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Introduction: This study aims to investigate the influence of the Affordable Care Act (ACA) on the utilization of Roux-en-Y gastric bypass (RYGB) procedures in Maryland., Methods: Using the Maryland State Inpatient Database, this retrospective study compared all patients undergoing RYGB during the pre-ACA (2007-2009) and post-ACA (2018-2020) periods, including patient demographic factors, pre-existing conditions, and socioeconomic factors., Results: A total of 16,494 RYGB procedures were performed during the study period, of which 12,089 (73.3 ​%) were post-ACA. This was a 179.2 ​% increase in patients undergoing RYGB post-ACA; nearly triple that of the pre-ACA period. There was a significant decrease in uninsured patients (5.6 ​%-1.5 ​%, p ​< ​0.01) an increase in Black patients (32.1 ​%-46.8 ​%, p ​< ​0.01) and Medicaid beneficiaries (6.0 ​% pre-ACA to 17.8 ​% post-ACA, p ​< ​0.01). There were significant reductions in adverse outcomes (long hospital stays, hemorrhage, GIT leaks, and mortality) across all insurance types (all p ​< ​0.01)., Conclusion: The ACA increased access to RYGB procedures, especially in Black and Medicaid recipients in Maryland, enhancing healthcare across all insurance types., Competing Interests: Declaration of competing interest We have no conflicts of interest to disclose. During the preparation of this work the authors did not use AI programs for any reason beyond checking grammar, spelling, and references., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Obesity is a global epidemic that has been increasing in prevalence. The only treatment method for durable weight loss is bariatric surgery. The aim of this study was to observe trends in usage and outcomes of bariatric operations used in the United States from 2008 to 2012., Methods: Analysis was performed on bariatric surgery admissions from 2008 to 2012 based off of the Nationwide Inpatient Sample database. Data were selected from using International Classification of Disease, 9th Revision codes correlating to bariatric procedures for the purpose of obesity. Annual estimates and trends were reviewed for patient demographics, procedure type, patient outcomes, and length of stay (LOS)., Results: A total of 598,756 bariatric procedures were examined. Laparoscopic gastric bypass was the most commonly used surgical method in 2008 (58.2%). A decreasing trend in its use, and the use of laparoscopic gastric banding (LGB), was equipoised with increasing use of laparoscopic sleeve gastrectomy (LSG). Use of LSG accounted for 8.2% of procedures in 2011 and 39.6% in 2012. LGB and LSG had the lowest rates of complications, in-hospital morbidity and mortality, and the shortest LOS whereas open bypass and duodenal switch had the highest rates of complications, in-hospital morbidity and mortality, and longest LOSs. Overall rates of venous thromboembolism increased from .08% in 2008 to .215% in 2012. Respiratory complications decreased from 6.1% to 3.9%. There were no observed trends in rates of renal complications, visceral injury, bleeding, and infections. In-hospital morbidity decreased, whereas mortality rates were stable at .1%., Conclusions: The utilization of bariatric procedures has reached a plateau in the United States. Changes in the composition of procedural types suggest that LSG has become a popular alternative to gastric bypass and LGB., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: With the advent of clinical fellowships in general surgery, there has been a continual debate over the effect on general surgical resident training. Will a fellowship interfere with a chief resident's experience or case volume? The aim of this study was to test the hypothesis that the presence of an advanced laparoscopic fellow in a tertiary care hospital and residency has had no deleterious effect on chief resident laparoscopic case volume., Methods: The operative case logs of graduating residents and fellows from 2001 to 2011 were reviewed, focusing on laparoscopic basic and complex cases and comparing between those 2 groups and comparing residents' case numbers with the national average published by the Accreditation Council for Graduate Medical Education., Results: Residents graduating from 2001 to 2011 (4-6 chief residents per year) performed an average of 989 ± 76.2 laparoscopic cases per graduating chief class, with each chief averaging 207.7 ± 10.7. The average number of laparoscopic basic cases per graduating chief year was 555.3 ± 42.1, with each chief averaging 116.2 ± 4.9. The average number of laparoscopic complex cases per graduating chief year was 434.4 ± 39.2, with each chief averaging 91.5 ± 7.2. Over the same period of time (1 or 2 fellows per year), fellows performed an average of 336 ± 23.3 cases per year. When comparing residents' total average cases with the national data, the residents performed a similar number of cases (209.9 ± 11.9 vs 195.0 ± 19.5, P = .53). When comparing years when there were 2 clinical fellows vs years with 1 fellow, there was no change in the total number of laparoscopic cases per chief (224.2 vs 195.6, P = .26) and no change in the number of complex laparoscopic cases (97.1 vs 88.7, P = .63). There was a significant difference for basic laparoscopic cases, with a slight decrease when there were 2 fellows (127.8 vs 106.9, P = .04)., Conclusions: A laparoscopic fellowship has not had an adverse impact on the complex or basic laparoscopic case experience of surgical residents. In a busy academic practice, laparoscopic fellowships and general surgical residency can coexist., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Revisional bariatric surgery may be necessary due to inadequate weight loss or postoperative complications of the primary operation. We sought to identify the reasons for revision, characteristics of the surgery, and outcomes. We hypothesize that revisional surgery, although technically challenging, can produce desirable outcomes., Methods: Patients undergoing bariatric surgery at our institution between 1998 and 2007 were reviewed from a prospective database. Patients who had revisional surgery were compared to those who had primary surgery., Results: We have identified 46 of 1,038 patients who underwent revisional surgery. Twenty of 46 had a primary Roux-en-Y gastric bypass. The most common indication for revisions is inadequate weight loss secondary to gastrogastric fistula (15/20). Leaks occurred more frequently following revisional surgeries (11% vs 1.2%), but intensive care unit (ICU) utilization was less (11% vs 4.4%) and mortality was lower (0% vs .3%) with bariatric revision surgery., Conclusions: Although we saw a 9-fold increase in leaks, a 2-5 fold increase in ICU utilization, and 1.5-fold increase in length of stay, our mortality rate was zero. In experienced hands, bariatric revision surgery can be performed to produce desirable outcomes.

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has a reported learning curve of 100 cases. Robotic-assisted surgery decreases the learning curve in complex laparoscopic surgeries. We hypothesize that robotic-assisted, hand-sewn gastrojejunostomy during a LRYGB will improve results during the initial 100 cases when compared with the literature., Methods: Our first 100 robotic-assisted gastrojejunostomies performed during LRYGB were reviewed from a prospective database. Patient demographics, operative times, length of stay, reoperations, anastomotic leak, pulmonary embolus, and death were all evaluated., Results: The mean age and body mass index were 42 and 50, respectively. Operative times ranged from 148 minutes to 437 minutes (mean = 254). There were no leaks or deaths. Four patients had complications, including reoperation (1), incisional hernia (1), pulmonary embolus (1), and recurrent umbilical hernia (1)., Conclusions: Robotic-assisted LRYGB is feasible and safe, as evidenced by the excellent outcomes from this series during the initial learning curve for LRYGB.

Background: The epidemic of morbid obesity has increased bariatric procedures performed. Trend analyses provide important information that may impact individual practices., Methods: Patient data from 137 surgeons were examined from 1987 to 2004 (41,860 patients) using Cochran-Armitage Trend test and Generalized Linear Model., Results: Over an 18-year period, surgeon preference for combined restrictive-malabsorptive procedures increased from 33% to 94%, while simple gastric restriction decreased correspondingly (P < .0001). Surgeons per worksite doubled and cases per surgeon increased 71%. Laparoscopic procedures increased to 24%. The percentage of males, mean operative age, and initial body mass index (BMI) increased significantly (P < .0001). Postoperative hospital stay decreased from 5.0 to 3.9 days (P < .0001). The most common procedure in 2004 was Roux-en-Y gastric bypass (RYGB) (59%)., Conclusion: Bariatric surgery patients are now older and heavier, length of stay is shorter, and the laparoscopic approach is more frequent. From 1987 to 2004, the general trend shows a clear preference for combined restrictive-malabsorptive operations.

Background: Failure to lose weight or intractable symptoms after bariatric surgery presents a complex diagnostic and management challenge. The outcome of a standardized surgical approach to this problem has not been well described. Conversion of failed bariatric procedures to a resectional gastric bypass (RGB) can achieve symptomatic relief and acceptable weight loss., Methods: We reviewed all patients in a prospectively maintained database who underwent reoperative bariatric surgery over a 4-year period. Reoperative patients (RO) were case-matched (by age, body mass index, and comorbidities) in a 1:2 ratio with control patients undergoing an initial bariatric procedure (IN)., Results: Twenty-seven reoperative patients and 54 case-matched control patients were identified. Mean body mass index was 42 in the RO group versus 45 in the IN group (P = not significant). Indications for conversion were weight gain (89%), dysphagia/emesis (30%), esophagitis (19%), and marginal ulcer (7%). All patients in both groups underwent RGB (subtotal gastrectomy with Roux-Y gastrojejunostomy). Compared with IN patients, the RO patients had significantly longer operative times (420 versus 268 minutes), greater blood loss (650 versus 315 cc), longer time to oral intake (3.1 versus 2.2 days), and longer hospital stays (6.5 versus 4.7 days), all P <0.01. There were no deaths or anastomotic leaks in either group. Excess body weight lost at 6 months was 46% for RO versus 54% for IN (P = 0.02). One-year excess weight lost was 71% for RO versus 77% for IN (P = not significant). All RO patients achieved symptomatic relief, and no patient required further bariatric revision. There was significant improvement in weight-related comorbidity in each group., Conclusions: Conversion of failed bariatric procedures to RGB, although technically demanding, resulted in relief of presenting symptoms, significant 6-month and 1-year weight loss, and improvement of major comorbidities. Conversion of failed bariatric procedures to resectional gastric bypass can achieve results comparable with those of patients undergoing an initial bariatric procedure.