National Trends in Bariatric Surgery 2012-2015: Demographics, Procedure Selection, Readmissions, and Cost

Metabolic and Bariatric Surgery Outcomes in African American Patients: a Single Institution Experience

BACKGROUND

The incidence of obesity in African Americans (AAs) is higher than in non-AA in the USA. Previous studies using large national databases report that AA patients have worse outcomes than non-AA patients.

OBJECTIVES

To assess perioperative outcomes among AA patients after MBS at a center of excellence (COE) that serves a large, diverse patient population.

SETTING

University Hospital METHODS: A retrospective analysis was performed on patients undergoing MBS between 2010 and 2020 at our two accredited MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program) COEs where the AA population makes up over 35% of the population. Preoperative variables were compared using unpaired t-test or chi-squared test where appropriate. Thirty-day outcomes were compared following propensity score matching (exact algorithm) of demographics and comorbidities.

RESULTS

Overall, 5742 patients (AA = 2058, 36%) had Roux-en-Y gastric bypass (AA = 1028, 26%) or sleeve gastrectomy (AA = 1030, 27%). AA patients were more often female (90.2% vs. 80.2%, p < 0.001) and had higher rates of hypertension (56.3% vs. 47.8%, p < 0.001), while non-AA patients had higher rates of hyperlipidemia (27.3% vs. 20.7%, p < 0.001) and obstructive sleep apnea (41.2% vs. 37.1%, p = 0.0024). Matched data showed that AA patients had higher rates of pulmonary embolism (PE) (0.3% vs. 0.1%, p = 0.020) and more emergency department visits (7.0% vs. 5.1%, p = 0.012) but no differences in mortality, readmission, reintervention, or reoperation rates.

CONCLUSIONS

In a diverse area, AA patients who underwent MBS had similar perioperative outcomes compared to non-AA patients except that they experienced higher rates of PE. They also experienced higher rates of emergency department visits but had similar readmission rates.

A Bibliometric Analysis of the 50 Most Cited Articles on Body Contouring Surgery After Massive Weight Loss

BACKGROUND

Body contouring surgery after massive weight loss has emerged a safe and reliable option to improve self-esteem, social life, work ability, physical activity, and sexual activity, and it is considered as an essential step in the multidisciplinary approach to morbid obesity. In this study, we aim to provide a comprehensive overview of the current state of literature on body contouring after massive weight loss, identifying research trends and areas for future investigation.

METHODS

The Web of Science Core Collection was used to identify the 50 most cited publications on post-massive weight loss surgery. Data collected from each article included: title, journal, publication year, total citations, average citations per year, authors, study type, study topic, country, and institution of origin.

RESULTS

The top 50 most-cited articles include 44 original articles and 6 review articles. The most cited article, published by Lockwood in 1991, received a total of 224 citations. The research areas included surgical outcomes and complications (n=19, 38%), psychological aspects such as body image, quality of life and desire for body contouring procedures (n=18, 36%), surgical techniques (n=11, 22%), an anatomical study (n=1, 2%), and a classification system (n=1; 2%). Plastic and Reconstructive Surgery journal published most (44%) of the papers identified. The University of Pittsburgh was the single institution that contributed the most (n=11; 22%).

CONCLUSION

This bibliometric analysis provides insights and research trends for clinicians interested in body contouring after massive weight loss, facilitating the understanding and evolution of post-bariatric surgery and elucidating the rationale behind current practice.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Understanding preferences of patients with obesity for metabolic bariatric surgery: a comprehensive adaptive choice-based conjoint analysis

BACKGROUND

Patient preferences toward metabolic bariatric surgery (MBS) remain inadequately explored.

OBJECTIVE

This study aims to identify and analyze the key factors influencing the decision-making process of patients considering MBS.

SETTING

The research was conducted at the metabolic bariatric surgery clinic of the Medical Research Institute Hospital, Alexandria University, Egypt.

METHOD

Patients with obesity were recruited at the clinic before MBS. The surgical profiles were characterized by attributes including treatment method, recovery and reversibility, treatment tenure, expected weight loss, impact on associated medical problems, risk of complication, side effects, dietary changes, and out-of-pocket costs. Patients engaged in an online survey comprising sociodemographic data, Build Your Own (BYO) section, screening section, and choice tournament section. Adaptive choice-based conjoint analysis was employed to discern the preferences.

RESULTS

Of the 299 respondents, the surgical profiles with the highest preference involved a loss of 80% of excess weight without any recurrence (14.67 [95% CI, 14.10-15.23]), 0% risk of complication (13.74 [95% CI, 13.03-14.45]), and absence of adverse effects (11.32 [95% CI, 10.73-11.91]). K-mean cluster analysis identified 2 distinct groups: "patients prioritize weight loss" group prioritized excess weight loss, surgery availability, and diet change, whereas "patients prioritize avoidance of complications" group focused on the risk of complication, adverse effects, and the surgery mechanism.

CONCLUSIONS

MBS candidates predominantly value weight loss without recurrence, followed by minimization of complication risks and adverse effects, within 3 years postsurgery. Conversely, initial out-of-pocket costs and resolution of medical conditions were deemed the least influential attributes.

Evaluation of Healthcare Utilisation and Expenditures in Persons with Type 2 Diabetes Undergoing Bariatric-Metabolic Surgery

PURPOSE

Changes in healthcare utilisation and expenditures after bariatric-metabolic surgery (BMS) for people with type 2 diabetes mellitus (T2DM) are unclear. We used the Dutch national all-payer claims database (APCD) to evaluate utilisation and expenditures in people with T2DM who underwent BMS.

METHODS

In this cohort study, patients with T2DM who had BMS in 2016 were identified in the APCD. This group was matched 1:2 to a control group with T2DM who did not undergo BMS based on age, gender and healthcare expenditures. Data on healthcare expenditures and utilisation were collected for 2013-2019.

RESULTS

In total, 1751 patients were included in the surgery group and 3502 in the control group. After BMS, total median expenditures in the surgery group stabilised (€ 3156 to € 3120) and increased in the control group (€ 3174 to € 3434). Total pharmaceutical expenditures decreased 28% in the surgery group (€957 to €494) and increased 55% in the control group (€605 to €936). In the surgery group, 67.1% did not use medication for T2DM in 2019 compared to 13.3% in the control group. Healthcare use for microvascular complications increased in the control group, but not in the surgery group.

CONCLUSION

BMS in people with T2DM stabilises healthcare expenditures and decreases medication use and care use for microvascular complications. In contrast, healthcare use and expenditures in T2DM patients who do not undergo surgery gradually increase over time. Due to the progressive nature of T2DM, it is expected that these differences will become larger in the long-term.

MBSAQIP risk calculator use in bariatric surgery is associated with a reduction in serious complications: a retrospective analysis of 210,710 patients

BACKGROUND

The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) Bariatric Surgical Risk/Benefit Calculator was developed to provide patient-specific information to assist surgical decision-making. To date, no study has characterized which patients are being evaluated with this tool.

OBJECTIVE

We sought to characterize the use and impact of the MBSAQIP calculator.

SETTING

MBSAQIP collects data from 955 centers in North America.

METHODS

The 2021 MBSAQIP database was evaluated for the use of the calculator on preoperative counseling for patients undergoing bariatric surgery. Patient characteristics, operative techniques, and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including use of the calculator independently associated with serious complications and mortality.

RESULTS

Our study included 210,710 patients, 35,158 (16.7%) of whom were evaluated using the calculator. Patients with whom the calculator was used preoperatively were older (43.8 ± 11.6 yr versus 43.6 ± 11.7 yr; P < .001) and were more likely to have insulin-dependent diabetes, hypertension, gastroesophageal reflux disease, renal insufficiency, and sleep apnea. More patients underwent Roux-en-Y gastric bypass in the calculator cohort compared with the cohort that did not use the calculator (29.6% versus 28.6%; P < .003). The rate of serious complication was significantly less in the calculator cohort (3.1% versus 3.4%; P < .030). Multivariable modeling evaluating serious complications showed that use of the calculator was independently associated with reduced risk of serious complications (odds ratio .87, CI .82-.93, P < .001) but was not associated with mortality.

CONCLUSION

The use of the risk calculator may help to reduce the incidence of complications by opening a dialogue between healthcare professionals and patients, setting realistic expectations, and identifying modifiable risk factors.

Possible technical aspects involved in the development of GERD after sleeve gastrectomy: Surgical technique considerations

Sleeve gastrectomy (SG) is the most common bariatric surgery worldwide and has shown to cause de novo or worsen symptoms of gastroesophageal reflux disease (GERD). Esophageal motility and physiology studies are mandatory in bariatric and foregut centers. The predisposing factors in post-SG patients are disruption of His angle, resection of gastric fold and gastric fundus, increased gastric pressure, resection of the gastric antrum, cutting of the sling fibers and pyloric spasm. There are symptomatic complications due to sleeve morphology as torsion, incisura angularis stenosis, kinking and dilated fundus. In this article, we present recommendations, surgical technique and patient selection flow diagram for SG and avoid de novo or worsening GERD.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Bariatric Surgical Risk/Benefit Calculator: 1-year weight

BACKGROUND

Data-driven tools can be designed to provide patient-personalized estimates of health outcomes. Clinical calculators are commonly built to assess risk, but potential benefits of treatment should be equally considered. The American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) sought to create a risk and benefit calculator for adult patients considering primary metabolic and bariatric surgery with multiple prediction features: (1) 30-day risk, (2) 1-year body mass index (BMI) projections, and (3) 1-year co-morbidity remission.

OBJECTIVE

To assess the performance of the 1-year BMI projections feature of this tool.

SETTING

Not-for-profit organization, clinical data registry.

METHODS

MBSAQIP data from 596,024 cases across 4.5 years from 882 centers with ∼2.5 million records through 18 months postoperatively were included. A generalized estimating equation model was used to estimate BMI over time for 4 primary procedures: laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch.

RESULTS

The mean absolute error (MAE) in BMI predictions through postoperative month 12 was 1.68 units; overall correlation of actual and predicted BMI was .94. MAE of postoperative BMI estimates (1-12 mo) was lowest for laparoscopic sleeve gastrectomy (1.64) and highest for biliopancreatic diversion with duodenal switch (1.99). BMI predictions at 12 months showed MAE = 2.99 units.

CONCLUSIONS

Predicted BMI closely aligned with actual BMI values across the 12-month postoperative period. The MBSAQIP Bariatric Surgical Risk/Benefit Calculator is publicly available with the intent to facilitate patient-clinician communication and guide surgical decision making. This tool can aid in evaluating postoperative risk as well as benefits and long-term expectations.

Gastric Bypass Mortality Trends in Racial Cohorts: Are We Improving?

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) continues to be safely performed in racial cohorts. However, studies continue to report differences in complications, with non-Hispanic black (NHB) patients having a higher rate of adverse outcomes, including mortality. It is unclear how these disparate outcomes have evolved over time. Our objective was to determine RYGB procedure and mortality trends in racial cohorts.

METHODS

Using the 2015 to 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) database, we identified primary RYGB cases performed laparoscopically or robotically. Non-Hispanic white (NHW) and non-Hispanic black (NHB) patient cohorts were matched based on patient and surgical characteristics. Conditional logistic regression analysis was conducted on the matched pairs. Primary outcomes of interest included year-to-year all-cause and procedure-related mortality. Stata/MP 16.1 was utilized for analysis, and a p-value of < 0.05 and a 95% confidence interval that excluded 1 were considered significant.

RESULTS

A total of 148,829 RYGB cases in NHW (82.8%) and Black (17.2%) patients were analyzed. RYGB trends remain similar for NHB and NHW patients over 5 years. In matched cohorts, all-cause mortality (OR 2.23; 95% CI: 1.16-4.29), aggregate related readmission (OR 1.39; 95% CI: 1.27-1.51), related reintervention (OR 1.36; 95% CI: 1.19-1.56), and VTE (OR 1.86; 95% CI: 1.40-2.45) were more likely in NHB patients. During the study period, year-to-year mortality was higher in NHB patients compared to NHW patients.

CONCLUSION

Over a 5-year period, year-to-year mortality remains higher in NHB patients after RYGB. While bariatric outcomes continue to improve, outcome gaps between racial cohorts seem to persist.

Characteristics and outcomes for patients undergoing revisional bariatric surgery due to persistent obesity: a retrospective cohort study of 10,589 patients

BACKGROUND

Revisional bariatric surgery in an option for patients who experience weight regain or inadequate weight loss after primary elective bariatric procedures. However, there is conflicting data on safety outcomes of revisional procedures. We aim to characterize patient demographics, procedure type, and safety outcomes for those undergoing revisional compared to initial bariatric interventions to guide management of these patients.

METHODS

The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) registry was analyzed, comparing primary elective to revisional bariatric procedures for inadequate weight loss. Bivariate analysis was performed to determine between group differences. Multivariable logistic regression determined factors associated with serious complications or mortality.

RESULTS

We evaluated 158,424 patients, including 10,589 (6.7%) revisional procedures. Patients undergoing revisional procedures were more like to be female (85.5% revisional vs. 81.0% initial; p < 0.001), had lower body mass index (43.6 ± 7.8 kg/m² revisional vs. 45.2 ± 7.8 kg/m² initial; p < 0.001), and less metabolic comorbidities than patients undergoing primary bariatric surgery. The most common revisional procedures were Roux-en-Y gastric bypass (48.4%) and sleeve gastrectomy (32.5%). Revisional procedures had longer operative duration compared to primary procedures. Patients undergoing revisional procedures were more likely to experience readmission to hospital (4.8% revisional vs. 2.9% initial; p < 0.001) and require reoperation (2.4% revisional vs. 1.0% initial; p < 0.001) within 30 days of the procedure. Revisional procedures were independently associated with increased serious complications (OR 1.49, CI 1.36-1.64, p < 0.001) but were not a significant predictor of 30-day mortality (OR 0.74, CI 0.36-1.50, p = 0.409).

CONCLUSIONS

In comparison to primary bariatric surgery, patients undergoing revisional procedures have less metabolic comorbidities. Revisional procedures have worse perioperative outcomes and are independently associated with serious complications. These data help to contextualize outcomes for patients undergoing revisional bariatric procedures and to inform decision making in these patients.

Post-Operative but Not Pre-Operative COVID-19 Predicts Serious Complications and Mortality Following Elective Bariatric Surgery

PURPOSE

We sought to characterize the prevalence and subsequent impact of pre- and post-operative COVID-19 diagnosis on bariatric surgery outcomes. COVID-19 has transformed surgical delivery, yet little is known regarding its implications for bariatric surgery.

MATERIALS AND METHODS

The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was evaluated with three cohorts described: those diagnosed with COVID-19 pre-operatively (PRE), post-operatively (POST), and those without a peri-operative COVID-19 (NO) diagnosis. Pre-operative COVID-19 was defined as COVID-19 within 14 days prior to the primary procedure while post-operative COVID-19 infection was defined as COVID-19 within 30 days after the primary procedure.

RESULTS

A total of 176,738 patients were identified, of which 174,122 (98.5%) had no perioperative COVID-19, 1364 (0.8%) had pre-operative COVID-19, and 1252 (0.7%) had post-operative COVID-19. Patients who were diagnosed with COVID-19 post-operatively were younger than other groups (43.0 ± 11.6 years NO vs 43.1 ± 11.6 years PRE vs 41.5 ± 10.7 years POST; p < 0.001). Pre-operative COVID-19 was not associated with serious complications or mortality after adjusting for comorbidities. Post-operative COVID-19, however, was among the greatest independent predictors of serious complications (OR 3.5; 95% CI 2.8-4.2; p < 0.0001) and mortality (OR 5.1; 95% CI 1.8-14.1; p = 0.002).

CONCLUSIONS

Pre-operative COVID-19 within 14 days of surgery was not significantly associated with either serious complications or mortality. This work provides evidence that a more liberal strategy which employs early surgery after COVID-19 infection is safe as we aim to reduce the current bariatric surgery case backlog.

A Shared Decision-making Process may Affect Bariatric Procedure Selection and Alter Surgical Outcomes: a Single-unit Retrospective Study

PURPOSE

A shared decision-making (SDM) process centered on the patient perspective may increase understanding and treatment satisfaction. This study aimed to investigate whether SDM would increase the acceptance of bariatric/metabolic surgeries, change treatment decisions, and affect 1-year results.

MATERIALS AND METHODS

This retrospective analysis enrolled 315 consecutive patients with a body mass index between 32.5 and 50 kg/m² and aged 20-65 years who underwent consultation for a primary bariatric/metabolic procedure within 2 years before (pre-SDM) or after (post-SDM) SDM program implementation to assist in the decision to undergo Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery. Consent rate, procedure choice, weight loss, comorbidity remission, etc., were compared between periods and procedures. Statistical tests were two-sided, with p < 0.05 considered significant.

RESULTS

More eligible patients underwent metabolic/bariatric procedures post-SDM than pre-SDM (115/159 [72%] vs. 106/156 [68%]; p = 0.395), and a stronger preference for RYGB post-SDM was observed (71% vs. 62%; p = 0.153). Significantly more patients with diabetes (28 [34.1%] vs. 5 [15.2%]; p = 0.041) chose RYGB over SG post-SDM. Patients who underwent RYGB had a higher diabetes remission rate both pre-SDM (70.0% vs. 58.3%; p = 0.571) and post-SDM (76.2% vs. 66.7%; p = 0.712) than those who underwent SG. While 1-year weight loss was similar between procedures, adherence to nutritional supplementation did not appear to be broadly enhanced post-SDM.

CONCLUSION

SDM influenced procedure selection toward RYGB, which was more popular than SG among patients with diabetes. Higher diabetes remission was achieved with RYGB, although the results of other effects deserve further study.

Acute Care Utilization and Costs Up to 4 Years After Index Sleeve Gastrectomy or Roux-en-Y Gastric Bypass: A National Claims-based Study

OBJECTIVE

To compare acute care utilization and costs following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

SUMMARY BACKGROUND DATA

Comparing postbariatric emergency department (ED) and inpatient care use patterns could assist with procedure choice and provide insights about complication risk.

METHODS

We used a national insurance claims database to identify adults undergoing SG and RYGB between 2008 and 2016. Patients were matched on age, sex, calendar-time, diabetes, and baseline acute care use. We used adjusted Cox proportional hazards to compare acute care utilization and 2-part logistic regression models to compare annual associated costs (odds of any cost, and odds of high costs, defined as ≥80th percentile), between SG and RYGB, overall and within several clinical categories.

RESULTS

The matched cohort included 4263 SG and 4520 RYGB patients. Up to 4 years after surgery, SG patients had slightly lower risk of ED visits [adjusted hazard ratio (aHR): 0.90; 95% confidence interval (CI): 0.85,0.96] and inpatient stays (aHR: 0.80; 95% CI: 0.73,0.88), especially for events associated with digestive-system diagnoses (ED aHR: 0.68; 95% CI: 0.62,0.75; inpatient aHR: 0.61; 95% CI: 0.53,0.72). SG patients also had lower odds of high ED and high total acute costs (eg, year-1 acute costs adjusted odds ratio (aOR) 0.77; 95% CI: 0.66,0.90) in early follow-up. However, observed cost differences decreased by years 3 and 4 (eg, year-4 acute care costs aOR 1.10; 95% CI: 0.92,1.31).

CONCLUSIONS

SG may have fewer complications requiring emergency care and hospitalization, especially as related to digestive system disease. However, any acute care cost advantages of SG may wane over time.

Is development in bariatric surgery in Germany compatible with international standards? A review of 16 years of data

Bariatric surgery has expanded tremendously internationally over the past decade. In recent years, bariatric surgery has experienced a significant growth in Germany. However, the question arises as to whether this development is in line with international developments or whether there is still room for improvement that could be challenged. 63,990 primary bariatric procedures recorded in the German Bariatric Surgery Registry (GBSR) were analyzed from 2005 to April 2021. The distribution of procedures according to different variants was analyzed and presented. In the last 16 years, 17 different procedures have been performed. The most common surgical procedure was sleeve gastrectomy (SG), followed by Roux-Y gastric bypass (RYGB) (42%). Adjustable gastric banding (AGB) has declined over time, from 23.5% in the first 5 years to 0.2% in recent years. In comparison, omega-loop gastric bypass has increased over the past 5 years (from 0.4% in the first 5 years to 5.9% in the last 5 years). Laparoscopic procedures have accounted for 96.4% of all bariatric surgeries in recent years. The frequency of some procedures has decreased and some bariatric procedures have lost significance. Overall, bariatric surgery in Germany has developed positively compared to the international trend. Nevertheless, there is one area that needs to be optimized: the development of robotic bariatric surgery, which crawls behind in Germany compared to other countries. To establish the technology in bariatric surgery in a timely manner, a balance must be found between cost neutrality and patient-oriented applications.

Racial Differences in Bariatric Surgical Approach: a Cross-Sectional National Inpatient Sample Analysis

PURPOSE

Although racial inequalities in referral and access to bariatric surgical care have been well reported, racial difference in the selection of surgical techniques is understudied. This study examined factors associated with the utilization of the two main bariatric surgical techniques: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

MATERIALS AND METHODS

The National Inpatient Sample database was queried for patients who underwent elective LSG or LRYGB for the treatment of severe obesity. Chi-square tests and multivariable logistic regression assessed associations of surgical approach with patient and facility characteristics. Sensitivity analyses examined the following body mass index (BMI) subgroups: < 40.0 kg/m², 40.0-44.9 kg/m², 45.0-49.9 kg/m², and ≥ 50.0 kg/m².

RESULTS

Within the final cohort (N = 86,053), 73.0% (N = 62,779) underwent LSG, and 27.0% (N = 23,274) underwent LRYGB. Patients with BMI 45.0-49.9 kg/m² (OR = 0.85) and BMI ≥ 50.0 kg/m² (OR = 0.80) were less likely to undergo LSG than patients with BMI 40.0-45.0 kg/m² (all p < 0.001). However, Black (OR = 1.74) and White Hispanic patients (OR = 1.30) were more likely to undergo LSG than White non-Hispanic patients (all p < 0.005). In the BMI ≥ 50.0 kg/m² group, Black patients were still more likely to undergo LSG compared to White non-Hispanic patients (OR = 1.69, p < 0.001), while Asians/Pacific Islanders were less likely to receive LSG than White non-Hispanic patients (OR = 0.41, p < 0.05).

CONCLUSION

In this observational study, we identified racial differences in the selection of common bariatric surgical approaches across various BMI categories. Future investigations are warranted to study and to promote awareness of the racial/ethnic influence in attitudes on obesity, weight loss, financial support, and surgical risks during bariatric discussions with minorities.

Cost-effectiveness analysis of semaglutide 2.4 mg for the treatment of adult patients with overweight and obesity in the United States

BACKGROUND: The rising prevalence and associated public health burden of obesity has led to advancements in pharmaceuticals for weight management. Semaglutide 2.4 mg, an anti-obesity medication (AOM) recently approved by the US Food and Drug Administration, has demonstrated clinically relevant weight loss in its phase 3 clinical trials. Economic evaluation comparing semaglutide 2.4 mg with other available weight management therapies is essential to inform payers for decision-making. OBJECTIVES: To assess the cost-effectiveness of semaglutide 2.4 mg in the treatment of adult patients with obesity (ie, body mass index [BMI] ≥ 30) and adult patients who are overweight (ie, BMI 27-29.9) with 1 or more weight-related comorbidities from a US third-party payer perspective. METHODS: A cohort Markov model was constructed to compare semaglutide 2.4 mg with the following comparators: no treatment, diet and exercise (D&E), and 3 branded AOMs (liraglutide 3 mg, phentermine-topiramate, and naltrexone-bupropion). All AOMs, including semaglutide 2.4 mg, were assumed to be taken in conjunction with D&E. Changes in BMI, blood pressure, cholesterol level, experience of acute and chronic obesity-related complications, costs, and quality-adjusted life years (QALYs) were simulated over 30 years based on pivotal trials of the AOMs and other relevant literature. Drug and health care prices reflect 2021 standardized values. Cost-effectiveness was examined with a willingness-to-pay (WTP) threshold of $150,000 per QALY gained. Sensitivity analyses were conducted to test the robustness of the cost-effectiveness results to plausible variation in model inputs. RESULTS: In the base-case analysis, treatment with semaglutide 2.4 mg was estimated to improve QALYs by 0.138 to 0.925 and incur higher costs by $3,254 to $25,086 over the 30-year time horizon vs comparators. Semaglutide 2.4 mg is cost-effective against all comparators at the prespecified WTP threshold, with the incremental cost per QALY gained ranging from $23,556 to $144,296 per QALY gained. In the sensitivity analysis, extended maximum treatment duration, types of subsequent treatment following therapy discontinuation, and weight-rebound rates were identified as key drivers for model results. The estimated probability of semaglutide 2.4 mg being cost-effective compared with comparators ranged from 67% to 100% when varying model parameters and assumptions. CONCLUSIONS: As a long-term weight management therapy, semaglutide 2.4 mg was estimated to be cost-effective compared with no treatment, D&E alone, and all other branded AOM comparators under a WTP threshold of $150,000 per QALY gained over a 30-year time horizon. DISCLOSURES: Financial support for this research was provided by Novo Nordisk Inc. The study sponsor was involved in several aspects of the research, including the study design, the interpretation of data, the writing of the manuscript, and the decision to submit the manuscript for publication. Dr Kim and Ms Ramasamy are employees of Novo Nordisk Inc. Ms Kumar and Dr Burudpakdee were employees of Novo Nordisk Inc at the time this study was conducted. Dr Sullivan received research support from Novo Nordisk Inc for this study. Drs Wang, Song, Wu, Ms Xie, and Ms Sun are employees of Analysis Group, Inc, who received consultancy fees from Novo Nordisk Inc in connection with this study.

Variation of Laparoscopic Roux-en-Y Gastric Bypass Techniques: a Survey of 518 Bariatric Surgeons

INTRODUCTION

Surgical technique varies dramatically in the performance of laparoscopic Roux-en-Y gastric bypass (LRYGB) and these differences can potentially lead to variation in outcomes. The objective of this study was to characterize surgical techniques used during LRYGB.

METHODS

An anonymous 44-question survey was distributed by email to all bariatric surgeons with membership in the ASMBS, SAGES, and ACS from April to June 2020. Questions were designed to evaluate surgeon demographics, experience, and variation of techniques. Only surgeons who performed LRYGB within the past year were included for analysis.

RESULTS

A total of 534 (18.8%) surgeons responded and the majority (97.0%) reported performing LRYGB in the past year. Surgeons were predominantly from the USA (77.8%). For preoperative work-up, 20.1% performed upper gastrointestinal series while 60.8% performed esophagogastroduodenoscopy. Limb length evaluation revealed mean Roux and biliopancreatic limb lengths of 124.1 ± 29.4 cm and 67.4 ± 32.2 cm, respectively. The gastrojejunostomy was most commonly formed using a linear stapler with handsewn closure of the common enterotomy (53.1%) and the jejunojejunostomy using a linear stapled anastomotic technique with handsewn closure of the common enterotomy (60.6%). The majority of surgeons closed the jejunojejunostomy mesenteric defect (91.1%) and one of the antecolic or retrocolic mesenteric defects (65.1%). Intraoperative leak tests were performed in 95.9% of cases. Only 22.1% of surgeons routinely performed upper gastrointestinal swallow studies postoperatively.

CONCLUSIONS

There are wide variations in pre- and intraoperative practice patterns for LRYGB. Further clinical trials designed to evaluate the impact of these practice pattern differences on patient outcomes are warranted.

National recurrence of pancreatitis and readmissions after biliary pancreatitis

BACKGROUND

National and international guidelines support early cholecystectomy after mild gallstone pancreatitis but a recent nationwide study suggested these recommendations are not universally followed. Our study sought to quantify the national utilization of same hospitalization cholecystectomy versus non-operative management (NOM) and its association with pancreatitis recurrence, readmissions, and costs after mild gallstone pancreatitis (GP).

METHODS

Adult patients admitted with mild GP were identified from the Nationwide Readmission Database 2010-2015. Primary outcomes included the rate of cholecystectomy during the index admission as well as pancreatitis recurrence and readmission at 30 and 180 days (30d, 180d) comparing NOM to same hospitalization cholecystectomy. Mortality upon readmission, total length of stay (LOS), and total costs (combined index-readmission hospital costs) were also explored. Cox proportional hazards regression and generalized linear models controlled for patient/hospital confounders.

RESULTS

Among the 65,067 patients identified, 30% underwent cholecystectomy. The NOM cohort was older (58 vs. 50 years), had more comorbidities (Charlson index > 2, 23.5% vs. 11.5%), fewer female patients (56.7% vs. 67%) and less discharge-to-home (84.9% vs. 94.4%) (all p < 0.001). NOM was associated with increase in recurrence and unplanned readmissions at 30d [Hazard Ratio 3.53 (95% CI 2.92-4.27), 2.41 (2.11-2.74), respectively], and 180d [4.27 (3.65-4.98), 2.78 (2.54-3.04), respectively], as well as increased mortality during 180d readmission 1.88 (1.06-3.35). This approach was also associated with significant increase in LOS [predicted mean difference 2.79 days (95% CI 2.46-3.12)] and total costs [$2507.89 ($1714.4-$3301.4)].

CONCLUSIONS

In the USA, most patients presenting with mild GP do not undergo same hospitalization cholecystectomy. This strategy results in higher recurrent pancreatitis, mortality during readmission, and an additional $4.85 M/year in hospital costs nationwide. These data support same hospitalization cholecystectomy as the gold standard for mild GP.

Impact of the COVID-19 pandemic on bariatric surgery in North America – A retrospective analysis of 834,647 patients

Background

COVID-19 has transformed surgical care, yet little is known regarding implications for bariatric surgery.

Objective

We sought to characterize the effect of COVID-19 on bariatric surgery delivery and outcomes.

Setting

The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 885 centers in North America.

Methods

The MBSAQIP database was evaluated with 2 cohorts described: the COVID-19 and the pre–COVID-19, with patients receiving surgery in 2020 and 2015–2019, respectively. Yearly operative trends were characterized, and bivariate analysis compared demographics and postoperative outcomes. Multivariable modeling evaluated 30-day readmission, reintervention, and reoperation rates and factors associated with undergoing Roux-en-Y gastric bypass.

Results

We evaluated 834,647 patients, with 155,830 undergoing bariatric surgery during the 2020 pandemic year. A 12.1% reduction in total cases (177,208 in 2019 versus 155,830 in 2020; P < .001) and 13.8% reduction in cases per center occurred (204.2 cases per center in 2019 versus 176.1 cases per center in 2020; P < .001). Patients receiving bariatric surgery during the pandemic were younger and had fewer co-morbidities. Use of sleeve gastrectomy increased (74.5% versus 72.5%; P < .001), and surgery during COVID-19 was associated with reduced Roux-en-Y gastric bypass procedure selection (odds ratio = .83; 95% CI: .82–.84; P < .001). Length of stay decreased significantly (1.4 ± 1.4 days versus 1.6 ± 1.4 days; P < .001), yet postoperative outcomes were similar. After adjusting for co-morbidities, patients during COVID-19 had decreased 30-day odds of readmission and reintervention and a small increase in odds of reoperation.

Conclusion

The COVID-19 pandemic dramatically changed bariatric surgery delivery. Further studies evaluating the long-term effects of these changes are warranted.

The Influence of Roux-en-Y Gastric Bypass and Diet on NaCl and Sucrose Taste Detection Thresholds and Number of Circumvallate and Fungiform Taste Buds in Female Rats

Roux-en-Y gastric bypass (RYGB) in rats attenuates preference for, and intake of, sugar solutions. Additionally, maintenance on a high-fat diet (HFD) reportedly alters behavioral responsiveness to sucrose in rodents in short-term drinking tests. Due to the fact that the behavioral tests to date rely on the hedonic value of the stimulus to drive responsiveness, we sought to determine whether taste detection thresholds to sucrose and NaCl are affected by these manipulations as measured in an operant two-response signal detection paradigm. Female rats were maintained on HFD or chow for 10 weeks, at which point animals received either RYGB or SHAM surgery followed by a gel-based diet and then powdered chow. Upon recovery, half of the rats that were previously on HFD were switched permanently to chow, and the other rats were maintained on their presurgical diets (n = 5–9/diet condition x surgery group for behavioral testing). The rats were then trained and tested in a gustometer. There was a significant interaction between diet condition and surgery on NaCl threshold that was attributable to a lower value in RYGB vs. SHAM rats in the HFD condition, but this failed to survive a Bonferroni correction. Importantly, there were no effects of diet condition or surgery on sucrose thresholds. Additionally, although recent evidence suggests that maintenance on HFD alters taste bud number in the circumvallate papillae (CV) of mice, in a subset of rats, we did not find that diet significantly influenced taste pores in the anterior tongue or CV of female rats. These results suggest that any changes in sucrose responsiveness in intake/preference or hedonically oriented tests in rats as a function of HFD maintenance or RYGB are not attributable to alterations in taste sensitivity.

The effect of protein supplements on weight loss, body composition, protein status, and micronutrients post laparoscopic sleeve gastrectomy (LSG): A Randomised Controlled Trial (RCT)

Background

Low protein intake post-bariatric surgery can result in protein malnutrition, and muscle mass loss. Authors aim to assess the effect of protein supplements on weight loss, body composition, and micronutrient status following LSG.

Methods

This is a double-blinded RCT conducted between February/2017 to January/2018. Eligible post LSG patients were randomized into the intervention group who received daily protein supplements containing 20 g of protein and placebo group received zero protein supplements. Both groups received a standardized diet. Weight loss, body composition, and micronutrient status were analyzed at 1, 3, and 6 months.

Results

48 participants were included in the final analysis (intervention: 21 and placebo:27). Excess weight loss percentage (EWL%) at 6 months was comparable between both groups (69.44 ± 21.99% and 71.40 ± 19.27% respectively). No significant difference observed in the anthropometric parameters. There was an increase in muscle mass and a decrease in muscle mass loss in the intervention group throughout the study period. However, these changes were not statistically significant. There was a significant increase in total protein (P=0.027) and magnesium (P=0.008) in the intervention group at 3 months. Albumin and iron levels were significantly higher at 6 months in the intervention group (P=0.036 & P=0.028 respectively). Other micronutrients did not differ at any time point between both groups.

Conclusion

Protein supplements resulted in significant improvement in total protein, albumin, magnesium, and iron levels post LSG. Although not significant, protein supplements helped in maintaining the muscle mass and preventing muscle mass loss.

Original article

This RCT is an original article and provides a level 2 evidence.

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Low protein intake post-bariatric surgery results in protein malnutrition & muscle mass loss. Protein supplements may be of benefit.

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Eligible post LSG patients were randomized into the intervention group who received daily 20 g protein supplements & placebo group.

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No significant difference in weight, BMI, BMI change, EWL%, TWL%, and absolute weight loss. No statistically significant changes in the muscle mass.

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Percentage of muscle mass loss was noticeably higher in the control group over the 3 timelines. Fat percentages were less in the intervention group.

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Total protein and Albumin showed a significant increase in the intervention group.

Characterization and Risk Factors for Early Biliary Complications Following Elective Bariatric Surgery: an Mbsaqip Analysis

INTRODUCTION

Patients undergoing bariatric surgery are at risk of postoperative biliary complications. This study aims to characterize biliary complications occurring within 30 days of bariatric surgery and to determine factors associated with their occurrence.

METHODS AND PROCEDURES

The 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was analyzed comparing patients with early biliary complications to those without. Early biliary complications were defined by any reoperation, reintervention, or readmission due to gallstones within 30 days of surgery. Patients undergoing elective sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) were included; patients with prior surgery were excluded. Bivariate analysis compared groups using chi-squared for categorical data and ANOVA for continuous data was performed. Multivariable modeling was performed to determine factors independently associated with early biliary complications.

RESULTS

We evaluated 750,498 patients with 691 (0.1%) experiencing early biliary complications. Patients with early biliary complications were more often female (87.7% vs 79.6%, p < 0.001). Patients with early biliary complications required significantly more reoperations (86.0% vs 1.1%, p < 0.001), readmissions (82.5% vs 3.6%, p < 0.001), and reinterventions (15.8% vs 1.2%, p < 0.001). Female gender (OR 1.89; CI 1.47-2.44; p < 0.001), postoperative weight loss (OR 1.08; CI 1.06-1.09, p < 0.001), and LRYGB (OR 1.51, CI 1.27-1.79; p < 0.001) were substantial independent predictors of early biliary complications.

CONCLUSIONS

Early post-bariatric surgery biliary complications occur uncommonly but confer substantial morbidity. Female gender, postoperative weight loss, and RYGB are the greatest predictors for early biliary complications. Evaluation of preventative measures in these high-risk groups is needed.

Why Size Matters: an Evaluation of Gastric Pouch Size in Roux-en-Y Gastric Bypass Using CT Volumetric Analysis and its Effect on Marginal Ulceration

PURPOSE

Marginal ulceration (MU) is a common long-term complication following Roux-en-Y gastric bypass (RYGB). The causes of MU after RYGB are multifactorial and include surgical technique of constructing the gastrojejunal anastomosis (GJA). The purpose of this study is to evaluate the relationship between gastric pouch size in RYGB and MU using CT volumetrics.

MATERIAL AND METHODS

Patients were retrospectively identified who underwent esophagogastroduodenoscopy (EGD) following RYGB at a tertiary care teaching hospital. Measurement of gastric pouch size was performed using 3-D CT software. Standard statistical methods were used, a univariate comparison was performed between MU and non-MU patients followed by a propensity-matched comparison to control for factors known to affect MU, and a propensity-matched subgroup analysis was also performed.

RESULTS

In total, 122 patients met criteria, 57 of which had MU on EGD and 65 who did not. The MU group had more smokers and patients with PPI use than the non-MU group, and the mean time from operation to CT scan was 26.6 months (range: 0-108 months). The MU group had a larger gastric pouch size than the non-MU group (34.1 ± 11.8 versus 20.1 ± 6.8 cm³). When analyzed for matched patient cohorts, this difference remained for the MU group that included smokers and PPI use. When stratified for pouch size, for each 5 cm³ increase in pouch size, patients had 2.4 times odds increase of MU formation.

CONCLUSIONS

CT volumetric analysis demonstrated that a larger gastric pouch size was associated with MU following RYGB.

Bariatric surgery in patients with breast and endometrial cancer in California: population-based prevalence and survival

BACKGROUND

The number of bariatric surgeries performed in the United States has increased substantially since the 1990's. However, the prevalence and prognostic impact of bariatric surgery, or weight loss surgery (WLS), among patients with cancer are not known.

OBJECTIVES

We investigated the population-based prevalence of WLS in women with breast or endometrial cancer and conducted exploratory analysis to examine whether postdiagnosis WLS is associated with survival.

SETTING

Administrative statewide database.

METHODS

WLS records for women with nonmetastasized breast (n = 395,146) or endometrial (n = 69,859) cancer were identified from the 1991-2014 California Cancer Registry data linked with the California Office of Statewide Health Planning and Development database. Characteristics of the patients were examined according to history of WLS. Using body mass index data available since 2011, a retrospective cohort of patients with breast or endometrial cancer and obesity (n = 12,540) was established and followed until 2017 (5% lost to follow-up). Multivariable cause-specific Cox proportional hazards models were used to examine the associations between postdiagnostic WLS and time to death.

RESULTS

WLS records were identified for 2844 (.7%) patients with breast cancer and 1140 (1.6%) patients with endometrial cancer; about half of the surgeries were performed after cancer diagnosis. Postdiagnosis WLS was performed in ∼1% of patients with obesity and was associated with a decreased hazard for death (cause-specific hazard ratio = .37; 95% confidence interval = .014-.99; P = .049), adjusting for age, stage, co-morbidity, race/ethnicity, and socioeconomic status.

CONCLUSION

About 2000 patients with breast or endometrial cancer in California underwent post-diagnosis WLS between 1991 and 2014. Our data support survival benefits of WLS after breast and endometrial cancer diagnosis.

A nonhuman primate model of vertical sleeve gastrectomy facilitates mechanistic and translational research in human obesity

The obesity epidemic significantly contributes to overall morbidity and mortality. Bariatric surgery is the gold standard treatment for obesity and metabolic dysfunction, yet the mechanisms by which it exerts metabolic benefit remain unclear. Here, we demonstrate a model of vertical sleeve gastrectomy (VSG) in nonhuman primates (NHP) that mimics the complexity and outcomes in humans. We also show that VSG confers weight loss and durable metabolic benefit, where equivalent caloric intake in shams resulted in significant weight gain following surgery. Furthermore, we show that VSG is associated with early, weight-independent increases in bile acids, short-chain fatty acids, and reduced visceral adipose tissue (VAT) inflammation with a polarization of VAT-resident immunocytes toward highly regulatory myeloid cells and Tregs. These data demonstrate that this strongly translational NHP model can be used to interrogate factors driving successful intervention to unravel the interplay between physiologic systems and improve therapies for obesity and metabolic syndrome.

Bariatric surgery and its impact on fertility, pregnancy and its outcome: A narrative review

Bariatric procedures are on the rise as a surgical treatment for morbid obesity. In reproductive age of women, bariatric surgeries will improve factors related to anovulation and lead to spontaneous fertility. Spontaneous pregnancy can happen within a year after bariatric surgery due to higher level of sex hormone binding globulin and follicular stimulating hormone and reduction in androgens level. Reduction of length of follicular phase of menstrual cycle was reported and contribute to improved ovulatory status.

The major impact to pregnant women is development of small for gestational age babies due to persistent weight loss but this can be minimized by avoiding pregnancies too soon after bariatric surgery and good nutrition supplement. Risk of developing gestational diabetes mellitus and preeclampsia reduced among post bariatric surgery compared to no surgery. Another benefit observed are reduction in the risk of caesarean section and admission to neonatal intensive care unit. There are no significant changes in composition of breast milk in postpartum women without bariatric surgery and with women whom undergone surgery although more study needed to evaluate this effect.

Good prenatal care, micronutrient supplement during antenatal follow up and close supervision from expert managing this pregnancy are essential component to ensure good outcome to mothers and their newborn.

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Bariatric surgery in obese women will lead to improvement in ovulation.

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Bariatric surgery will improve the BMI and reduce risk associated with Gestational Diabetes Mellitus and Preeclampsia.

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Bariatric surgery will improve BMI and reduce miscarriages.

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Bariatric surgery in obese women will improve perinatal outcome.

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Mode of delivery and role of breastfeeding after bariatric surgery in obese women.

Five Years of MBSAQIP Data: Characteristics, Outcomes, and Trends for Patients with Super-obesity

PURPOSE

Incidence of super obesity (SO; BMI ≥ 50 kg/m²) is growing rapidly and confers worse metabolic complications than non-SO (BMI 30-50 kg/m²). We aim to characterize bariatric surgery patients with SO, their postoperative complications, and treatment trends over the last 5 years in hopes of informing SO-specific treatment protocols.

MATERIALS AND METHODS

The MBSAQIP database was analyzed, and two cohorts were compared, those with SO and non-SO. Univariate analysis was performed to determine between-group differences. Multivariable logistic regression analysis was performed to determine if SO was independently associated with serious complications or mortality.

RESULTS

We evaluated 751,952 patients with 173,110 (23.0%) having SO. Patients with SO were younger (42.2 ± 11.8 SO vs 45.1 ± 12.0 years non-SO, p < 0.001) and less likely to be female (74.8% vs 81.1%, p < 0.001). While comorbidities seem to be decreasing overall in bariatric surgery patients, those with SO have worse functional capacity and more endocrine, pulmonary, and vascular comorbidities. Patients with SO also have worse 30-day postoperative complications, and SO was independently associated with severe complications (OR 1.08; CI 1.05-1.11, p < 0.001) and mortality (OR 2.49; CI 2.12-2.92, p < 0.001) CONCLUSIONS: Patients with SO have significantly increased preoperative comorbidities resulting in worse postoperative outcomes. SO remains an independent risk factor for serious complications and the greatest independent risk factor for 30-day postoperative mortality. Considering the expected increase in patients with SO, substantial work is required to optimize bariatric surgery strategies specific to these patients.

Systemic and Environmental Contributors to Obesity Inequities in Marginalized Racial and Ethnic Groups

Obesity is a multifactorial disease that disproportionally affects diverse racial and ethnic groups. Structural racism influences racial inequities in obesity prevalence through environmental factors, such as racism and discrimination, socioeconomic status, increased levels of stress, and bias in the health care delivery system. Researchers, clinicians, and policy makers must work to address the environmental and systematic barriers that contribute to health inequities in the United States. Specifically, clinicians should quantitatively and qualitatively assess environmental and social factors and proactively engage in patient-centered care to tailor available treatments based on identified needs and experiences.

Analysis of Emergency Department Visits and Unplanned Readmission After Bariatric Surgery: An Experience From a Tertiary Referral Center

BACKGROUND

Bariatric surgery is the most effective treatment of morbid obesity. As the number of bariatric procedures performed has increased, visits to the emergency department (ED) and readmissions have subsequently increased. The present study aimed to assess the rates and indications for of ED visits and readmission after bariatric surgery and to identify the predictors of hospital readmission.

PATIENTS AND METHODS

This was a retrospective cohort study on patients who underwent bariatric surgery from January 2018 to April 2020. The percentage of ED visits and unplanned readmission was estimated and the indications and management of each were analyzed. The association of age, sex, body mass index, and type of procedure with readmission was assessed.

RESULTS

Of 582 patients who underwent bariatric surgery in the study period, 204 (35%) required ED visits, and 42 (7.2%) required readmission. The mean age of patients was 33 years, and the mean body mass index was 43 kg/m2. The most common indication for ED visits was abdominal pain (41.2%). In all, 64.8% of ED visits and 43% of readmissions were unrelated to bariatric surgery complications. A total of 94.1% of patients who required ED visits and 71.4% of readmitted patients were managed conservatively. The most common procedure followed by readmission was laparoscopic sleeve gastrectomy (50%) then one-anastomosis gastric bypass (21.4%). Age, sex, body mass index, and procedure type were not significantly associated with higher readmission.

CONCLUSIONS

The rates of ED visits and readmission in our cohort were 35% and 7.2%, respectively. Most cases of ED visits were not related to adverse effects of bariatric surgery and the majority of which were managed conservatively.

Changes in clinical depression following Sleeve Gastrectomy

INTRODUCTION

Bariatric surgery is safe and efficient surgical method for weight loss, but it is not free from complications. We aim to evaluate the prevalence of depression after Sleeve Gastrectomy (SG) in a narrow period of time on Iranian ethnicity.

METHODS

307 cases that underwent SG in Erfan Niayesh hospital were included. The questionnaire was based on International Classification of Diseases, Ninth Revision (ICD-9) codes to define diagnoses. Screening follow-up period was 20 to 24 months. The level of statistical significance was set at p < .05.

RESULTS

Of 307 subjects, preoperative depression was 30.2% and post-operative depression was 37.7% (p = .025). Besides, BMI, dyslipidaemia, good feelings about body size and weight loss were statistically significant at p < .05.There was an increased risk of depression following the procedure mainly in divorced cases.

CONCLUSION

The prevalence of clinical depression after sleeve gastrectomy was statistically significant and dependent on other variables. We provided guidance for people considering SG and their clinicians in terms of evaluating potential risks and benefits of surgery.

Pharmacotherapeutic options for weight regain after bariatric surgery

PURPOSE OF REVIEW

We sought to critically evaluate the recent literature published over the past 3 years on the topic of weight regain after bariatric surgery in children, adolescents, and adults, with an emphasis on clinically- relevant information for pharmacologic treatment of weight regain after metabolic and bariatric surgery.

FINDINGS

There are multiple pharmacotherapeutic agents available to treat obesity in children, adolescents, and adults; these agents have varying efficacy and indications for use and have been studied in a variety of clinical and research scenarios. We present an overview of these findings.

SUMMARY

This review represents a comprehensive compilation of the recently published data on efficacy of anti-obesity pharmacotherapy in the treatment of weight regain after bariatric surgery for children, adolescents, and adults.

Characterizing Timing of Postoperative Complications Following Elective Roux-en-Y gastric Bypass and Sleeve Gastrectomy

Purpose

With the growing prevalence of bariatric procedures performed worldwide, it is important to understand the timing of postoperative complications following bariatric surgery and the differences which may exist between procedures.

Methods

This retrospective study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2017 to 2018. All patients with primary elective Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were included. The primary outcome was to characterize the timing of postoperative complications for RYGB and SG.

Results

A total of 316,314 patients were identified with 237,066 (74.9%) in the SG cohort and 79,248 (25.1%) in the RYGB cohort. Early complications included myocardial infarction (4.7 ± 6.4 days), cardiac arrest (6.4 ± 8.5 days), pneumonia (6.9 ± 6.9 days), progressive renal insufficiency (8.1 ± 8.1 days), and acute renal failure (8.2 ± 7.6 days). Late complications included Clostridioides difficile infection (11.3 ± 7.8 days), organ space infections (11.7 ± 7.9 days), deep incisional infections (12.4 ± 6.6 days), superficial incisional infections (13.2 ± 6.9 days), and urinary tract infections (14.0 ± 8.4 days). SG patients were more likely to be diagnosed later than RYGB patients with regard to superficial incisional infections (14.0 ± 7.4 days vs 12.5 ± 6.3 days; p = 0.002), organ space infections (12.6 ± 7.8 days vs 10.8 ± 7.9 days; p = 0.001), acute renal failure (9.3 ± 8.1 days vs 6.8 ± 6.8 days; p = 0.03), and pulmonary embolism (13.7 ± 7.5 days vs 11.3 ± 8.0 days; p = 0.003). No significant difference in timing was observed for any other complication by procedures.

Conclusion

We demonstrate that significant differences in timing exist between complications and that these differences also vary by surgical procedure.

Graphical abstract

The Effect of Social Determinants and Socioeconomic Status on Laparoscopic Roux-En-Y Gastric Bypass for Weight Loss: An Analysis of the National Inpatient Sample

Objective  In the United States, Black and Hispanic patients have a higher prevalence of obesity than Whites (49.6 vs. 44.8 vs. 42.2%, respectively). Despite higher rates of obesity among minority populations, bariatric surgery is performed at higher obesity levels in minorities than in Whites. This study examines the effects of various socioeconomic factors such as race, payer type, and income on the likelihood of undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) at class II versus class III obesity and their associated complications. Materials and Methods  National Inpatient Sample (NIS) from 2016 to 2017 was queried to identify patients at least 18 years of age with a concomitant diagnosis of class II or class III obesity who underwent LRYGB. We analyzed obesity level at the time of LRYGB (class II vs. class III), postoperative intestinal obstruction during the admission, and occurrence of any noninfectious complication related to the surgery as our main outcomes. A multivariate logistic regression model was utilized to assess the association between our outcomes and socioeconomic factors associated with the admission. Results  A total of 76,405 LRYGB operations were included. Out of this total, 83% (63,640) LRYGB operations were in class III obesity. Black patients had a lower rate (11.6%) of LRYGB procedures at class II obesity than White (17.6%) and Hispanic (18%) patients ( p  < 0.001). Medicare, Medicaid, and lower income quartiles also showed lower rates of operation at class II obesity ( p  < 0.001). Black patients were 29% (95% confidence interval [CI]: 0.61-0.83, p  < 0.001) less likely than Whites to have a LRYGB procedure at class II obesity, they were 119% (95% CI: 1.17-4.11, p  = 0.0014) more likely to suffer a postoperative intestinal obstruction, and they were 93% (95% CI: 1.31-2.84, p  < 0.001) more likely to suffer a noninfectious complication. Conclusion  Socioeconomic disparities in the surgical management of severe obesity persist in the United States, especially for LRYGB. This study highlights multiple demographic factors that led to LRYGB at later obesity levels. Black patients were also more likely to be associated with postoperative complications during the admission. The determinants of health disparities in obese patients need to be examined further to reduce potential long-term morbidity and mortality in minorities. Further research is also required to identify the adverse effects of health disparities in patients with severe obesity and obesity-related comorbidities.

Long-term Emergency Department Visits and Readmissions After Laparoscopic Roux-en-Y Gastric Bypass: a Systematic Review

PURPOSE

There is considerable evidence on short-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB), but data on long-term outcome is scarce, especially on postoperative emergency department (ED) visits and readmissions. We aim to systematically review evidence on the incidence, indications, and risk factors of ED visits and readmissions beyond 30 days after LRYGB.

MATERIALS AND METHODS

A systematic search in PubMed, Scopus, Embase.com , Cochrane Library, and PsycINFO was performed. All studies reporting ED visits and readmissions > 30 days after LRYGB, with ≥ 50 patients, were included. PRISMA statement was used and the Newcastle-Ottawa Scale for quality assessment.

RESULTS

Twenty articles were included. Six studies reported on ED visits (n = 2818) and 19 on readmissions (n = 276,543). The rate of patients with an ED visit within 90 days after surgery ranged from 3.9 to 32.6%. ED visits at 1, 2, and 3 years occurred in 25.6%, 30.0%, and 31.1% of patients. Readmissions within 90 days and at 1-year follow-up ranged from 4.1 to 20.5% and 4.75 to 16.6%, respectively. Readmission was 29% at 2 years and 23.9% at 4.2 years of follow-up. The most common reason for ED visits and readmissions was abdominal pain.

CONCLUSION

Emergency department visits and readmissions have been reported in up to almost one in three patients on the long-term after LRYGB. Both are mainly indicated for abdominal pain. The report on indications and risk factors is very concise. A better understanding of ED visits and readmissions after LRYGB is warranted to improve long-term care, in particular for patients with abdominal pains.

Gender as a Deterministic Factor in Procedure Selection and Outcomes in Bariatric Surgery

Background and Objectives:

With obesity rates rising in the United States, bariatric surgery has become a well-established and effective treatment for morbid obesity and its comorbid conditions. Laparoscopic Roux-en-Y gastric bypass and laparoscopic Sleeve Gastrectomy are two of the more common bariatric procedures. This study analyzes whether gender differences play a role in procedure selection and outcomes following either procedure.

Methods:

Using the American College of Surgeons National Surgical Quality Improvement Program database for years 2015 to 2017, we assessed demographics, postoperative complications, and readmission rates. Chi-square analysis, student t-test, and propensity analyses were performed appropriately.

Results:

Data review found that men presenting for bariatric surgery had a higher incidence of comorbidities and higher body mass index than women. More men than women underwent Sleeve Gastrectomy (68.5% vs 63.0%, P <0.0001), while more women than men underwent Laparoscopic Roux-en-Y gastric bypass (37.0% vs 31.5%, P < 0.0001). In the Laparoscopic Roux-en-Y group, men experienced more postoperative complications, including cardiac arrest (0.2% vs 0.1%, P = 0.02) and unplanned intubation (0.4% vs 0.2%, P = 0.02). In the Sleeve Gastrectomy group, men experienced more postoperative complications, including myocardial infarction (0.2% vs 0.1%, P = 0.006). In both groups, women experienced higher rates of unplanned readmissions (3.5% vs 2.8%, P = 0.0012).

Conclusions:

This study found that men are more likely to undergo Sleeve Gastrectomy than Laparoscopic Roux-en-Y gastric bypass, despite higher complication rates for both. Women have higher rates of unplanned readmission rates regardless of procedure, despite lower postoperative morbidity.

Factors Associated with the Development of Anemia During Pregnancy After Sleeve Gastrectomy

PURPOSE

Nutritional deficiencies, particularly anemia, are commonly encountered following bariatric surgery. While anemia during pregnancy is associated with various adverse maternal and perinatal outcomes, the factors associated with its occurrence following bariatric surgery have not been established. We explored the factors associated with the development of anemia during pregnancy after laparoscopic sleeve gastrectomy (SG).

MATERIALS AND METHODS

We reviewed the records of women who underwent SG and delivered during 2010-2018 in a single university hospital.

RESULTS

Of 121 women, 68 (56.2%) had evidence of anemia (hemoglobin < 11.0 g/dL) prior to delivery, with significantly lower hemoglobin levels compared with those (n = 53) without anemia (median 9.9 vs. 11.4 g/dL, P < 0.001). Significantly lower hemoglobin levels were found among those with pre-delivery anemia, both at the pre-operative stage (median 12.9 vs. 13.3 g/dL, P = 0.02) and at early pregnancy (median 12.0 vs. 12.6 g/dL, P = 0.05), compared with those without anemia. In multivariate analysis, a lower pre-operative hemoglobin level was the only independent factor associated with pre-delivery anemia (OR (95% CI) 1.59 (1.05, 2.40), P = 0.03). The rate of blood transfusion was significantly higher in women with pre-delivery anemia than in women without anemia (7.4% vs. 0, P = 0.04).

CONCLUSIONS

Anemia during pregnancy after SG was common; pre-operative hemoglobin level was identified as an independent predictor of its occurrence. Efforts should be invested to implement anemia risk stratification before surgery among reproductive-age women, and to optimize maternal nutritional status prior to pregnancy, as well as during the prenatal course.

High Prevalence of Food Insecurity in Participants Attending Weight Management and Bariatric Surgery Programs

We evaluated the prevalence and correlates of household food insecurity (HFI) in participants attending weight management and bariatric surgery programs (WMP). We surveyed participants (N = 298) residing with a child and romantic partner from two WMP offering bariatric surgery and medical weight management. We assessed HFI using the Hunger Vital Sign and conducted multivariate logistic regression to assess correlates of HFI. HFI was present in 29.2% of participants. There were increased odds of HFI in participants with lower income and those with three or more children living at home. There was no association with sex, race, program type, education, or BMI. HFI is highly prevalent among participants of WMP. WMP should screen all participants for food insecurity to address this potential barrier to a healthy lifestyle.

Celiac Disease and Obesity: Is Bariatric Surgery an Option?

Celiac disease is an immune-mediated enteropathy associated with malabsorptive syndrome and fat-soluble vitamin deficiencies. Celiac disease affects 1% of individuals but is largely underdiagnosed, as its multifaceted clinical presentations create challenging diagnostic scenarios. With the rise of the obesity epidemic, doctors are increasingly seeing celiac disease patients with overweight or obesity, which raises the question of bariatric surgery. However, few studies so far have investigated bariatric surgery in this patient population. Here, we provide a comprehensive review of the literature on celiac disease, its nutritional consequences and complications, and we discuss the possible impact of bariatric surgery on weight loss, nutritional deficiencies, response to gluten-free diet, and long-term post-operative complications. We also review the effect of bariatric surgery on the incidence of celiac disease.

Accuracy of High-Resolution Manometry in Hiatal Hernia Diagnosis in Primary and Revision Bariatric Surgery

PURPOSE

There is a complex association between obesity, hiatal hernia (HH), and reflux. There is a deficiency of literature on the accuracy of preoperative high-resolution manometry (HRM) in detecting HH before both primary and revision bariatric surgery.

MATERIALS AND METHODS

A retrospective analysis of a prospective database of all HRM performed before bariatric surgery from 2014 to 2019. An electronic medical records review was conducted. Sensitivity, specificity, and global diagnostic test accuracy were calculated.

RESULTS

Sixty-seven patients with HRM (mean age of 44.0 ± 11.3 years, body mass index 40.8 ± 6.9 kg/m²) were eligible. Intraoperative diagnosis of HH was made in 37 patients (55.2% prevalence). The HRM sensitivity was 48.7% (95% confidence interval (CI) 31.9-65.6%), specificity 90.0% (95% CI 73.5-97.9%), and accuracy was 67.2% (95% CI 54.6-78.2%). Comparing primary (28) and revision (39) surgery, the sensitivity (37.5% vs 57.1%), specificity (75.0% vs 100%), and diagnostic accuracy (54.3% vs 76.3%) were comparable, with overlapping 95% CI. Endoscopy performed in 30 patients had a sensitivity of 25.5% (95% CI 6.8-49.9%), specificity of 100% (95% CI 75.3-100%), and accuracy of 57.8% (95% CI 38.5-75.5%) and was comparable to HRM.

CONCLUSION

High-resolution manometry for the detection of HH before bariatric surgery has a high specificity and maintains a high accuracy in both primary and revision bariatric surgery.

Neonatal Outcomes of Pregnancy Following Roux-en-Y Gastric Bypass: a Matched Case-Control Study

PURPOSE

To compare perinatal outcomes and to assess the predictors of birth weight (BW) after Roux-en-Y gastric bypass (RYGB) to those women unexposed to bariatric surgery.

MATERIALS AND METHODS

Singleton births from women submitted to RYGB (BSG) were matched to two control births by maternal age, delivery year, and gender. Control group 1 (CG1) and control group 2 (CG2) were selected according to the prepregnancy body mass index (BMI) < 35 kg/m² and ≥ 35 kg/m², respectively, without previous bariatric surgery.

RESULTS

Fifty-eight pregnancies were evaluated in each group (n = 174). Neonates born after RYGB presented lower BW compared to CG1 (mean difference - 182.3 g; 95% CI - 333; - 31, P = 0.018) and CG2 (mean difference - 306.6 g, 95% CI - 502; - 111, P = 0.02). Although gestational age (GA) was similar (P = 0.219), fetal growth rate (in grams) per gestational week was higher in CG2 (β = 196.27, P < 0.001) vs. BSG (β = 127.65, P < 0.001), irrespective of gestational weight gain (GWG). Pregnancies post-RYGB showed lower GWG, lower BW, and higher prevalence of cesarean section than CG1 and were associated with lower BW, smaller cephalic perimeter, lower prevalence of macrosomia, hypertension, and gestational diabetes than CG2.

CONCLUSION

Birth weight was higher in neonates from women with higher prepregnancy BMI, as compared to births from women submitted to RYGB, irrespective of GWG. Although nearly half of the RYGB mothers were classified with obesity at conception, those pregnancies were associated with better obstetric and neonatal outcomes than among women with prepregnancy BMI ≥ 35 kg/m² who had never undergone RYGB.

An Evaluation of the Modern North American Bariatric Surgery Landscape: Current Trends and Predictors of Procedure Selection

PURPOSE

The last 5 years have produced a dramatic transformation in the landscape of bariatric and metabolic surgery. Yet, while the landscape of bariatric procedures is changing, little is known about these trends or which factors are responsible for their evolution.

METHODS

All primary elective laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) cases were extracted from the comprehensive Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2018.

RESULTS

A total of 590,971 patients were identified, with 79.6% being female. Overall, 73.4% of patients underwent LSG. The mean age was 44.5 ± 12.0 years and mean BMI was 45.3 ± 7.9 kg/m². An increase in proportion of LSG cases was observed and associated with a decrease in LRYGB cases from 2015 to 2018. Multivariable analysis identified dialysis dependence as the greatest predictor of LSG (OR 2.67; 95% CI 2.34-3.04), whereas insulin-dependent diabetes (OR 2.27; 95% CI 2.23-2.32) and gastroesophageal reflux disease (OR 1.52; 95% CI 1.51-1.55) were the two greatest predictors of LRYGB, respectively. Patients offered LSG in 2018 had a near 1.3-fold increase in odds of receiving sleeve gastrectomy vs. those offered surgery in 2015.

CONCLUSION

The overall numbers of bariatric cases have increased from 2015 to 2018 and are associated with an increase in proportion of LSG cases and a decrease in proportion of LRYGB cases over time. Factors other than patient comorbidities alone are responsible for the current trends and modern landscape of bariatric surgery.

Postnatal Health in Children Born to Women After Bariatric Surgery

INTRODUCTION

The aim of this study is to evaluate short- and long-term consequences in children born to women after different bariatric surgery (BS) procedures.

METHODS

A questionnaire survey was given to the mothers referred from 1994 to 2019 to our center for pregnancy and delivery management after BS procedures: (a) malabsorptive surgery, (b) restrictive procedures, and (c) combined restrictive-malabsorptive procedures.

RESULTS

Data from 74 children born after BS, aged 0 month to 12 years, were analyzed. The prevalence of children with underweight was 5.4%, normal weight 59.5%, overweight 16.2%, and obesity 18.9%. The prevalence of obesity was higher in children pre-school aged than that in school-aged ones. Neurodevelopmental disorders were more frequent if maternal BMI before bariatric surgery was ≥ 41 kg/m² (p = 0.008), as well as if the pregnancy occurred less than 18 months after BS (p = 0.028). In school-aged children conceived within 18 months after BS, the highest risk of neurodevelopmental disorders (p = 0.028) and overweight (p = 0.018) was observed. The prevalence of neurodevelopmental disorders was much higher for small for gestational age babies (p = 0.048). Children born after biliopancreatic diversion (BPD) showed less maternal breastfeeding, shorter breastfeeding duration, more overweight, and more occurrence of atopic dermatitis in comparison with children born after other bariatric procedures.

CONCLUSIONS

Postnatal health in children born to women after BS was impaired by long-term consequences and by other diseases later in life. Children born after BPD were particularly at higher risk for short and long term consequences when compared to children born after other BS procedures.

Revisional Surgery for Insufficient Loss or Regain of Weight After Roux-en-Y Gastric Bypass: Biliopancreatic Limb Length Matters

INTRODUCTION

Weight regain after laparoscopic Roux-en-Y gastric bypass (RYGB) occurs in up to 35% of patients. Revisional surgery may be applied. Conversion from RYGB to a long biliopancreatic limb (BPL) RYGB is a potential option for revisional surgery and short-term results are promising.

METHODS

All patients who underwent conversion to long BPL RYGB due to weight loss failure, defined as excess weight loss (EWL) < 50% or body mass index (BMI) > 35 kg/m², were assessed. Proximal RYGB or very very long limb RYGB (VVLL RYGB) was modified by shortening of the total alimentary limb length (TALL) to create a long BPL.

RESULTS

A total of 28 patients received revisional surgery from either PRYGB (n = 22) or VVLL RYGB (n = 6). Mean age at operation was 45.3 ± 10.4 years, with 78% females. Mean prerevisional BMI was 41.7 ± 4.4 kg/m². Mean time to revision was 76.5 ± 38.5 months. Limb lengths were 150 cm (95% CI 133-156 cm) for RL and 100 cm (95% CI 97-113 cm) for CC, thus providing a total median alimentary limb length of 250 (95% CI 238-260 cm). Additional %EWL and TWL improved significantly in long-term. Five years postoperatively, all patients (n = 9) had an EWL% > 50%. Six patients (21.4%) required reoperation due to severe malnutrition during the postoperative course.

CONCLUSION

Conversion from RYGB to BPL RYGB leads to significant additional weight loss in the long term. However, the morbidity is relevant, especially severe protein malnutrition and the frequency of revisional surgery. Therefore, this type of surgery should not be done routinely.

Evidence-based weight loss interventions: Individualized treatment options to maximize patient outcomes

Against the backdrop of obesity as a major public health problem, we examined three questions: How much weight loss is needed to benefit patients with obesity? How well do current therapies do in producing weight loss? What strategies can be used to improve patient outcomes using evidence-based studies. This paper reviews literature on the outcomes of lifestyle, diet, medications and surgical treatments for obesity using literature searches for obesity treatments. Current treatments, including lifestyle, diet and exercise, produce a weight loss of 5% to 7% on average. Despite continued attempts to identify superior dietary approaches, most careful comparisons find that low carbohydrate diets are not significantly better than low fat diets for weight loss. The four medications currently approved by the US Food and Drug Administration for long-term management of obesity are not as effective as surgery, adding about 5% on average to lifestyle approaches to weight loss. Two new medications that are under investigation, semaglutide and tirzepatide, significantly improve on this. For all treatments for weight loss, including lifestyle, medications and surgery, there is enormous variability in the amount of weight lost. Examination of this literature has yielded evidence supporting baseline and process predictors, but the effect sizes associated with these predictors are small and there are no prospective studies showing that a personalized approach based on genotype or phenotype will yield uniform success. Because obesity is a chronic disease it requires a 'continuous treatment model' across the lifespan.

Type 2 Diabetes Modifies Skeletal Muscle Gene Expression Response to Gastric Bypass Surgery

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) is an effective treatment for type 2 diabetes mellitus (T2DM) that can result in remission of clinical symptoms, yet mechanisms for improved skeletal muscle health are poorly understood. We sought to define the impact of existing T2DM on RYGB-induced muscle transcriptome changes.

METHODS

Vastus lateralis biopsy transcriptomes were generated pre- and 1-year post-RYGB in black adult females with (T2D; n = 5, age = 51 ± 6 years, BMI = 53.0 ± 5.8 kg/m²) and without (CON; n = 7, 43 ± 6 years, 51.0 ± 9.2 kg/m²) T2DM. Insulin, glucose, and HOMA-IR were measured in blood at the same time points. ANCOVA detected differentially expressed genes (p < 0.01, fold change < |1.2|), which were used to identify enriched biological pathways.

RESULTS

Pre-RYGB, 95 probes were downregulated with T2D including subunits of mitochondrial complex I. Post-RYGB, the T2D group had normalized gene expression when compared to their non-diabetic counterparts with only three probes remaining significantly different. In the T2D, we identified 52 probes upregulated from pre- to post-RYGB, including NDFUB7 and NDFUA1.

CONCLUSION

Black females with T2DM show extensive downregulation of genes across aerobic metabolism pathways prior to RYGB, which resolves 1 year post-RYGB and is related to improvements in clinical markers. These data support efficacy of RYGB for improving skeletal muscle health, especially in patients with T2DM.

Where Has All the Complexity Gone? An Analysis of the Modern Surgical Resident Operative Experience

OBJECTIVES

The operative experience of today's general surgery (GS) residents are changing. The Surgical Council on Resident Education (SCORE) was founded to provide a standardized, competency-based curriculum. We set out to evaluate resident operative experience in core and advanced operations.

DESIGN

Accreditation Council for Graduate Medical Education (ACGME) national operative log reports from 2010 to 2018 were reviewed. Operative volume data for 344 operations were extracted and analyzed. Operations were designated as core, advanced, or undefined as listed by SCORE, and stratified as GS or subspecialty.

SETTING

National analysis utilizing ACGME operative log reports.

PARTICIPANTS

All graduating general surgery residents between 2010 and 2018.

RESULTS

A total of 10,118 residents completed GS training with an average of 1121.5 ± 29.3 total cases. Core operations comprised 80.5% of total volume while advanced comprised only 8.0%. The total core experience increased (+7.0 cases/year), while total advanced experience decreased (-1.4 cases/year) (p < 0.01 each). Compositional analysis among core operations revealed an increase in 9/13 GS domains and a decrease in 8/10 subspecialty domains (all p < 0.05).

CONCLUSIONS

There has been an increase in core operative experience with a concurrent decrease in advanced operative experience of graduating GS residents. These findings highlight the continued narrowing of the operative experience for trainees, with increasing focus on GS and less on subspecialty domains. Ongoing efforts to look beyond operative volume to ensure competency of graduates will prove beneficial.

Bariatric surgery outcomes in Medicare beneficiaries

Background

The Medicare population is increasing while the prevalence of obesity remains high. Bariatric surgery is the most efficacious treatment of obesity and its comorbidities. The objective of this investigation was to assess trends in utilization, readmission, mortality, and cost of bariatric surgery in the Medicare population.

Methods

Utilizing the Medicare Provider Analysis and Review database, patients with clinically severe obesity undergoing laparoscopic Roux‐en‐Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB) from 2011–2015 were identified. Trends in procedure selection, readmissions, mortality, and cost were examined. A multivariable logistic regression analysis to evaluate factors associated with readmission and mortality was performed.

Results

Of the 73,718 patients identified, 53,949 (73%) of patients were enrolled in Medicare due to disability, 19,191 (26%) due to age, and 578 (<1%) due to end stage renal disease (ESRD). Utilization of SG increased (1% in 2011 to 61% in 2015), while utilization of RYGB (68% to 32%) and LAGB (31% to 1%) decreased. Length of stay (LOS) was highest after RYGB (2.54 days), and lowest after LAGB (1.32 days). LOS decreased from 2.23 days in 2011 to 2.12 days in 2015. Thirty‐day readmissions were 8.24% for the disabled, 5.5% for the elderly, 12.8% with ESRD. Odds of readmission increased with black race, higher body mass index (BMI), and RYGB. Readmission decreased from 8% in 2011 to 7% in 2015. Thirty‐day mortality was 0.22% in the disabled, and 0.28% in the elderly. Odds of 30‐day mortality increased among men, those with higher BMI, some comorbidities, and those who underwent RYGB. Cost of SG decreased while cost of RYGB increased.

Conclusions

Among the Medicare population, an increase in SG while a decrease in RYGB and LAGB utilization was noted from 2011–2015. Readmissions and cost have decreased, while mortality has remained low.