Results: Compared to non-MENA patients, MENA patients were more likely to be males (25.6% vs 18.6%; p < 0.0001), present at younger ages (age < 30 years: 21.8% vs 11.0%, p < 0.0001), and have a lower initial body mass index (BMI, kg/m2: 45.0 vs 47.4, p < 0.001). There were no differences in 30-day complications (6.2% vs 5.9%, p = 0.586), although MENA patients had lower rates of ED visits (6.3% vs 7.0%, p = 0.017) and healthcare utilization (8.8% vs 9.9%, p = 0.034). Overall, there were no differences in weight loss outcomes or rates of comorbidity improvement at 1 year. Among MENA patients undergoing gastric bypass specifically, percent total weight loss (%TWL) was lower than non-MENA patients (30.1% vs 33.4%, p = 0.008).

Conclusion: MENA individuals tend to pursue bariatric surgery at a younger age and at a lower BMI. Bariatric surgery appears to be equally safe and similarly effective in this patient population.

First Reported Clinical and Histopathologic Outcomes after Revisional Median Arcuate Ligament Surgery

Jamie P Decicco, BS, Fnu Raja, MD, Santhi Ganesan, MD, Kevin M El-Hayek, MD, MBA, FACS

Cleveland Clinic Lerner College of Medicine, Cleveland, OH; The MetroHealth System, Cleveland, OH

Introduction: Median arcuate ligament syndrome (MALS) is a neurovascular disorder due to celiac artery and ganglion compression. Symptom improvement ranges from 70-90% after primary operation, with a subset having recurrence. This study describes indications and outcomes of revision MALS surgery.

Methods: Patients ≥18 years undergoing revision robotic MAL release and celiac ganglionectomy from 2020-2023. Clinical and histopathologic outcomes were described and analyzed.

Results: Ten of 61 patients met inclusion criteria (100% female, 39.2 ± 9.9 yrs, BMI 23.8 [22.6-34.9] kg/m2). Primary operations included: 1 endovascular, 5 laparoscopic, 4 robotic. Time from primary operation to symptom recurrence and reoperation were 5 [0.6-17.5] and 28.1 [11.4-32.3] months, respectively. Comorbidities included: GERD (80%), depression/anxiety (70%), POTS/dysautonomia (60%), tobacco use (50%), opioid medication use (50%), gastroparesis (40%). Preoperatively, 7/10 had compression on ultrasound and 4/10 on angiography. All had celiac plexus block relief. Operative time was 155 [129-191] minutes. No conversions occurred. Eight had significant adhesions. Histopathologically, all had fibroadipose tissue and reactive lymph nodes. Four had lipogranulomas. Median fibrosis score was 2 [1-3]. Celiac artery velocity decreased from 271 [194-362] preoperatively to 243 [225-295] cm/s postoperatively. Symptoms improved in 50% of patients. Of the 5 patients with unchanged symptoms, 2 had subsequent operations.

Conclusion: This is the first report of histopathologic and clinical outcomes after revision MALS surgery with ganglionectomy. Compared to primary operations, revisions were more technically challenging, had greater fibrosis, and poorer clinical outcomes. Recurrence may occur due to incomplete primary operation, adhesions, nerve dysfunction, and/or comorbidities. Future research on long-term follow-up and multidisciplinary collaboration will aid in understanding recurrence and role of revision surgery.

Helicobacter Pylori Testing: Is It Necessary in Bariatric Patients?

Christian Hadeed, MD, Catherine Tsai, MD, Gustavo G Fernandez-Ranvier, MD, PhD, FACS

Mount Sinai Icahn School of Medicine, New York, NY; Mount Sinai Icahn School of Medicine, Long Island City, NY

Introduction: Conflicting evidence exists regarding the association of H. pylori (HP) with complications after bariatric surgery, including marginal ulcers and gastroesophageal reflux disease (GERD). We aim to study bariatric surgery outcomes in patients who test positive for HP on preoperative esophagogastroduodenoscopy (EGD).

Methods: We identified all patients who underwent either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at our institution from 2015 to 2018. The electronic medical records of these patients were retrospectively reviewed to identify patient demographics, preoperative HP status and surgical outcomes, in particular, incidence of marginal ulcers and GERD.

Results: Of the 735 patients who underwent either RYGB or SG, 179 (24.4%) tested positive for HP on preoperative EGD. Positive HP was not associated with preoperative GERD (p = 0.68) or GERD at 1 year postoperatively (p = 0.61). In patients who underwent SG, positive HP status on the pathology specimen was not significantly associated with GERD at 1 year postoperatively. Of the 130 patients who underwent RYGB, 24 tested positive for HP on preoperative EGD (18.5%). Of these, 8.3% (2/24) developed marginal ulcers. This was not significantly different from the HP negative patients who developed marginal ulcers, 9.4% (10/106) (p = 0.82). HP was also not significantly associated with major postoperative complications including major bleeds, leaks, or readmissions.

Conclusion: Our data show that H. pylori was not associated with marginal ulcers, GERD or major complication after bariatric surgery. Further studies are needed to determine the significance of HP testing and treatment in the management of bariatric surgery patients.

Impact of Anti-Coagulation Therapy on Perioperative Outcomes in Patients Undergoing Minimally Invasive Metabolic and Bariatric Surgery: Propensity Score Matched Analysis Using the 2020-2021 MBSAQIP

Elad Boaz, MD, Pauline Aeschbacher, MD, Noam Kahana, MD, Nir Horesh, MD, Samuel Szomstein, MD, FACS, Emanuele Lo Menzo, MD, FACS, Raul J Rosenthal, MD, FACS

Cleveland Clinic Florida, Weston, FL; Cleveland Clinic Florida, Wabern, Switzerland; Cleveland Clinic Florida, Hollywood, FL; Cleveland Clinic Florida, North Miami Beach, FL

Introduction: The management of individuals receiving chronic anticoagulation (AC) undergoing bariatric surgery presents a complex challenge, as there is a delicate balance between risks of perioperative bleeding and thromboembolic events. The aim of this study was to evaluate and compare rates of bleeding, thrombotic events, and overall outcomes of patients on preoperative AC undergoing bariatric surgery.

Methods: Data spanning from 2020 to 2021 was extracted using the MBSAQIP database, focusing on patients who underwent primary minimally invasive bariatric surgery. A multivariable regression analysis examined 30-day outcomes for preoperatively anticoagulated patients. Additionally, a propensity-matched analysis was performed comparing outcomes among patients on pre-op AC and those without.

Results: A total of 331,201 patients were analyzed, with 8,428 (2.5%) receiving preoperative AC. Propensity score matching revealed that patients on preoperative AC exhibited higher rates of reoperations within 30 days (1.9% vs. 1.3%, p < 0.001), overall readmissions after 30 days (7.2% vs. 3.3% respectively, p < 0.0001), and reinterventions within 30 days (1.6% vs. 0.9%, p < 0.0001) compared to those without preoperative therapeutic AC. Transfusion intra/post-op and post-op GI tract bleeding events were elevated in the preoperative therapeutic anticoagulant group (2.2% vs. 0.8%, p < 0.0001 and 1.4% vs. 0.3%, p < 0.0001, respectively) compared to no preoperative AC group.

Conclusion: Patients undergoing bariatric surgery while on preoperative AC face significantly increased risks of adverse postoperative outcomes. Individuals requiring long-term anticoagulation should undergo careful consideration before proceeding with bariatric surgery.

Improved Perioperative Outcomes and Reduced Adverse Events in Robotic Compared to Laparoscopic Hiatal Hernia Repair

Niloufar Salehi, MD, Gala Cygiel, MD, Teagan Marshall, MD, Hala Al Asadi, MD, Maria Alqamish, MD, Anjani H Turaga, MD, Brendan M Finnerty, MD, FACS, Thomas J Fahey III, MD, FACS, Rasa Zarnegar, MD, FACS

Weill Cornell Medical Center, New York, NY

Introduction: Robotic hiatal hernia (HH) repair has emerged as a promising alternative to laparoscopic techniques, offering potential advantages in precision and dexterity. However, concerns persist regarding prolonged operative times and outcomes associated with robotic procedures. This study compares perioperative outcomes between robotic and laparoscopic HH repair.

Methods: A retrospective review of robotic and laparoscopic HH repairs between January 2012 and January 2024 at a tertiary academic medical center was performed. Operative time, length of hospital stays (LOS), and 30-day readmission rates were compared between the robotic and laparoscopic cohorts. Reasons for readmission were graded using the Clavien-Dindo classification.

Results: Of 1085 included patients, 746 underwent robotic and 339 underwent laparoscopic HH repair. Baseline characteristics were comparable in BMI, comorbidities, and re-operative surgeries. LOS was significantly shorter after the robotic repair (0.0 (IQR 0.0-1.0) versus 1.0 (IQR 0.0-2.0) nights, P < 0.01). Operative time (robotic: 99.00 (IQR 87.00-116.0), laparoscopic: 105.00 (IQR 90.00-128.00) minutes, p = 0.45) and 30-day readmission rates (robotic: 12.87%, laparoscopic: 10.62%, p = 0.32) were similar between the two cohorts. However, laparoscopic cases had more severe adverse events (Clavien-Dindo ≥3) leading to readmission (OR:0.38, 95% CI: 0.16-0.89). Other factors, including diabetes, pulmonary disease, preoperative atypical GERD symptoms and dysphagia, and LINX implantation, predicted higher readmission rates for the entire cohort.

Conclusion: Robotic and laparoscopic hiatal hernia repairs have similar operative times, with robotic surgeries resulting in shorter hospital stays. Although 30-day readmission rates were comparable, laparoscopic cases had more severe adverse events. These findings suggest improved perioperative outcomes of robotic HH repair compared to laparoscopic approaches.

Is Bariatric Surgery at Risk Due to Ozempic?

Jane Tian, MD, Shubham Bhatia, MBBS, Christina Sneed, Patrick Kiarie, Andrew Miele, MS, Aldona Chorzepa, MS, Martine A Louis, MD, FACS, Noman Khan, DO

Flushing Hospital Medical Center, Flushing, Queens, NY; Medisys Health Network, Flushing, Queens, NY

Introduction: Obesity affects over 70 million Americans and is projected to incur substantial costs due to associated chronic diseases. Effective weight management, including bariatric surgery, is crucial. The FDA’s approval of subcutaneous Ozempic (Semaglutide) in June 2021 for long-term weight management has sparked interest. The Semaglutide Treatment Effect in People With Obesity (STEP) trials demonstrated its efficacy, with patients experiencing significant weight loss. However, the potential impact of Ozempic on bariatric surgery remains uncertain.

Methods: This study retrospectively reviewed bariatric patients seen in clinic between Jan 2022 and Nov 2023. All patients with initial BMI greater than 35 were included. Analysis compared Ozempic and non-Ozempic patients in terms of time to surgery, procedure cancellation rates, and weight changes. Secondary outcomes included side effects and adverse events.

Results: Among 515 patients, 13% were prescribed Ozempic. Ozempic patients were more likely to have diabetes (p < 0.001). Although their starting and final preoperative BMI did not differ significantly, Ozempic patients’ lowest BMI before surgery was higher (p = 0.02). Ozempic patients were less likely to undergo surgery (p = 0.01) and experienced longer time intervals between evaluation and surgery (8 vs. 6 months, p = 0.03). Weight- loss percentages at 2 and 6 months post-surgery did not significantly differ between Ozempic and non-Ozempic patients. 7% of Ozempic patients no longer qualified for surgery based on BMI. Only one reported side effects.

Conclusion: The increased use of Ozempic has led to fewer bariatric surgeries, though its long-term effects on patient outcomes and clinical practice warrant further investigation.

Lipid Trends in Patients Experiencing Weight Regain after Bariatric Surgery

Kunal Khurana, BS, Vincent E Xu, BS, Adam Odolil, BS, Sarah Cho, BS, Luca Bertozzi, BS, Kelly Feng, BS, Marijane Hynes, MD, Hope T Jackson, MD, FACS, Khashayar Vaziri, MD, FACS, Juliet Lee, MD, FACS

George Washington University School of Medicine, Washington, DC; University of Michigan Medical School, Ann Arbor, MI

Introduction: Bariatric surgery is the most effective treatment for obesity. In addition to weight loss, bariatric surgery reduces cardiovascular risk by producing other metabolic benefits, such as the improvement of dyslipidemia. Weight regain can occur in up to 20% of bariatric surgery patients. However, it is unclear whether improvements in lipid levels persist despite weight regain. The aim of this study was to determine whether lipid trends differ in bariatric patients with weight regain.

Methods: Charts for 800 patients who underwent bariatric surgery were reviewed (2017-2021). Data was collected retrospectively for weight, body mass index (BMI), low and high density lipoprotein (LDL, HDL), triglycerides, and total cholesterol. Patients were categorized based on the occurrence of weight regain (WR), defined as gaining back ≥20% of the total weight loss (TWL) after surgery.

Results: Of the original 800 patients, 51 had complete lipid profiles available and met inclusion criteria. Of these 51 patients, 95% underwent sleeve gastrectomy and 19 experienced WR. Cholesterol levels reduced postoperatively in all patients. Multivariate analysis suggested there was no significant association between weight regain status (yes or no) and LDL (p = 0.316), HDL (p = 0.115), triglycerides (p = 0.488), or cholesterol (p = 0.414). There was also no significant association between the amount of weight regained (lbs) and lipid levels.

Conclusion: These results suggest that bariatric surgery may be associated with a weight-independent improvement in lipid levels. Prospective studies are needed in which lipid results are longitudinally monitored after surgery.

Metabolic Syndrome Is Associated with Increased Rate of Complications Following Minimally Invasive Esophagectomy for Esophageal Adenocarcinoma

Elliot Ballato, BS, Thitiporn Chobarporn, MD, Stephanie G Wood, MB, BCh, FACS

Oregon Health & Science University, Portland, OR

Introduction: It has been reported that obesity is associated with adverse outcomes following esophagectomy for resectable esophageal adenocarcinoma (EAC). To our knowledge, however, no study has investigated the direct impact of underlying metabolic syndrome (MetS) on perioperative outcomes following minimally invasive esophagectomy.

Methods: This is a retrospective, chart-review analysis of our institutional esophageal cancer database combined with institutional NSQIP data between the years of 2013 - 2023. The definition of MetS was based on a modified version of the 2001 NCEP ATP III definition. Univariate analyses were performed via chi-squared for categorical variables and Student’s t-test for continuous data. Multivariate analysis was conducted including variables, with p < 0.2 or clinically relevant, for complications and 90-day mortality.

Results: There were 247 patients included in this study, of which 79 (32.0%) met criteria for MetS. The MetS group reported a significantly higher complication rate (64.6% vs. 37.9%, p < 0.001) and 90-day mortality (8.9% vs 2.4%, p = 0.02) along with a trend toward more prolonged ICU stay (45.6% vs. 33.7%, p = 0.07), compared to non-MetS group. MetS was a significant predictor of postoperative complications (OR = 2.49, p = 0.005) and 90-day mortality (OR 4.48, p = 0.04) in the multivariate analysis.

Conclusion: Our data suggest that the presence of underlying MetS increases the likelihood of experiencing a perioperative complication and 90-day mortality following minimally invasive esophagectomy for EAC.

Outcomes after Anterior Gastropexy for Paraesophageal Hernia Repair?

Robert L Rettig, MD, Sohil Patel, MD, Nicole M Garcia, Sidney Ezenwugo, Aditya Dwivedi, Shreyas Kiran, Philip E Shih, Russyan Mark Mabeza, MD, Stanley Rogers, MD, FACS

University of California San Francisco, San Francisco, CA

Introduction: The optimal approach for repairing large paraesophageal hernias remains unclear. Anterior gastropexy is a simple technique that could decrease recurrence rates. This study evaluated outcomes in patients undergoing paraesophageal hernia repair (PEHR) with anterior gastropexy (AG) to those undergoing PEHR alone (NAG).

Methods: A retrospective review was performed of 355 patients undergoing laparoscopic or robotic PEHR from 2012-2022. Patients with symptomatic paraesophageal hernias (type III or type IV) were included. The primary outcome was PEH recurrence at 1 year. Secondary endpoints included hospital length-of-stay (LOS), duration of procedure, inpatient opioid use, 30-day readmission, return to urgent care (UC) or emergency department (ED) in 1 year, and postoperative symptoms of gas bloat, regurgitation, abdominal pain, dysphagia, odynophagia, postprandial pain, cardiovascular, or pulmonary symptoms.

Results: The AG group had 5 recurrences, while the NAG group had 14, though this did not reach statistical significance. There were no differences in LOS, 30-day readmission, or return to UC or ED in either group. The AG group had a longer procedure duration (p = 0.007), but a decreased need for inpatient opioids (p = 0.031). There were no differences in postoperative symptoms for either group.

Conclusion: One year recurrence rates were similar in patients with and without anterior gastropexy in PEHR, though AG was associated with reduced inpatient opioid requirements. The recurrences in the AG arm were smaller and asymptomatic, and noted only on imaging that was obtained for other reasons. Further trials are needed to evaluate the effectiveness of this technique in improving patient outcomes.

Per-Oral Pyloromyotomy Outcome Disparities in Gastroparesis

Hee Kyung Kim, BS, Jamie P Decicco, BS, Rachna Prasad, BA, Hemasat Alkhatib, MD, Kevin M El-Hayek, MD, MBA, FACS

Case Western Reserve University, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Cleveland, OH; Northeast Ohio Medical University, Rootstown, OH; The MetroHealth System, Cleveland, OH

Introduction: Gastroparesis symptom severity may worsen with psychological distress. Per-oral pyloromyotomy (POP) is the first-line endoscopic intervention for gastroparesis. We investigated whether POP outcomes were impacted by social determinants of health (SDH) and mental health.

Methods: Retrospective analysis from October 2019—September 2023 included patient demographics, psychiatric diagnoses, outcomes measured by the validated gastroparesis cardinal symptom index (GCSI), and gastric emptying study (GES).

Results: Thirty-two patients (28 [87.5%] female, 48.9 ± 3.11 years, BMI 28.6 ± 5.18 kg/m2) underwent POP. Average operative time was 42 ± 17.9 minutes. There were no complications. Patients identified as White (22 [68.8%]), Black (6 [18.8%]), and Hispanic (4 [12.5%]). Insurance coverage was from private policies (13 [39.4%]), Medicare (11 [33.3%]), or Medicaid (9 [27.3%]). Median income of zip codes was $57,622 (41411, 81700). Many patients had mood disorders: depression (n = 6), anxiety (n = 2), both (n = 13).At 18 (12.25, 33.75) days post-procedure, GCSI score decreased significantly (29.5/45 to 17/45, S = -187.00, p < 0.0001). At 96 (88, 123.5) days, 4-hour retention on GES decreased significantly (29% vs 19%, S = -108.00, p = 0.0038). Post-op GCSI improvements did not differ by race, income, or psychiatric condition. Those with Medicaid had smaller decreases in GSCI than those with other insurances (F = 4.05, p = 0.03). There was a moderate negative association between income and postoperative 4-hour retention on GES (r = -0.56, p = 0.003). Those with depression, anxiety, and both had less improvement in gastric emptying (0.5% vs 25%, S = 79, p = 0.03) (2% vs 25%, S = 157, p = 0.025) (-1% vs 25%, S = 142, p = 0.029).

Conclusion: This study emphasizes the importance of mental health and SDH in treating gastroparesis as they were associated with lower degree of improvements in GCSI and GES after POP. Future studies should utilize this knowledge to optimize gastroparesis treatment in context of patients’ SDH and psychiatric comorbidities.

Preoperative Determinants of Hernia Repair Pain among Females with Hernia at One Month

Abigail L Kappelman, MA, Dana A Telem, MD, MPH, FACS, Annie Ehlers, MD, FACS

University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Surgery, VA Ann Arbor Healthcare System; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI

Introduction: Outcomes of females undergoing abdominal wall hernia repair are understudied, but limited evidence suggests worse postoperative outcomes compared to males. Identifying disparities by sex in patient-reported outcomes (PROs) and in their determinants is essential to inform shared decision-making and motivate quality improvement.

Methods: Leveraging the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC-COHR), we studied a representative cohort of male and female adults who underwent ventral or incisional repair between January 2020-March 2023. We tested associations by sex between PROs and patient and hernia characteristics. Female-only multivariable ordinal regression models evaluated the association between 1-month PROs (Numerical Rating Pain Scale) and patient demographics, comorbidities, and clinical and surgical factors.

Results: At one month, women (n = 778) reported moderate to severe pain more frequently than men (n = 920) (38.17% vs. 21.31%). Hernia size ≥6 cm, Black (vs. White) race, younger age, and laparoscopic/robotic (vs. open) surgical approach were independent predictors of worse pain for both sexes. Prevalence of all risk factors was higher among female patients than male patients. On multivariable regression, hernia size ≥6 cm (OR 2.82; 95% CI [1.67-4.75]) and Black race (OR 2.08; [1.29-3.37]) remained significant predictors of a higher pain score category for females (all p < 0.05).

Conclusion: In a statewide cohort we found that females reported higher pain following elective ventral hernia repair, and that certain females may face even higher risk. Further characterizing this disparity is important to improve care for female patients; meanwhile, differences by sex in risk factors for postoperative pain should be incorporated into surgical decision-making.

Risk Factors for Early Bowel Obstruction Following Bariatric Surgery: A Comprehensive Analysis of MBSAQIP Database (2015-2021)

Narayan Osti, MBBS, Maria F Guevara-Kissel, MD, Sharique Nazir, MD, FACS, Stephen S Carryl, MD, FACS, Javier E Andrade, MD, FACS, FASMBS, Karina McArthur, MD, FACS

Harlem Hospital Center, New York, NY; Woodhull Medical Center, Brooklyn, NY

Introduction: Bowel obstruction is a rare but significant complication following bariatric surgery, with particular concern in patients undergoing Roux-en-Y Gastric Bypass (RYGB) due to the altered anatomy predisposing them to internal hernias and adhesive small bowel obstruction.

Methods: This retrospective analysis utilized the MBSAQIP database from 2015 to 2021. We included sleeve gastrectomy (SG), RYGB, and duodenal switch (DS) procedures. Subgroup analysis of RYGB cases was performed. Chi-square test, and multivariate regression analysis was conducted using STATA software.

Results: Among the 1,192,875 cases, 486 (0.06%) of SG, 3,094 (0.9%) of RYGB, and 670 (0.45%) of DS patients experienced bowel obstruction within 30 days. The odds of bowel obstruction were significantly higher in RYGB, 14.21 (CI: 12.86-15.71, p < 0.01), and DS, 7.16 (CI: 5.5-9.3, p < 0.01), compared to SG. Robotic surgical approach was associated with higher odds of bowel obstruction 1.3 (CI: 1.18-1.4, p < 0.01). Subgroup analysis of RYGB cases revealed that factors such as Black race, age over 50, conversion/revision procedures, hypertension, BMI over 40, male sex, patients with GERD, previous surgery, robotic surgery, operation by general surgeons, and operations exceeding 130 minutes were all associated with significantly higher odds of bowel obstruction.

Conclusion: Bowel obstruction is more common following RYGB and duodenal switch compared to sleeve gastrectomy. Robotic approach, conversion/revision cases, and previous surgery are associated with increased odds of bowel obstruction. These findings provide valuable insights for clinical practice and patient management in bariatric surgery.

Risk Factors for Postoperative Venous Thromboembolism in Patients with Previous Deep Vein Thrombosis or Pulmonary Emboli: Analysis of the MBSAQIP National Registry

Zachary D Leslie, Sayeed Ikramuddin, MD, FACS, Eric S Wise, MD, FACS

Carleton College, Northfield, MN; University of Minnesota, Minneapolis, MN

Introduction: Deep venous thrombosis (DVT) and pulmonary emboli (PE) cause short-term morbidity and mortality after bariatric surgery. Patients with previous DVT/PE require greater vigilance for postoperative venous thromboembolic events (VTE). We aim to determine risk factors for postoperative VTE in patients with and without previous DVT/PE.

Methods: The MBSAQIP national databases from 2020-2022 were queried for patients who underwent minimally-invasive Roux-en-Y gastric bypass or sleeve gastrectomy. Cohorts with and without prior DVT/PE were compared by demographics, comorbidities and operative factors. Summary statistics were prepared using Python 3.12 to test for normality and perform t-test and chi-square tests. Logistic multivariable regression models were built to determine predictors of postoperative VTE in both cohorts.

Results: We identified 12,650 and 500,421 patients with and without previous DVT/PE, respectively. The cohort with previous DVT/PE had a higher rate of postoperative VTE (1.3% vs. 0.3%; P < 0.001). The previous DVT/PE cohort was older, more frequently male, had higher BMI, more comorbidities, more readmissions and reoperations. Pharmacologic DVT prophylaxis was used more frequently in patients with previous DVT/PE (93.5% vs. 88.0%; P < 0.001). Risk factors (P < 0.05) in the former cohort were hypertension (odds ratio 1.3; 95%-confidence interval [1.1, 1.6]) and lower preoperative weight loss (0.80/pound; [0.64, 0.996]). In the latter cohort, risk factors included Black race (1.3 [1.2, 1.4]), prolonged operative time (1.1/min [1.06, 1.2]), diabetes (0.93 [0.87, 0.998]), hyperlipidemia (0.93 [0.86, 0.998]) and low albumin (0.91/unit [0.86, 0.97).

Conclusion: Consequential predictors of postoperative VTE have been identified in patients with previous DVT/PE. Consideration of postoperative anticoagulation is imperative to mitigate associated morbidity.

Robotic versus Laparoscopic Bariatric Surgery in Patients with Super Obesity: An Analysis of Outcomes of the MBSAQIP Data Registry

Roberto J Valera, MD, David Romero-Funes, MD, Emanuele Lo Menzo, MD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS

Cleveland Clinic Florida, Weston, FL

Introduction: The population with super-obesity (BMI ≥ 50 Kg/m2) can represent a surgical challenge. There is an assumption that the robotic platform may offer technical advantage. This study aimed to compare outcomes of robotic vs. laparoscopic bariatric surgery (BaS) in patients with supe-obesity.

Methods: A retrospective analysis of the MBSAQIP data registry of patients undergoing primary robotic or laparoscopic BaS from 2015 to 2019 was done. Patients older than 18 years with super-obesity were included. Demographics, comorbidities, perioperative variables and surgical approach were collected. Outcomes were defined as 30-days postoperative complications. Univariate analysis was performed to assess differences between both approaches. Multivariate logistic regression was used to adjust for confounding variables.

Results: A total of 188,154 cases were identified; 90.3% (n = 169,788) were laparoscopic and 9.7% (n = 18,366) robotic. Robotic surgery was associated with longer operative (128.33 ± 66.91 vs. 90.84 ± 52.07 min, p ≤ 0.001) and length of stay (1.84 ± 1.99 vs. 1.74 ± 1.86 days, p ≤ 0.001). Postoperative analysis showed higher rate of organ/spaces SSI (0.5% vs. 0.3%, p ≤ 0.001), sepsis (0.3%vs. 0.2%, p ≤ 0.001) 30-day readmissions (5.4% vs. 4.4%, p ≤ 0.001), and reinterventions (1.9% vs. 1.5%, p ≤ 0.001) in the robotic arm. However, robotic surgery was associated with less transfusions (0.5% vs. 0.7%, p = 0.002), and lower rate of superficial SSI (0.4% vs. 0.7%, p ≤ 0.001). Multivariate analysis confirmed these results.

Conclusion: Robotic BaS in the population with super obesity is associated with longer operative times and length of stay, higher incidence of postoperative infectious complications, and higher readmission/reintervention rates. Our results suggest that the advantage of robotic surgery in this context is only theoretical.

Short- and Long-Term Outcomes of Laparoscopy and Endoscopy Cooperative Surgery and Endoscopic Submucosal Dissection for Duodenal Tumors

Shuhei Komatsu, MD, PhD, FACS, Hiroshi Arakawa, MD, Keiji Nishibeppu, MD, PhD, Ryo Ishida, MD, Takuma Ohashi, MD, PhD, Hirotaka Konishi, MD, PhD, Atsushi Shiozaki, MD, PhD, Takeshi Kubota, MD, PhD, Hitoshi Fujiwara, MD, PhD, Eigo Otsuji, MD, PhD

Kyoto Prefectural University of Medicine, Kyoto, Japan

Introduction: Laparoscopy and endoscopy cooperative Surgery (LECS) was developed in Japan as an excellent surgical technique with both merits to minimize surgical margin and avoid the deformity. In this study, we aim to compare outcomes of duodenal LECS (D-LECS) and duodenal endoscopic submucosal resection (D-ESD) for superficial duodenal tumors and present our innovative techniques.

Methods: We retrospectively analyzed 113 patients between 2015 and 2020. We have mainly performed D-LECS which include the procedure of ESD followed by laparoscopic all layer suturing in more than 20 mm tumor, and D-ESD with or without mucosal clipping using OTSC (Over-The-Scope Clip) system in less than 20 mm tumor.

Results: We performed D-LECS for 13 and D-ESD for 100 patients. D-LECS was performed in larger tumors and 2nd, 3rd, 4th portion tumors. D-ESD group had significantly shorter operative time (D-ESD: 72 minutes vs. D-LECS: 367 minutes) and postoperative hospital stay (D-ESD: 5.4 days vs. D-LECS: 12.6 days) (P < 0.001) than D-LECS. However, D-ESD group had higher incidence of postoperative complications such as perforation, leakage and bleeding than D-LECS group (P = 0.033). Regarding long-term outcomes, there was no recurrence or death of the primary disease in both groups.

Conclusion: Although D-ESD is less invasiveness, D-LECS is useful to avoid the risk of complications in high-risk tumors such as large and 2nd to 3rd portion tumors.

Swallowing the Evidence: A Comparative Study of Postoperative Dysphagia in Anti-Reflux Surgery with Ineffective Esophageal Motility

Teagan Marshall, MD, Maria Alqamish, MD, Abhinay Tumati, MD, Benjamin Greenspun, MD, Hala Al Asadi, MD, Niloufar Salehi, MD, Brendan M Finnerty, MD, FACS, Thomas J Fahey III, MD, FACS, Rasa Zarnegar, MD, FACS

Weill Cornell Medical Center, New York, NY

Introduction: Concerns have historically existed regarding the risk of postoperative dysphagia following anti-reflux surgery (ARS), particularly in patients with ineffective esophageal motility (IEM). This study aimed to explore postoperative outcomes between patients with and without IEM, focusing on symptoms of dysphagia, as well as complications and reoperations.

Methods: A retrospective review of an institutional ARS database identified patients who underwent an index ARS procedure following preoperative manometry. Patients were classified as having normal esophageal motility (NEM) or IEM. Outcomes were analyzed early postoperatively (1-3 months), and at short-term (3-18 months) and long-term (beyond 18 months) follow-up.

Results: The cohort consisted of 373 NEM and 91 IEM patients, with a higher proportion of males in the IEM group (54.9% vs 37.3% p = 0.002). No other significant differences in demographics, surgical technique, or mesh use were found. No significant differences were observed between the two groups regarding reflux symptoms, complications, or reoperations across all follow-up intervals. Early postoperative new or worsening dysphagia was more common in IEM patients, but the increase was not statistically significant (NEM 15.4% vs. IEM 32.0%, p = 0.051). Similar nonsignificant trends were seen at short-term (NEM 21.4% vs. IEM 15.2%, p = 0.27) and long-term follow-ups (NEM 18.5% vs. IEM 16.5%, p = 0.81). Logistic regression confirmed that IEM and fundoplication type were not predictive of postoperative dysphagia.

Conclusion: IEM criteria is not a strong predictor of postoperative dysphagia after ARS and should not deter clinicians from considering surgery. Future studies should consider refinement of manometric parameters that best correlate with postoperative outcomes.

The Efficacy and Side Effects of Orbera 365 12 Months Intragastric Balloon: A Retrospective Analysis of a Prospectively Maintained Database

Sara Adham, BSc, Muhammed A Memon, MBBS, FRACS, FRCSI, FRCSEd, FRCSEng, FACS, FRCSEng, FACS

University of Queensland, Brisbane, Australia; University of Southern Queensland, Toowoomba, Australia

Introduction: Intragastric balloon (IGB) therapy is a minimally invasive endoscopic method for weight reduction. Orbera 365 IGB in Australia which has been approved for 12 months intragastric placement, therefore, providing longer assistance to the patients in weight reduction. The aim of this study was to investigate its efficacy and side effect profile.

Methods: Ninety-four consecutive patients undergoing Orbera 365 IGB placement between August 2020 and September 2023 were retrospective analyzed from a prospectively maintained databases. Monthly consultations in the clinic were undertaken and TANITA body composition analyzer was used for recording various parameters such as weight, BMI, fat percentage, fat mass, muscle mass etc., to determine patients’ progress. Furthermore, any side effects such ongoing nausea, vomiting etc. were also noted.

Results: Pre-insertion mean weight and BMI were 236 lb and 37.5 respectively. At 6 months, the mean weight decreased to 210 lb, and the BMI was 33.1. At 12 months, the mean weight was 213 lb and the BMI was 33.7. Upon removal of the IGB, the mean total body weight loss was 22 lb and the BMI decreased by 3.8. Twenty-two patients underwent early removal of IGB due to ongoing nausea, vomiting and reflux, and the remaining 10 requested voluntary removal. In the remaining 62 patients, the side effects were short lived (48 hours) and controlled with antiemetics and antispasmodics.

Conclusion: A 12-month endoscopic placement of the Orbera 365 balloon is a safe and effective method for reducing moderate amount of weight in obese patients who are not keen on resectional bariatric surgery.

The Impact of Area Deprivation Index on Bariatric Surgical Outcomes

Justine Chinn, MD, Madeline Adams, MD, Kayla R Kulhanek, BA, Jason X Shen, BS, Lakshika Tennakoon, MSc, MPhil, Sebastiano Bartoletti, MD, Dan E Azagury, MD, FACS, Micaela Esquivel, MD, FACS

Stanford University, Stanford, CA

Introduction: Though bariatric surgery reduces obesity-related morbidity and mortality, it requires extensive preoperative education. Since the COVID pandemic, our academic medical center shifted to an entirely virtual practice. Due to potential difficulties in virtual education, we aimed to assess outcomes for socioeconomically disadvantaged patients. Our goal was to compare outcomes for this group using Area Deprivation Index (ADI), a marker for income, education, employment and housing quality.

Methods: We analyzed data from 681 patients who underwent bariatric surgery between 2018-2022. We used a chi2 test and student’s t-test to compare the outcomes between patients with virtual vs. in-person care stratified by ADI quartile (with a ranking of 100 indicating the highest level of disadvantage). Significance was set at P < 0.05.

Results: 332 (48.8%) patients were seen and educated in person and 349 (51.2%) through telehealth. There were 604 (88.7%) patients within ADI quartile 0-25, 53 (7.8%) within quartile 26-50, 21 (3.1%) within quartile 51-75, and 3 (0.4%) within quartile 75-100. There was no significant difference in weight loss at 1 year, emergency department visits, or readmissions within 30 days between in-person and telemedicine groups when compared within each ADI quartile.

Conclusion: Bariatric surgery patients with preoperative telemedicine care had comparable outcomes in weight loss and postoperative complications compared to in-person visits, regardless of ADI quartile. However, most of our patients undergoing bariatric care come from relatively advantaged neighborhoods. This suggests our institution needs to make active efforts to expand access to disadvantaged groups.

The Influence of Age on Weight Regain after Sleeve Gastrectomy & Roux-en-Y Gastric Bypass

Kayla Switalla, BS, Madi Sundlof, BA, Charles Quinn, BS, Eric S Wise, MD, FACS, Daniel Leslie, MD, FACS, Sayeed Ikramuddin, MD, FACS

University of Minnesota Medical School, Minneapolis, MN; University of Minnesota Department of Surgery, Minneapolis, MN

Introduction: With escalating obesity rates, bariatric surgery remains the most effective option for weight loss. Yet its efficacy in older patients is debated given doubts about sustained weight loss. Despite this, there has been a rise in bariatric surgeries among older patients. However, there is limited research on weight regain after bariatric surgery in older compared to younger patients. Therefore, we evaluated how age influences weight regain after bariatric surgery.

Methods: We retrospectively analyzed an institutional database of patients ≥18 years old who underwent sleeve gastrectomy or Roux-en-Y gastric bypass between 2011-2020. The primary outcome was significant weight regain from nadir weight, assessed two years post-surgery. Significant weight regain was defined as regaining ≥10% of the total weight lost since surgery.

Results: We identified 1,131 patients with baseline and follow-up weight data. The frequency of follow-up was 94.9%, and average weight regain was 4.5%. There was no difference in follow-up rates for patients ≥60 years old and those <60 years (98.3% versus 94.5%, p = 0.071). Adjusted multivariable logistic regression revealed no significant difference in the odds for significant weight regain in patients ≥60 years old compared to younger patients (OR 1.1, 95% CI 0.8-1.7, p = 0.527).

Conclusion: Older patients exhibit weight regain patterns similar to younger patients two years following surgery, suggesting that concerns regarding sustained weight loss in this population may not be solely attributed to age-related factors. These findings highlight the importance of adopting a multifaceted approach to weight management post-surgery, emphasizing the need to consider factors beyond age alone.

To Collis or Not to Collis: Robotic Surgery Predicts Needs for Collis Gastroplasty during Hiatal Hernia Repair

Harry Wong, MD, MS, Rushil Rawal, BS, Danny Shouhed, MD, Kulmeet Sandhu, MD, FACS, Harmik J Soukiasian, MD, FACS, Miguel A Burch, MD, FACS

Cedars-Sinai Medical Center, Los Angeles, CA

Introduction: The advent of robotic surgery has introduced distinct advantages in foregut operations. Despite complete mediastinal dissection, Collis gastroplasty (CG) is occasionally necessary to address the short esophagus during hiatal hernia repair (HHR). Our objective was to identify predictors of CG during minimally invasive HHR.

Methods: A retrospective review of a gastroesophageal database was performed including all patients who underwent laparoscopic or robotic HHR and fundoplication with or without CG from 2013 to 2021 at a single institution. Univariate and multivariate logistic regression were used to identify predictors for CG at the time of the operation.

Results: Of 309 patients included in the analysis, 146 (47.3%) underwent robotic HHR and 93 (30.1%) underwent CG. On univariate analysis, large hiatal hernia size on upper GI (OR 1.81, 95% CI 1.25-2.61, p < 0.01), hiatal hernia size on endoscopy (OR 1.35, 95% CI 1.14-1.60, p < 0.01) and Barrett’s esophagus (OR 3.00, 95% CI 1.12-8.01, p = 0.03) were positive predictors of CG while robotic approach was a negative predictor for CG (OR 0.50, 95% CI 0.30-0.83, p < 0.01). On multivariate logistic regression analysis, adjusting for potential confounders, robotic approach (OR 0.24, 95% CI 0.06-0.88, p = 0.03) and hiatal hernia size on endoscopy (OR 1.71, 95% CI 1.22-2.38, p < 0.01) remained as significant independent predictors for CG.

Conclusion: Our study identified robotic surgery among other factors to be significant predictors of CG during hiatal hernia repair, emphasizing the importance of tailored operative approach and preoperative planning to optimize patient outcomes.

Transforming Clinical Care: The Emergence of Ambulatory Bariatric Surgery for Patients with Obesity

Lakshika Tennakoon, MD, MPhil, Justine Chinn, MD, Micaela Esquivel, MD, FACS

Stanford University, Stanford, CA

Introduction: Bariatric surgical (BS) procedures are increasingly being completed at Ambulatory Surgical Centers (ASC). The American College of Surgeons has established clinical standards for treating less severe morbidly obese patients at ASC nationally. We aimed to examine the demographic characteristics, BS procedures, and healthcare encounters of patients with obesity who utilize ambulatory surgery centers.

Methods: We utilized the Nationwide Ambulatory Surgery Sample (NASS) 2020 to analyze data for patients ≥18 years old with obesity, identified through ICD-10-CM codes. The primary outcome was bariatric surgery ascertained by Current Procedural Terminology (CPT) codes. Weighted data was employed to generate national estimates.

Results: A total of 438,540 obesity patients were identified, 1% (4,035) underwent bariatric surgical procedures, while 99% (434,505) patients did not. Patients who underwent BS were younger (45 vs. 52 years, p < 0.001), predominantly females (83% vs 32%, p < 0.001), and more likely to have private insurance (66% vs. 51%, p < 0.001). The majority of patients who underwent BS procedure were discharged home on the same day (98% vs.94%, p < 0.001) and were primarily treated at urban teaching hospitals (97% vs 90%, p = 0.02). Adjusted analyses indicated significantly higher odds of BS procedures among females (aOR 2.0, p < 0.001) and those with Private insurance (aOR 4.8, p < 0.001).

Conclusion: Our analyses identified significant disparity in the utilization of bariatric surgery at ASC. The majority of BS patients were female, had Private insurance, and were discharged on the same day. These findings underscore the need for further investigation into factors influencing access to bariatric surgery at ambulatory surgery centers.

Trends in Open, Laparoscopic, and Robotic Bariatric Surgery Utilization in North America from 2015 to 2022

Scott Mu, MD, MHS, Moamena El-Matbouly, MD, FACS, Alan A Saber, MD, MS, FACS

Rutgers New Jersey Medical School, Newark, NJ; Newark Beth Israel Medical Center, Newark, NJ

Introduction: Approaches to bariatric and metabolic surgery continue to evolve, and so we sought to understand the trends in case volume and surgical approach of the most commonly performed bariatric operations in North America.

Methods: We used the MBSAQIP-PUF from 2015 to 2022 to calculate the relative proportion of open, laparoscopic, and robotic non-endoscopic operations per year by operation. We tested for trends in case volumes with Mann-Kendall tests and calculated the changes in absolute case volume and proportion per approach using Sen’s slope. We also investigated whether or not these trends were similar for primary bariatric operations versus revisional cases.

Results: 1,553,671 non-endoscopic bariatric operations were recorded from 2015 to 2022 and bariatric case volumes increased by 6,755 cases per year (95% CI: 2,047 to 13,113, p = 0.019). The proportion of cases performed laparoscopically decreased from 93% in 2015 to 69% in 2022, and robotic cases increased from 5.9% in 2015 to 30.5% in 2022. Robotic utilization increased for all considered procedures, with the greatest increases seen in SADI at 6.5% yearly increase and RYGB at 3.5% yearly increase. Revisional robotic bariatric surgery accounted for 1.8% of recorded cases and saw 8-fold growth from 2015 to 2022 (1,040 to 8,297), whereas primary robotic bariatric surgery saw 7-fold growth (from 8,758 to 61,454).

Conclusion: Bariatric surgery case volume continues to increase in North America. The robotic approach is becoming increasingly common, with the greatest increases seen in revisional surgery and anastomotic procedures such as SADI and RYGB.

© 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.
Bariatric and Foregut : Journal of the American College of Surgeons (2025)
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