Race, Insurance, and Socioeconomic Influences on Outcomes Following Roux-En-Y Gastric Bypass

The effectiveness of Roux-en-Y gastric bypass (RYGB) might be shadowed by disparities in outcomes related to patient race and insurance type. We determine the influence of patient race/ethnicity and insurance types on complications following RYGB. We performed a retrospective analysis using data sourced from the National Inpatient Sample Database (2010 to 2019). A multivariate analysis was employed to determine the relationship between patient race/ethnicity and insurance type on RYGB complications. The analysis determined the interaction between race/ethnicity and insurance type on RYGB outcomes. We analyzed 277714 patients who underwent RYGB. Most of these patients were White (64.5%) and female (77.3%), with a median age of 46 years (IQR 36-55). Medicaid beneficiaries displayed less favorable outcomes than those under private insurance: Extended hospital stay (OR = 1.68; 95% CI 1.58-1.78), GIT Leak (OR = 1.83; 95% CI 1.35-2.47), postoperative wound infection (OR = 1.88; 95% CI 1.38-2.55), and in-hospital mortality (OR = 2.74; 95% CI 1.90-3.95).

The impact of the affordable care act on access to bariatric surgery in Maryland

INTRODUCTION

This study aims to investigate the influence of the Affordable Care Act (ACA) on the utilization of Roux-en-Y gastric bypass (RYGB) procedures in Maryland.

METHODS

Using the Maryland State Inpatient Database, this retrospective study compared all patients undergoing RYGB during the pre-ACA (2007-2009) and post-ACA (2018-2020) periods, including patient demographic factors, pre-existing conditions, and socioeconomic factors.

RESULTS

A total of 16,494 RYGB procedures were performed during the study period, of which 12,089 (73.3 ​%) were post-ACA. This was a 179.2 ​% increase in patients undergoing RYGB post-ACA; nearly triple that of the pre-ACA period. There was a significant decrease in uninsured patients (5.6 ​%-1.5 ​%, p ​< ​0.01) an increase in Black patients (32.1 ​%-46.8 ​%, p ​< ​0.01) and Medicaid beneficiaries (6.0 ​% pre-ACA to 17.8 ​% post-ACA, p ​< ​0.01). There were significant reductions in adverse outcomes (long hospital stays, hemorrhage, GIT leaks, and mortality) across all insurance types (all p ​< ​0.01).

CONCLUSION

The ACA increased access to RYGB procedures, especially in Black and Medicaid recipients in Maryland, enhancing healthcare across all insurance types.

Should I be Concerned? Surgical Training in the Time of COVID19

As the US healthcare system restructured to deal with the COVID-19 pandemic, medical training was significantly disrupted. During the peak of the crisis, three surgical trainees in different stages of their residency shared their experiences and concerns on how this pandemic affected their training. The article is intended to generate discussion on the concerns of derailment and stagnation of surgical training and difficulties faced at all levels of surgical training to perform clinical duties and fulfill academic responsibilities during the early months of the COVID pandemic.

Are we doing too many non-therapeutic laparotomies in trauma? An analysis of the National Trauma Data Bank

BACKGROUND

Exploratory laparotomy (EL) has been the definitive diagnostic and therapeutic modality for operative abdominal trauma in the US. Recently, many trauma centers have started using diagnostic laparoscopy (DL) in stable trauma patients in an effort to reduce the incidence of non-therapeutic laparotomy (NL). We aim to evaluate the incidence of NL in the trauma population in the US and compare the outcomes between DL and NL.

METHODS

Using ICD-9 codes, the National Trauma Data Bank (2010-2015) was queried for patients undergoing any abdominal surgical intervention. Patients were divided into two groups: diagnostic laparoscopy (DL) and exploratory laparotomy (EL). Hemodynamically unstable patients on arrival and patients with abbreviated injury score (AIS) > 3 were excluded. Patients in EL group without any codes for gastrointestinal, diaphragmatic, hepatic, splenic, vascular, or urological procedures were considered to have undergone NL. After excluding patients who were converted to open from the DL group, multivariate regression models were used to analyze the outcomes of DL vs NL group with respect to mortality, length of stay, and complications.

RESULTS

A total of 3197 patients underwent NL vs 1323 patients who underwent DL. Compared to DL group, the NL group were older (mean age: 35 vs. 31, P < 0.01). Rate of penetrating injury was 77% vs 86% for patients in NL vs DL. On multivariate analysis, NL was associated with increased mortality (OR 4.5, 95% CI 2.1-9.7), higher rate of complications (OR 2.2, 95% CI 1.4-3.3), and a longer hospital stay (OR 2.7, 95% CI 2.1-3.5). NL was also associated with higher rates of pneumonia, VTE, ARDS, and cardiac arrest.

CONCLUSION

With increasing experience in minimally invasive surgery, DL should be a part of the armamentarium of trauma surgeons. This study supports that in well-selected trauma patients DL has favorable outcomes compared to NL. These findings warrant further investigation.

Midterm outcomes of revisional surgery for gastric pouch and gastrojejunal anastomotic enlargement in patients with weight regain after gastric bypass for morbid obesity

Reoperative surgery for the morbidly obese has become increasingly common due to postoperative weight regain. There are limited studies evaluating the effectiveness of revisional surgery. This study evaluates the weight loss outcomes of revisional surgery over a 2-year period at our University Hospital, USA. Of the 412 patients who underwent laparoscopic bariatric surgery between June 2009 and June 2011, we identified 25 patients who had Roux-en-Y gastric bypass (RYGB) originally, who underwent laparoscopic revisional surgery for weight regain. Preoperative and postoperative data were reviewed. Statistical analysis was performed using paired t test. This study includes 0 male and 25 female patients with an average age of 42 (range min to max: 28-58), mean original body mass index (BMI) of 54.6 kg/m(2) (r = 37.3-80.7), average lowest BMI achieved of 32.2 (r = 20.1-50.9), and average BMI at the time of revision of 41.0 kg/m(2) (r = 29.5-60.7, standard deviation (SD) = 8.5). All laparoscopic revisions consisted of resizing the gastric pouch by resection and recreating the gastrojejunostomy. Average hospital length of stay was 1.28 days (r = 1-4). Perioperative morbidity was 8 %; one patient developed a trocar site hernia which required repair, and another suffered postoperative bleeding requiring transfusion. There was no mortality. Postoperative BMI averages at 3, 6, 9, 12, and 24 months were 35.0 (SD = 7.15), 34.7 (SD = 4.26), 36.2 (SD = 7.63), 33.0 (SD = 6.58), and 44.2 (SD = 12.87), respectively. Statistically significant weight loss was achieved at 3 [t (10) = 6.74, p < 0.05], 6 [t (7) = 4.69, p < 0.05], 9 [t (9) = 2.94, p < 0.05], and 12 [t (6) = 3.78, p < 0.05] months. However, there was no statistically significant weight loss at 24 months postoperatively [t (4) = -0.16, p > 0.05]. Laparoscopic revisional bariatric surgery can be performed with significant weight loss up to 1 year postoperatively. However, additional studies are required to evaluate longer-term success.

Open abdominal surgery: a risk factor for future laparoscopic surgery?

BACKGROUND

This study seeks to investigate the outcomes of laparoscopic procedures in patients with previous open abdominal surgery.

METHODS

Using data from the National Surgical Quality Improvement Program (2005 to 2009), we identified patients who had undergone laparoscopic cholecystectomy, Nissen fundoplication, Heller myotomy, splenectomy, Roux-en-Y, sleeve gastrectomy, gastric band, appendectomy, or colectomy. Patients were then classified as to whether adhesiolysis (AD) was also carried out. Bivariate and multivariate analysis was used to compare groups.

RESULTS

A total of 162,415 patients met our inclusion criteria, comprising 4,501 (3%) in the AD group and 157,913 (97%) in the nonadhesiolysis (NAD) group. Patient who had received lysis of adhesion were older, had 41% higher odds of overall complications, 17% higher adjusted mean lysis of adhesion (P < .001), and 26% higher adjusted mean operation duration (P < .001).

CONCLUSIONS

A history of previous open abdominal surgery increases the potential complication rate and hospital length of stay during subsequent laparoscopic surgery. The extent of this relationship deserves further investigation.

Asian race/ethnicity as a risk factor for bile duct injury during cholecystectomy

Iatrogenic bile duct injury (BDI) is an uncommon but serious complication of cholecystectomy, with identified risk factors of acute cholecystitis, male sex, older age, and aberrant biliary anatomy. The Nationwide Inpatient Sample (1998-2006) was queried for cholecystectomy performed on hospital day 0 or 1. Bile duct injury repair procedure codes were used as a surrogate for BDI. We identified 377,424 patients who underwent cholecystectomy, with 1124 BDIs (0.3%). On multivariate logistic regression analysis, Asian race/ethnicity was a significant risk factor for BDI (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.59-3.23; P < .001). This persisted for laparoscopic (OR, 2.62; 95% CI, 1.28-5.39; P = .009) and open (2.21; 1.59-3.07; P < .001) cholecystectomies. No other race/ethnicity was identified as a risk factor for BDI. We report a new finding that Asian race/ethnicity is a significant risk factor for BDI in laparoscopic and open cholecystectomies.

The effects of laparoscopic cholecystectomy, hysterectomy, and appendectomy on nosocomial infection risks

BACKGROUND

Recent reviews of the literature have concluded that additional, well-defined studies are required to clarify the superiority of laparoscopic or open surgery. This paper presents precise estimates of nosocomial infection risks associated with laparoscopic as compared to open surgery in three procedures: cholecystectomy, appendectomy, and hysterectomy.

METHODS

A retrospective analysis was performed on 11,662 admissions from 22 hospitals that have a nosocomial infection monitoring system. The Nosocomial Infection Marker (NIMtrade mark, patent pending) was used to identify nosocomial infections during hospitalization and post discharge. The dataset was limited to admissions with laparoscopic or open cholecystectomy (32.7%), appendectomy (24.0%), or hysterectomy (43.3%) and was analyzed by source of infection: urinary tract, wounds, respiratory tract, bloodstream, and others. Single- and multivariable logistic regression analyses were performed to control for the following potentially confounding variables: gender, age, type of insurance, complexity of admission on presentation, admission through the emergency department, and hospital case mix index (CMI).

RESULTS

Analyses were based on 399 NIMs in 337 patients. Laparoscopic cholecystectomy and hysterectomy each reduced the overall odds of acquiring nosocomial infections by more than 50% (p < 0.01) Laparoscopic cholecystectomy and hysterectomy also resulted in statistically significantly fewer readmissions with nosocomial infections (p < 0.01). Excluding appendectomy, the odds ratio for laparoscopic versus open NIM-associated readmission was 0.346 (p < 0.01). Laparoscopic appendectomy did not significantly change the odds of acquiring nosocomial infections.

CONCLUSION

As compared to open surgery, laparoscopic cholecystectomy and hysterectomy are associated with statistically significantly lower risks for nosocomial infections. For appendectomy, when comparing open versus laparoscopic approaches, no differences in the rate of nosocomial infections were detected.

Telementoring: pushing the telemedicine envelope

Telemedicine offers significant advantages in bringing consulting support to distant colleagues. Our aim in this study was to evaluate the role of telementoring in the training of advanced laparoscopic surgical procedures. Student surgeons received a uniform training format to enhance their laparoscopic skills and intracorporeal suturing techniques and specific procedural training in laparoscopic colonic resections and Nissen fundoplication. Subsequently, operating rooms were equipped with three cameras. A telestrator (teleguidance device), instant replay (to critique errors), and CD-ROM programs (to provide reference information) were used as intraoperative, educationally assistant tools. In phase 1, four colonic resections were performed with the mentor in the operating room (group A), and four colonic resections were performed with the mentor on the hospital grounds but not in the operating room (group B). The voice and video signals were received at the mentor's location using coaxial cable. In phase 2, two Nissen fundoplications were performed with the mentors in the operating room (group C), and two Nissen fundoplications were performed with the mentors 5 miles away from the operating room (group D) using existing land lines at the T1 level. We found no differences in the performances of the surgeons or the outcomes of the operations between groups A and B and groups C and D. Intraoperative problems were tackled effectively. Preliminarily, we conclude that the telementoring concept is potentially a safe and cost-effective option for advanced training in laparoscopic operations. Further investigation is necessary before routine transcontinental patient applications are attempted.