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Background: Periampullary malignancies are often unresectable tumors that frequently cause biliary or duodenal obstruction. Advances in endoscopic and percutaneous options have lessened the need for operative palliation. Nevertheless, many patients are still found to be unresectable at the time of exploration, making palliative bypass a consideration. Several prior studies have examined the morbidity of operative palliation, but many were conducted over lengthy time periods, and few have examined the impact of these procedures on future therapy. This study is a contemporary analysis of the short- and long-term outcomes of palliative bypass procedures for unresectable periampullary malignancies at a single high-volume institution., Methods: We identified a contemporary cohort of patients in whom a pancreatoduodenectomy was planned for periampullary malignancy but instead underwent an aborted procedure. Patients were divided into 5 procedure groups: laparoscopy only, laparotomy with or without cholecystectomy, gastrointestinal bypass, biliary bypass, and double bypass (gastrointestinal and biliary). Data regarding the patient cohort, procedures, morbidity/mortality, and the interval to initiation of systemic therapy were collected prospectively and reviewed retrospectively., Results: Between July 2011 and November 2018, 128 out of 615 (17%) patients had an aborted pancreatoduodenectomy; 113 out of 128 patients had pancreatic adenocarcinoma, and 86 (67.1%) had duodenal or biliary obstruction at the time of operation. Patients who underwent laparoscopy only (n = 34) had no operative complications and a 90-day mortality of 6%; 88% of these patients went on to receive systemic therapy (median 21 days postprocedure). Double bypass was associated with a far lesser complication rate than in prior studies; 17% of patients had some complication(s), but only 9% had a severe complication. The 90-day all-cause mortality was 13%, and only 71% of these patients went on to receive systemic therapy (median 47 days postprocedure). Notably, 27 out of 34 (79%) of patients who underwent laparoscopy alone needed additional procedures for local obstruction, whereas only 5 out of 42 (12%) double bypass patients needed additional interventions. Median survival for the entire cohort was 10.3 months., Conclusion: Palliative procedures in this cohort had a far lesser complication rate than that of historical series. Palliative procedures, however, delayed systemic therapy, and a fair number of patients never received additional treatments. Palliative procedures markedly decreased the need for future interventions. Intraoperative decisions regarding palliative procedures must incorporate the functional status and motivations of the patient; these procedures are increasingly safe but may still affect survival., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Bariatric surgery is the most effective intervention for achieving durable weight loss and improvement of comorbidities in patients with obesity. Limited data exist on the impact of Medicare status in patients undergoing Roux-en-Y gastric bypass. We hypothesized that there is no difference in outcomes between Medicare beneficiaries and non-Medicare patients at the 10-year follow-up., Methods: All patients who underwent Roux-en-Y gastric bypass with 10-year follow-up at a single medical center from 1985 to 2005 were stratified by Medicare insurance status. Outcomes included 10-year percent reduction in excess body mass index and comorbidity resolution., Results: Of 617 patients who underwent Roux-en-Y gastric bypass with 10-year follow-up, 117 (19%) were insured under Medicare. Medicare patients were older (43 vs 40 years, P = .01) and had a greater preoperative body mass index (53.2 vs 51.0 kg/m 2 , P = .03) than non-Medicare patients, but there were no differences in preoperative median comorbidity index scores (3 [interquartile range 1-4] vs 2 [interquartile range 1-5], P = .33). At 10 years, weight loss (58.3% vs 57.0 percent reduction in excess body mass index, P = .16) and the decrease in median comorbidity index (1 [interquartile range 0-3] vs 1 [interquartile range 0-3], P = .85) were equivalent between groups., Conclusions: Roux-en-Y gastric bypass is equally beneficial in Medicare Disability and non-Medicare patients at 10 years. These findings support the continued and expanded coverage of bariatric surgery operations by Medicare., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Concerns regarding care quality prompted credentialing processes for bariatric "Centers of Excellence" (COE). It is hypothesized that high-volume surgeons and hospitals have better outcomes., Objective: This population-based study examines the effect of bariatric surgery volume on mortality in Pennsylvania., Methods: Between 1999 and 2003, 14,716 patients having gastric bypass surgery in Pennsylvania hospitals were identified from the Pennsylvania Health Care Cost Containment Council database. Individual surgeons and hospitals were stratified as high (> 100 cases/yr), medium (50-100 cases/yr), or low volume (< 50 cases/yr). The relationship between surgeon and hospital volume on length of stay (LOS), in-hospital, and 30-day mortality were examined, adjusting for age, gender, ethnicity, payor, and MedisGroups Admission Severity Group (ASG) score., Results: There were 26-50 low (n = 2,158), 35-54 medium (n = 1,835), and 43-64 high (n = 10,723) volume hospitals in Pennsylvania. The mean volume/hospital increased between 1999 and 2003 (30-120 cases/yr) and in-hospital mortality decreased (0.8-0.2%). Thirty-day mortality (1.15%) was approximately 2 times the in-hospital mortality (0.37%). Male gender (odds ratio [OR] 3.6, P < .001), ASG (OR 2.5, P < .001), hospital and surgeon volume were associated with increased in-hospital and 30-day mortality. Controlling for other factors, patients treated by low- and medium-volume surgeons (OR 3.7, P = .002; OR 2.8, P = .015) and hospitals (OR 2.3, P = .01; OR 2.44, P = .017) had increased odds of 30-day mortality versus high-volume surgeons and hospitals. LOS was significantly shorter at high-volume hospitals as well., Conclusions: In Pennsylvania, high volume is associated with decreased mortality and LOS. The results support the use of surgical volume in the COE credentialing process.

Background: The bariatric patient is among the most complex in general surgery. Morbid obesity and associated comorbidities create a higher likelihood for intensive care unit (ICU) services. Obstructive sleep apnea (OSA) is often unrecognized and may contribute to increased respiratory events and ICU admissions. Identifying and treating occult OSA may decrease the need for ICU utilization. This retrospective review attempts to evaluate this hypothesis., Patients and Methods: From 1998 to 2005, 890 bariatric procedures were performed at our center: 858 primary gastric bypasses and 32 revisions. Before 2004, patients were evaluated selectively for OSA; after 2004, all patients have had a sleep study., Results: A postoperative ICU stay was required in 43 patients (5%). From 1998 to 2003, when OSA evaluation was not mandatory, a respiratory-related ICU stay was necessary in 11 of 572 patients. When OSA evaluation was mandated in all patients (2004-2005), there was one respiratory related ICU stay (1/318)., Conclusion: Multiple variables lead to a decrease in ICU stay. Our study suggests that recognizing and treating occult sleep apnea may further improve this quality metric. In our center, mandatory OSA screening and aggressive preoperative treatment have eliminated the need for respiratory-related ICU stays after bariatric surgery.

Background: Super-super obesity (body mass index [BMI] >/= 60 kg/m(2)) is thought to be a risk factor for complications and mortality in laparoscopic Roux-en-Y gastric bypass. Excess weight loss has been demonstrated to be diminished compared with less obese patients following surgery. However, we hypothesize that super-super obese patients who undergo laparoscopic gastric bypass can realize major improvements in their health and a good quality of life without a significantly increased risk of complications when compared with less obese patients., Methods: From July 2002 to July 2005, University of Wisconsin Health bariatric surgeons performed 288 consecutive laparoscopic Roux-en-Y gastric bypass procedures. Patients were divided into 2 groups: BMI >/= 60 kg/m(2) (n = 28) and BMI < 60 kg/m(2) (n = 260). The groups were compared at defined time intervals during a 2-year period following surgery. Comparison criteria included complications, weight loss, comorbidities, and quality of life., Results: Both groups had similar morbidity and mortality rates. Excess weight loss was shown to be less, but total pounds lost were greater, for the super-super obese patients at all postoperative time intervals specified for postoperative analysis. Despite this fact, overall health improved to a similar degree in each group of patients following surgery; both groups also had similar Moorehead-Ardelt quality of life scores. Using the Bariatric Analysis and Reporting Outcome System (BAROS) to categorize outcomes, the average result for a patient in either group of patients would be considered "very good" at 1 year following surgery., Conclusions: Laparoscopic Roux-en-Y gastric bypass can be accomplished safely even in extremely obese patients. Although excess weight loss in the super-super obese is diminished postoperatively when compared with less obese patients, health is improved and quality of life is good regardless of a patient's preoperative BMI. Therefore, laparoscopic gastric bypass is a good option even in the extremely obese.

Background: Obesity is increasing in the American population in epidemic proportions. Weight reduction surgery results in sustained weight loss for morbidly obese individuals-a group of patients refractory to nonsurgical obesity treatment. Surgical indications were outlined in a National Institutes of Health (NIH) consensus conference published in 1991. Using the NIH criteria, we compared the socioeconomic characteristics of the population eligible for these operations to those receiving them., Methods: The 2000 National Health Interview Survey database was examined to identify how many individuals in the American population were eligible for obesity operations. Socioeconomic characteristics for those individuals were then assessed. The Healthcare Cost and Utility Project and National Hospital Discharge Survey databases were queried to determine how many gastric bypass operations were performed and what the patient's socioeconomic characteristics were., Results: There are 5,324,123 people, or 2.8% of the American population, who are eligible for obesity surgery. Of these, a disproportionate number were black, poorly educated, or impoverished, and 38% rely on Medicare or Medicaid for their health insurance. Of the 28,590 gastric bypass operations performed in 2000, only 13% of patients used Medicare or Medicaid to pay for the operation. Fewer than expected operations were performed on blacks. Regional differences were observed with disproportionately more operations performed in the Northeast and fewer in the Midwest than would be predicted from the surgery-eligible population living in these regions., Conclusions: A significant fraction of the American population could potentially benefit from obesity surgery. However, many of those individuals are black, poorly educated, and impoverished. Public assistance programs need to account for these patients. Centers performing bariatric operations need to accommodate the educational and financial constraints these patients have when planning long-term postoperative care.

Background: This study explores the volume-outcome relationship for gastric bypass surgery for obesity to determine whether higher-volume hospitals, higher-volume surgeons, or both are associated fewer adverse outcomes., Methods: The Pennsylvania state discharge database was used to identify 4685 cases of gastric bypass surgery for obesity between 1999 and 2001. Statistical modeling analyses were used to determine whether mortality or adverse outcome rate was significantly related to hospital and surgeon volume; the data were controlled for risk factors such as age, gender, comorbidities, and others., Results: There were 28 deaths (0.6%) and 813 adverse outcomes (17.4%). There was a significant risk-adjusted relationship between surgeon volume and adverse outcome, and the same trend was observed for deaths. Surgeons who performed fewer than 10 procedures per year had a 28% risk of adverse outcome and a 5% risk of death, compared with 14% (P<.05) and 0.3% (P=.06), respectively, for high-volume surgeons. Hospital volume did not reach significance, but there was a striking interaction between surgeon and hospital volume; surgeons who performed 10 to 50 cases per year operating in low-volume hospitals had a 55% risk of adverse outcome (P<.01)., Conclusion: Risk-adjusted in-hospital adverse outcome is significantly lower when gastric bypass is performed by higher-volume surgeons.