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Background Some bariatric procedures have been associated with increased gastroesophageal reflux disease (GERD) symptoms; however, there are limited data on the long-term changes to the esophagus across bariatric procedures, and how preoperative esophageal disease is impacted by bariatric surgery. Objectives To estimate incidence of GERD, esophagitis, Barrett's esophagus, and esophageal adenocarcinoma before and after bariatric surgery and to identify potential risk factors for these conditions. Setting Retrospective analysis of New York State Database (SPARCS). Methods Adult patients undergoing bariatric surgery (Roux-en-Y gastric bypass, adjustable gastric banding, laparoscopic sleeve gastrectomy, and biliopancreatic diversion) from 1995 to 2010. Multivariable Cox proportional hazard models were used to examine the association between preoperative diagnosis, surgery type, and postoperative diagnosis. Results A total of 48,967 records were analyzed; 30.3% had a diagnosis of GERD at the time of surgery and .4% had a diagnosis of esophagitis and Barrett's. Preoperative GERD/esophagitis/Barrett's was associated with higher risk of GERD, esophagitis, and Barrett's, but not esophageal adenocarcinoma, postoperatively. Roux-en-Y gastric bypass patients had lowest risk of being diagnosed with GERD postoperatively. Overall, esophageal adenocarcinoma incidence in the sample was .04%; the rate among patients with preoperative GERD and Barrett's was .1% and .9%, respectively. Incidence of esophageal adenocarcinoma did not differ by bariatric surgery type. Conclusions Preoperative diagnosis is a risk factor for postoperative esophageal disease after bariatric surgery. Adjustable gastric banding and laparoscopic sleeve gastrectomy are associated with higher risk of postoperative GERD and esophagitis compared with Roux-en-Y gastric bypass. Incidence of esophageal adenocarcinoma did not differ by surgery type.

Background Gut microbiota may induce obesity, diabetes, and metabolic syndrome. Different weight reduction programs may induce different changes in gut microbiota. Objectives To assess the changes in gut microbiota between obese adults who participated in 2 different weight reduction programs, the dietary counseling (DC) group and sleeve gastrectomy (SG) group, for 3 months. Setting A University Hospital. Methods Ten obese participants from each group were matched according to sex, age, and body mass index. Gut microbiota compositions were determined by metagenomics using next-generation sequencing before and after treatment. Anthropometric indices, metabolic factors, and gut microbiota were compared between and within groups. Results After 3 months of treatment, compared with subjects in DC group, subjects in SG group experienced a greater reduction in body weight, body mass index, body fat, waist and hip circumference, diastolic blood pressure, hemoglobin, insulin, insulin resistance, glutamate pyruvate transaminase, blood urine nitrogen, and glycated hemoglobin (HbA1C). A total of 8, 17, and 46 species experienced significant abundance changes in DC, in SG, and between the 2 groups, respectively. Diversity of the gut flora increased in SG and between the 2 groups after treatment. The weight change over the course of the weight loss program was further adjusted and only 4 species, including Peptoniphilus lacrimalis 315 B, Selenomonas 4 sp., Prevotella 2 sp., and Pseudobutyrivibrio sp., were found to be significantly different between the 2 weight loss programs. These 4 species may be the different gut microbiota change between internal and surgical weight reduction programs. Conclusions There are significant differences not only in anthropometric indices and metabolic factors but also in gut microbiota change between the 2 programs.

Background Obesity is a significant health problem and additional therapies are needed to improve obesity treatment. Objective Determine the efficacy and safety of a 6-month swallowable gas-filled intragastric balloon system for weight loss. Setting Fifteen academic and private practice centers in the United States. Methods This was a double-blind, randomized sham-controlled trial of the swallowable gas-filled intragastric balloon system plus lifestyle therapy compared with lifestyle therapy alone for weight loss at 6 months in participants aged 22 to 60 years with body mass index 30 to 40 kg/m2, across 15 sites in the United States. The following endpoints were included: difference in percent total weight loss in treatment group versus control group was >2.1%, and a responder rate of >35% in the treatment group. Results Three hundred eighty-seven patients swallowed at least 1 capsule. Of participants, 93.3% completed all 24 weeks of blinded study testing. Nonserious adverse events occurred in 91.1% of patients, but only .4% were severe. One bleeding ulcer and 1 balloon deflation occurred. In analysis of patients who completed treatment, the treatment and control groups achieved 7.1 ± 5.0% and 3.6 ± 5.1% total weight loss, respectively, and a mean difference of 3.5% (P = .0085). Total weight loss in treatment and control groups were 7.1 ± 5.3 and 3.6 ± 5.1 kg (P Conclusions Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.

Data regarding gender disparities in surgeon case volumes across subspecialties is sparse.Through the use of the New York SPARCS database, top 25 yearly performers of major surgical procedures were identified for each year from 2000 to 2014. Gender and academic affiliation was determined.Breast surgery had the highest number (51.6%) of female top performers by surgical volume. Higher number of female surgeons in bariatric and breast surgery were associated with academic institutions (p 0.001). Significantly higher number of female plastic surgeons were associated with community institutions (p = 0.02). While there was an increase in female top performers during the study period, the number of female top performing surgeons remained disproportionately low compared to male top performing surgeons. There were no female surgeons among the top performers in vascular, orthopedics, cardiac, and urology during the studied period.There is a gender disparity in surgeon case volumes. While some subspecialties showed some increase in female top performers, the majority remained male-dominated fields during the fifteen-year period.

Background Bariatric surgery predisposes patients to development of cholelithiasis, and therefore the need of a subsequent cholecystectomy; however, the incidence of cholecystectomy after bariatric surgery is debated. Objective The purpose of our study is to assess the incidence of cholecystectomy after 3 of the most common bariatric procedures. Setting University Hospital, involving a large database in New York State. Methods The Statewide Planning and Research Cooperative System administrative longitudinal database was used to identify all patients undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB) between 2004 and 2010. Through the use of a unique identifier patients were followed to evaluate for the need of a subsequent cholecystectomy over at least 5 years. Cox proportional hazard regression analysis was used to identify risk factors for subsequent cholecystectomy. Results During this time period, there were 15,301 LAGB procedures, 19,996 RYGB, and 1650 SG. There were 989 (6.5%) patients who underwent cholecystectomy after LAGB, 1931 (9.7%) patients after RYGB, and 167 (10.1%) after SG. Approximately one quarter of follow-up cholecystectomies were performed at the same institutions. LAGB and RYGB were less likely to have a subsequent cholecystectomy compared with SG (hazard ratio .5, 95% confidence interval .4–.6 for LAGB; and hazard ratio .7, 95% confidence interval .6–.9 for RYGB). Risk factors for a subsequent cholecystectomy included age, sex, race, and some co-morbidities and complications (P Conclusion The rate of cholecystectomy after LAGB, RYGB, and SG was 6.5%, 9.7% and 10.1%, respectively. Patients should be counseled preoperatively about this risk and biliary prophylaxis should be contemplated.

The relationships between industry and medical professionals are controversial. The purpose of our study was to evaluate surgeons' current opinions regarding the industry-surgery partnership, in addition to self-reported industry ties.After institutional review board approval, a survey was sent via RedCap to 3,782 surgeons across the United States. Univariate and multivariable regression analyses were performed to evaluate the responses.The response rate was 23%. From the 822 responders, 226 (27%) reported at least one current relationship with industry, while 297 (36.1%) had at least one such relationship within the past 3 years. There was no difference between general surgery versus other surgical specialties (P = .5). Among the general surgery subspecialties, respondents in minimally invasive surgery/foregut had greater ties to industry compared to other subspecialties (P = .001). In addition, midcareer surgeons, male sex, and being on a reviewer/editorial board were associated with having industry ties (P .05). Most surgeons (71%) believed that the relationships with industry are important for innovation.Our study showed that relationships between surgeons and industry are common, because more than a quarter of our responders reported at least one current relationship. Industry relations are perceived as necessary for operative innovation.

Controversy exists regarding the relevance of Center of Excellence accreditation to bariatric surgery outcomes. The objective of this study was to evaluate the impact of national hospital accreditation on perioperative and long-term outcomes following bariatric surgery.Retrospective, longitudinal study using 2004-2010 data from the New York Statewide Planning and Research Cooperative longitudinal administrative database (n = 47,342). Multivariable logistic regression analyzed outcomes following laparoscopic bariatric surgery. Accredited hospitals and accreditation year were identified from the Centers for Medicaid and Medicare website. Outcomes were analyzed with and without temporal correlation to accreditation year.30-day mortality was determined from social security death records.Risk of perioperative morbidity OR 1.4 (range 1.2-1.6, P.001), mortality OR 2.6 (range 1.3-5.4, P = .01) and all-cause long-term mortality OR 1.4 (range 1.2-1.7, P = .0002) were significantly increased in unaccredited versus accredited hospitals on univariate analysis. In accredited hospitals, significant changes in payor and patient mix, operation, perioperative, and long-term outcomes were demonstrated following accreditation. A significant decrease in operations performed on black patients, Hispanic patients, and Medicare patients was also identified. Controlling for patient demographics, co-morbidity, insurance, and operative procedure, multivariable logistic regression demonstrated accreditation as independently associated with fewer major complications versus unaccredited hospitals OR 0.72 (range .63-.83, P.001) and within the same hospital following accreditation OR .86 (range 0.77-0.96, P = .01). Following multiple cox proportional hazard model analysis, long-term mortality differences were not significant.In New York State, bariatric hospital accreditation improved patient outcomes as compared to unaccredited hospitals and within the same hospital compared to preaccreditation. Significant changes were identified for some underserved at-risk populations. Measures to ensure equitable health care for at-risk populations following institutional accreditation are imperative.

Background There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent increase in number of weight reduction surgeries in these individuals. As a result, special attention needs to be paid to potential postsurgical complications during pregnancy, particularly after Roux-en-Y gastric bypass (RYGB). We are presenting our small case series and our suggestions for management for the pregnant bariatric patient. The aim of this study is to review our institutional experience and present our algorithm to approach pregnant women presenting with abdominal pain and/or emesis after RYGB. Methods After Institutional Review Board approval, a retrospective chart review was performed at a single center institution between 2010 and 2013. Data regarding clinical presentation, physical exam findings, laboratory values, radiographic studies, intraoperative findings, and clinical outcomes of both mother and fetus were collected and reviewed for pregnant patients with history of RYGB and abdominal distress. Results Five patients were identified. Patient age ranged from 22–34 years (mean 28.4). Gestational age ranged from 9–31 months (mean 19.2). Average body mass index at presentation was 30.3 kg/m 2 . Of the 5 patients, 4 presented with abdominal pain and one with intractable emesis. Four patients were taken to the operating room. One was successfully discharged. Two of the patients had an obstruction from adhesions, and the other 2 were found to have internal hernia. There was no mortality for either fetus or mother. One patient required premature delivery at 28 weeks. Conclusions Pregnant women with history of RYGB who present with abdominal pain should be evaluated urgently for internal hernia or obstruction. A systematic approach is needed to ensure prompt diagnosis.

Background Many new techniques and bariatric endoluminal procedures are being developed and used for the treatment of obesity. Clear guidelines or opinions of the new techniques are not readily available. The aim of this study was to gauge the level of interest and opinions of bariatric surgeons regarding these new techniques, using online and real poll surveys. Methods The American Society for Metabolic and Bariatric Surgery (ASMBS) Emerging Technologies committee developed a questionnaire that was distributed among the membership and conducted a live poll of attendees at Obesity Week 2013. Opinions of new technologies and techniques by practitioners were assessed. Results A total of 134 responses to the questionnaire were returned. Most responses (79%) expressed the belief that new bariatric techniques are needed to improve the practice of bariatric and metabolic surgery. The responses describing the effects of new procedures and technology as beneficial were (1) increased interest from patients or referring physicians (94%), (2) expanded indications for intervention (93%), and (3) lower risk intervention (96%). Nearly all respondents (90.2%) identified value in informational guidelines on new technologies and procedures, and most (88.7%) agreed that the ASMBS should coordinate clinical trials or registries to evaluate these therapies. Conclusion Although most bariatric and metabolic surgeons agree that new endoluminal surgical techniques are beneficial, most also are unable to offer the procedures to their patients without more clinical evidence and clear guidelines from the society.

Background Weight recidivism after Roux-en-Y gastric bypass (RYGB) is a challenging problem for patients and bariatric surgeons alike. Traditional operative strategies to combat weight regain are technically challenging and associated with a high morbidity rate. Endoluminal interventions are thus an attractive alternative that may offer a good combination of results coupled with lower periprocedure risk that might one day provide a solution to this increasingly prevalent problem. The purpose of this article is to systematically review the available literature on endoluminal procedures used to address weight regain after RYGB, with specific attention to the safety profile, efficacy, cost, and current availability. This review focuses only on endoluminal procedures that are performed for weight regain after RYGB, as opposed to primary endoluminal obesity procedures. Methods This study was a retrospective review. Results Several methods of endoluminal intervention for weight regain are reviewed, ranging from injection of inert substances to suturing and clipping devices. The literature review shows the procedures on the whole to be well tolerated with limited efficacy. The majority of the literature is limited to small case series. Most of the reviewed devices are no longer commercially available. Conclusions Endoluminal therapy represents an intriguing strategy for weight regain after RYGB. However, the current and future technologies must be rigorously studied and improved such that they offer durable, repeatable, cost-effective solutions.

Over the past few decades, advancements in minimally invasive surgery techniques have made surgical management of gastroesophageal reflux diseases increasingly popular. More recently, the field of minimally invasive surgery has experienced a natural evolution towards a reduction in the invasiveness of surgery and even in the number of abdominal access incisions. In fact, single site/access approaches have been successfully applied to a number of common minimally invasive surgery procedures including cholecystectomy, hysterectomy, colectomy, bariatric and even anti-reflux surgery. However, there is very little published data on the application of this technique in anti-reflux surgery. We present a brief review of available data as well as a summary of our experiences with this innovative approach to minimally invasive foregut surgery.

The consistency of the predictions using the formulas of Aldrich et al1 is dependent on the stability of the ST-segment deviations. In the present study, it was determined that 2 3 of patients were in a period of ST-segment stability, and 1 3 of patients were in a period of ST-segment lability. The clinical decision regarding reperfusion therapy will typically be made on the basis of the appearance of the initial ECG. Continuous ST-segment monitoring during the time required to administer this therapy should determine whether the individual patient is in the stable majority or the labile minority. In a study by Hackett et al7 of 38 patients with acute pain and ST-segment elevation, 8 had documented ST-segment lability before thrombolytic therapy. Because such transient episodes cannot be determined from a single ECG, continuous ST-segment monitoring should be used until the ST segments remain sufficiently stable for the application of the formulas. A further study is required to identify the length of ST monitoring time required to determine the stability of ST-segment deviation in individual patients.

were no significant differences between active and sedentary (BMI in kg / m2 1⁄4 43.5 5.4 vs 42.5 5.2, respectively), demonstrating that individuals who underwent activities for more than 30 minutes 5 times a week showed no significant difference in body weight and BMI compared to sedentary. Conclusion: The results showed that even patients considered active do not showed significant differences in BMI compared to sedentary, proving the inefficiency of the current practices of physical activity for weight loss. Thus, it is essential to review the current concepts regarding prescription of continuous long-term aerobic exercise aimed at weight loss in obese individuals, especially those undergoing bariatric surgery.

Introduction: Radiographic imagingwith CT scan in patients presentingwith acute abdominal pain following Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD/DS) is becoming commonplace. While surgical exploration remains the gold standard for diagnosing internal hernia, decisions for operative intervention are often based on CT findings. The accuracy of CT scan to reliably identify internal hernia in this subset of patients remains unknown. The purpose of this study is to evaluate the reliability of CT scan as a diagnostic tool to identify internal hernia (IH) in bariatric patients with acute abdominal pain. Methods: Following institutional review board approval, a retrospective chart review of all patients presenting with symptoms concerning for obstruction following Roux-en-Y gastric bypass or BPD/DS switch was performed. Patients without CT scans were excluded. Fifty two patients who underwent an operation for a suspected internal hernia from 2008-2013 were identified from surgeons' records at 2 institutions. CT and intraoperative findings were compared via univariate statistical analysis. Patients with incidental finding of a hernia defect were excluded. Results: Of the 52 patients, 50 had previous RYGB and 2 BPD/DS. There was a higher number of female patients in this population (Table 1). Mean time to presentation was 5 years following initial bariatric procedure (5 months to 14 years). Of the 52 patients, 27 had IH at operation. Thirty one (60%) patients had CT scans read as positive for IH and/or obstruction. Of these 31, 21(68%) were found to have IH at operation and 10 (32%) underwent negative diagnostic laparoscopy. Of the 21 patients with negative CT scans, 6 (29%) had IH at operation versus 15 (71%) who were negative. The sensitivity of CT scan to identify IH and/or obstruction is 78% with 95% CI [57% to 91%], specificity is 60% with 95% CI [39%-78%], positive predictive value is 68% with 95% CI [49%-83%], and negative predictive value is 71% with 95% CI [48%-88%]. Kappa statistics comparing the agreement between CT findings and operative findings was 0.380 with 95 CI 0.131-0.629, which was consistent with fair agreement. Conclusions: This study examined the utilization of CT scans in detection of internal hernias. Positive CT scan is highly predictive of IH, but not specific. As CT scan will not detect IH in 1:4 patients, despite negative findings surgical exploration should remain the gold standard for patients with acute abdominal pain following RYGB or BPD when IH cannot be ruled out.