Publications by authors named "Luke M Funk"

70 Publications

Antireflux surgery leads to durable improvement in laryngopharyngeal reflux symptoms.

Surg Endosc 2021 Feb 2. Epub 2021 Feb 2.

Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue K4/752, Madison, WI, 53792-7375, USA.

Background: Laryngopharyngeal reflux (LPR) symptoms are often present in patients with Gastroesophageal reflux disease (GERD). Whereas antireflux surgery (ARS) provides predictably excellent results in patients with typical GERD, those with atypical symptoms have variable outcomes. The goal of this study was to characterize the response of LPR symptoms to antireflux surgery.

Methods: Patients who underwent ARS between January 2009 and May 2020 were prospectively identified from a single institutional database. Patient-reported information on LPR symptoms was collected at standardized time points (preoperative and 2 weeks, 8 weeks, and 1 year postoperatively) using a validated Reflux Symptom Index (RSI) questionnaire. Patients were grouped by preoperative RSI score: ≤ 13 (normal) and > 13 (abnormal). Baseline characteristics were compared between groups using chi-square test or t-test. A mixed effects model was used to evaluate improvement in RSI scores.

Results: One hundred and seventy-six patients fulfilled inclusion criteria (mean age 57.8 years, 70% female, mean BMI 29.4). Patients with a preoperative RSI ≤ 13 (n = 61) and RSI > 13 (n = 115) were similar in age, BMI, primary reason for evaluation, DeMeester score, presence of esophagitis, and hiatal hernia (p > 0.05). The RSI > 13 group had more female patients (80 vs 52%, p = < 0.001), higher mean GERD-HRQL score, lower rates of PPI use, and normal esophageal motility. The RSI of all patients improved from a mean preoperative value of 19.2 to 7.8 (2 weeks), 6.1 (8 weeks), and 10.9 (1 year). Those with the highest preoperative scores (RSI > 30) had the best response to ARS. When analyzing individual symptoms, the most likely to improve included heartburn, hoarseness, and choking.

Conclusions: In our study population, patients with LPR symptoms achieved a rapid and durable response to antireflux surgery. Those with higher preoperative RSI scores experienced the greatest improvement. Our data suggest that antireflux surgery is a viable treatment option for this patient population.
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http://dx.doi.org/10.1007/s00464-020-08279-9DOI Listing
February 2021

The Relative Impact of Specific Postoperative Complications on Older Patients Undergoing Hip Fracture Repair.

Jt Comm J Qual Patient Saf 2021 Apr 14;47(4):210-216. Epub 2020 Dec 14.

Background: Hip fractures affect a vulnerable population and are associated with high rates of morbidity, mortality, and resource utilization. Although postoperative complications are a known driver of mortality and resource utilization, the comparative impacts of specific complications on outcomes is unknown. This study assessed which complications are associated with the highest effects on mortality and resource utilization for older patients who undergo hip fracture repair.

Methods: Patients ≥ 65 years of age who underwent hip fracture repair during 2016-2017 included in the Hip Fracture Targeted ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database populated the data set. Prolonged hospitalization (≥ 75th percentile) and 30-day mortality and readmission were the primary outcomes. Population attributable fractions (PAFs) were used to quantify the anticipated reduction in the primary outcomes that would result from complete prevention of 10 postoperative complications.

Results: Of 17,755 patients across 117 hospitals, 70.9% were female, 26.0% were over age 90, 22.8% had an American Society of Anesthesiologists (ASA) score of 4-5, and 53.9% presented with an intertrochanteric fracture. Postoperative delirium affected 29.8% of patients and was associated with death (PAF 18.0%; 95% confidence interval [CI] = 13.2-22.5), prolonged hospitalization (PAF 14.3%; 95% CI = 12.7-15.8), and readmission (PAF 15.0%; 95% CI = 11.3-18.6). Pneumonia affected 4.1% of patients and was associated with death (PAF 10.9%; 95% CI = 8.9-12.8), prolonged hospitalization (PAF 4.0%; 95% CI = 3.5-4.5), and readmission (PAF 9.1%; 95% CI = 7.5-10.7). The impact of the other eight complications was comparatively small.

Conclusion: Postoperative delirium and pneumonia are the highest-impact complications for older hip fracture repair patients. These complications should be prioritized in quality improvement efforts that target this patient population.
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http://dx.doi.org/10.1016/j.jcjq.2020.12.005DOI Listing
April 2021

Association of Bariatric Surgical Procedures With Changes in Unhealthy Alcohol Use Among US Veterans.

JAMA Netw Open 2020 12 1;3(12):e2028117. Epub 2020 Dec 1.

Kaiser Permanente Washington Health Research Institute, Seattle, Washington.

Importance: Bariatric surgical procedures have been associated with increased risk of unhealthy alcohol use, but no previous research has evaluated the long-term alcohol-related risks after laparoscopic sleeve gastrectomy (LSG), currently the most used bariatric procedure. No US-based study has compared long-term alcohol-related outcomes between patients who have undergone Roux-en-Y gastric bypass (RYGB) and those who have not.

Objective: To evaluate the changes over time in alcohol use and unhealthy alcohol use from 2 years before to 8 years after a bariatric surgical procedure among individuals with or without preoperative unhealthy alcohol use.

Design, Setting, And Participants: This retrospective cohort study analyzed electronic health record (EHR) data on military veterans who underwent a bariatric surgical procedure at any of the bariatric centers in the US Department of Veterans Affairs (VA) health system between October 1, 2008, and September 30, 2016. Surgical patients without unhealthy alcohol use at baseline were matched using sequential stratification to nonsurgical control patients without unhealthy alcohol use at baseline, and surgical patients with unhealthy alcohol use at baseline were matched to nonsurgical patients with unhealthy alcohol use at baseline. Data were analyzed in February 2020.

Interventions: LSG (n = 1684) and RYGB (n = 924).

Main Outcomes And Measures: Mean alcohol use, unhealthy alcohol use, and no alcohol use were estimated using scores from the validated 3-item Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), which had been documented in the VA EHR. Alcohol outcomes were estimated with mixed-effects models.

Results: A total of 2608 surgical patients were included in the final cohort (1964 male [75.3%] and 644 female [24.7%] veterans. Mean (SD) age of surgical patients was 53.0 (9.9) years and 53.6 (9.9) years for the matched nonsurgical patients. Among patients without baseline unhealthy alcohol use, 1539 patients who underwent an LSG were matched to 14 555 nonsurgical control patients and 854 patients who underwent an RYGB were matched to 8038 nonsurgical control patients. In patients without baseline unhealthy alcohol use, the mean AUDIT-C scores and the probability of unhealthy alcohol use both increased significantly 3 to 8 years after an LSG or an RYGB, compared with control patients. Eight years after an LSG, the probability of unhealthy alcohol use was higher in surgical vs control patients (7.9% [95% CI, 6.4-9.5] vs 4.5% [95% CI, 4.1-4.9]; difference, 3.4% [95% CI, 1.8-5.0])). Similarly, 8 years after an RYGB, the probability of unhealthy alcohol use was higher in surgical vs control patients (9.2% [95% CI, 8.0-10.3] vs 4.4% [95% CI, 4.1-4.6]; difference, 4.8% [95% CI, 3.6-5.9]). The probability of no alcohol use also decreased significantly 5 to 8 years after both procedures for surgical vs control patients. Among patients with unhealthy alcohol use at baseline, prevalence of unhealthy alcohol use was higher for patients who underwent an RYGB than matched controls.

Conclusions And Relevance: In this multi-site cohort study of predominantly male patients, among those who did not have unhealthy alcohol use in the 2 years before bariatric surgery, the probability of developing unhealthy alcohol use increased significantly 3-8 years after bariatric procedures compared with matched controls during follow-up.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.28117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753905PMC
December 2020

pH Impedance Parameters Associated with Improvement in GERD Health-Related Quality of Life Following Anti-reflux Surgery.

J Gastrointest Surg 2021 Jan 27;25(1):28-35. Epub 2020 Oct 27.

Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.

Introduction: pH impedance testing is the most sensitive diagnostic test for detecting gastroesophageal reflux disease (GERD). The literature remains inconclusive on which preoperative pH impedance testing parameters are associated with an improvement in heartburn symptoms after anti-reflux surgery. The objective of this study was to evaluate which parameters on preoperative pH impedance testing were associated with improved GERD health-related quality of life (GERD-HRQL) following surgery.

Methods: Data from a single-institution foregut database were used to identify patients with reflux symptoms who underwent anti-reflux surgery between 2014 and 2020. Acid and impedance parameters were extracted from preoperative pH impedance studies. GERD-HRQL was assessed pre- and postoperatively with a questionnaire that evaluated heartburn, dysphagia, and the impact of acid-blocking medications on daily life. Patient characteristics, fundoplication type, and four pH impedance parameters were included in a multivariable linear regression model with improvement in GERD-HRQL as the outcome.

Results: We included 108 patients (59 Nissen and 49 Toupet fundoplications), with a median follow-up time of 1 year. GERD-HRQL scores improved from 22.4 (SD ± 10.1) preoperatively to 4.2 (± 6.2) postoperatively. In multivariable analysis, a normal preoperative acid exposure time (p = 0.01) and Toupet fundoplication (vs. Nissen; p = 0.03) were independently associated with greater improvement in GERD-HRQL.

Conclusions: Of the four pH impedance parameters that were investigated, a normal preoperative acid exposure time was associated with greater improvement in quality of life after anti-reflux surgery. Further investigation into the critical parameters on preoperative pH impedance testing using a multi-institutional cohort is warranted.
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http://dx.doi.org/10.1007/s11605-020-04831-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855403PMC
January 2021

Both gastric electrical stimulation and pyloric surgery offer long-term symptom improvement in patients with gastroparesis.

Surg Endosc 2020 Oct 6. Epub 2020 Oct 6.

Department of Surgery, Madison School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA.

Background: Gastroparesis (GP) is hallmarked by nausea, vomiting, and early satiety. While dietary and medical therapy are the mainstay of treatment, surgery has been used to palliate symptoms. Two established first-line surgical options are gastric electrostimulation (GES) and pyloric procedures (PP) including pyloroplasty or pyloromyotomy. We sought to compare these modalities' improvement in Gastroparesis cardinal symptom index (GCSI) subscores and potential predictors of therapy failure.

Methods: All patients undergoing surgery at a single institution were prospectively identified and separated by surgery: GES, PP, or combined GESPP. GCSI was collected preoperatively, at 6 weeks and 1 year. Postoperative GCSI score over 2.5 or receipt of another gastroparesis operation were considered treatment failures. Groups were compared using Pearson's chi-squared and Kruskal-Wallis one-way ANOVA.

Results: Eighty-two patients were included: 18 GES, 51 PP, and 13 GESPP. Mean age was 44, BMI was 26.7, and 80% were female. Preoperative GCSI was 3.7. The PP group was older with more postsurgical gastroparesis. More patients with diabetes underwent GESPP. Preoperative symptom scores and gastric emptying were similar among all groups. All surgical therapies resulted in a significantly improved GCSI and nausea/vomiting subscore at 6 weeks and 1 year. Bloating improved initially, but relapsed in the GES and GESPP group. Satiety improved initially, but relapsed in the PP group. Fifty-nine (72%) had surgical success. Ten underwent additional surgery (7 crossed into the GESPP group, 3 underwent gastric resection). Treatment failures had higher preoperative GCSI, bloating, and satiety scores. Treatment failures and successes had similar preoperative gastric emptying.

Conclusions: Both gastric electrical stimulation and pyloric surgery are successful gastroparesis treatments, with durable improvement in nausea and vomiting. Choice of operation should be guided by patient characteristics and discussion of surgical risks and benefits. Combination GESPP does not appear to confer an advantage over GES or PP alone.
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http://dx.doi.org/10.1007/s00464-020-07960-3DOI Listing
October 2020

Phone follow-up after inguinal hernia repair.

Surg Endosc 2020 Sep 30. Epub 2020 Sep 30.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI, 53792-7375, USA.

Background: Typically, in-person follow-up in clinic is utilized after outpatient inguinal hernia repair. Studies have shown that phone follow-up may be successfully used for the detection of postoperative hernia recurrences. However, no studies have evaluated the detection rates of other postoperative complications, such as emergency department visits and readmissions, with the utilization of phone follow-up after inguinal hernia repair. The objective of our study was to investigate the safety of a phone follow-up care pathway following elective, outpatient inguinal hernia repair.

Methods: In this retrospective cohort study, adult patients who underwent elective, outpatient inguinal hernia repair between 2013 and 2019 at a large academic health system in the Midwest United States were identified from the electronic health record. Patients were categorized by type of postoperative follow-up: in-person or phone follow-up. Baseline demographics, operative, and postoperative data were compared between follow-up groups. Multivariable logistic regression was performed to investigate predictors of having any related emergency department (ED) visit/readmission/reoperation within 90 days.

Results: We included 2009 patients who underwent elective inguinal hernia repair during the study period. 321 patients had in-person follow-up only, while 1,688 patients had phone follow-up. There was a higher rate of laparoscopic repair in the phone follow-up group (85.4% vs. 53.0% for in-person follow-up). There were no differences in rates of related 90-day ED visits, readmissions, and reoperations between the phone and in-person follow-up groups. On multivariable logistic regression, receipt of phone follow-up was not a predictor of having 90-day ED visits, readmissions, or reoperations (OR 1.30, 95% CI [0.83, 2.05]).

Conclusions: Patients who underwent phone follow-up had similarly low rates of adverse outcomes to those with in-person follow-up. Phone follow-up protocols may be implemented as an alternative for patients and provide a means to decrease healthcare utilization following inguinal hernia repair.
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http://dx.doi.org/10.1007/s00464-020-08005-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526072PMC
September 2020

Unnecessary use of radiology studies in the diagnosis of inguinal hernias: a retrospective cohort study.

Surg Endosc 2020 Sep 9. Epub 2020 Sep 9.

Division of Minimally Invasive, Foregut, and Bariatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI, 53792-7375, USA.

Background: The diagnosis of inguinal hernias is predominantly based on physical exam, although imaging may be used in select cases. The objective of this study was to determine the frequency of unnecessary imaging used in the diagnosis of inguinal hernias.

Methods: Patients who underwent elective inguinal hernia repair at a large academic health system in the U.S. from 2010 to 2017 were included. Within this cohort, we identified patients who received imaging 6 months prior to surgery. Through chart review of physical exam findings and imaging indications, we categorized patients into four imaging categories: unrelated, necessary, unnecessary, and borderline. Multivariable logistic regression analysis was used to identify factors associated with receipt of unnecessary imaging.

Results: Of 2162 patients who underwent inguinal hernia surgery, 249 patients had related imaging studies 6 months prior to surgery. 47.0% of patients received unnecessary imaging. 66.9% and 33.1% of unnecessary studies were ultrasounds and CT scans, respectively. 24.5% of patients had necessary studies, while 28.5% had studies with borderline indications. On multivariable analysis, having a BMI between 25.0 and 29.9 kg/m was associated with receipt of unnecessary studies. Primary care providers and ED physicians were more likely to order unnecessary imaging.

Conclusions: Nearly 50% of all patients who receive any related imaging prior to surgery had potentially unnecessary diagnostic radiology studies. This not only exposes patients to avoidable risks, but also places a significant economic burden on patients and our already-strained health system.
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http://dx.doi.org/10.1007/s00464-020-07947-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7940456PMC
September 2020

A Qualitative Study of the System-level Barriers to Bariatric Surgery Within the Veterans Health Administration.

Ann Surg 2020 May 19. Epub 2020 May 19.

*William S. Middleton VA Memorial Hospital, Madison, Wisconsin †Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin ‡Department of Veterans Affairs, National Center for Health Promotion and Disease Prevention, Durham, North Carolina §Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina.

Objective: To characterize system-level barriers to bariatric surgery from the perspectives of Veterans with severe obesity and obesity care providers.

Summary Of Background Data: Bariatric surgery is the most effective weight loss option for Veterans with severe obesity, but fewer than 0.1% of Veterans with severe obesity undergo it. Addressing low utilization of bariatric surgery and weight management services is a priority for the veterans health administration.

Methods: We conducted semi-structured interviews with Veterans with severe obesity who were referred for or underwent bariatric surgery, and providers who delivered care to veterans with severe obesity, including bariatric surgeons, primary care providers, registered dietitians, and health psychologists. We asked study participants to describe their experiences with the bariatric surgery delivery process in the VA system. All interviews were audio-recorded and transcribed. Four coders iteratively developed a codebook and used conventional content analysis to identify relevant systems or "contextual" barriers within Andersen Behavioral Model of Health Services Use.

Results: Seventy-three semi-structured interviews with veterans (n = 33) and providers (n = 40) throughout the veterans health administration system were completed. More than three-fourths of Veterans were male, whereas nearly three-fourths of the providers were female. Eight themes were mapped onto Andersen model as barriers to bariatric surgery: poor care coordination, lack of bariatric surgery guidelines, limited primary care providers and referring provider knowledge about bariatric surgery, long travel distances, delayed referrals, limited access to healthy foods, difficulties meetings preoperative requirements, and lack of provider availability and/or time.

Conclusions: Addressing system-level barriers by improving coordination of care and standardizing some aspects of bariatric surgery care may improve access to evidence-based severe obesity care within VA.
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http://dx.doi.org/10.1097/SLA.0000000000003982DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7674184PMC
May 2020

Comment on: Predictors of postoperative emergency department visits without readmission after laparoscopic bariatric surgery.

Surg Obes Relat Dis 2020 10 9;16(10):1489-1490. Epub 2020 Jul 9.

Department of Surgery, University of Wisconsin, Madison, Wisconsin; Department of Surgery, William S. Middleton Memorial Veterans Administration, Madison, Wisconsin.

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http://dx.doi.org/10.1016/j.soard.2020.06.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541776PMC
October 2020

Long-term opioid use after bariatric surgery.

Surg Obes Relat Dis 2020 Aug 7;16(8):1100-1110. Epub 2020 May 7.

University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota.

Background: Opioid analgesics are often prescribed to manage pain after bariatric surgery, which may develop into chronic prescription opioid use (CPOU) in opioid-naïve patients. Bariatric surgery may affect opioid use in those with or without presurgical CPOU.

Objective: To compare CPOU persistence and incidence in a large multisite cohort of veterans undergoing bariatric surgery (open Roux-en-Y gastric bypass, laparoscopic RYGB, or laparoscopic sleeve gastrectomy) and matched nonsurgical controls.

Setting: Veterans Administration hospitals.

Methods: In a retrospective cohort study, we matched 1117 surgical patients with baseline CPOU to 9531 nonsurgical controls, and 2822 surgical patients without CPOU at baseline to 26,392 nonsurgical controls using sequential stratification. CPOU persistence in veterans with baseline CPOU was estimated using generalized estimating equations by procedure type. CPOU incidence in veterans without baseline CPOU was estimated in Cox regression models by procedure type because postoperative pain, complications, and absorption may differ by procedure.

Results: In veterans with baseline CPOU, postsurgical CPOU declined over time for each surgical procedure; these trends did not differ between surgical patients and nonsurgical controls. In veterans without baseline CPOU, compared with nonsurgical controls, bariatric patients had higher CPOU incidence within 5 years after open Roux-en-Y gastric bypass (hazard ratio = 1.19; 95% confidence interval: 1.06-1.34) or laparoscopic open Roux-en-Y gastric bypass (hazard ratio = 1.22, 95% confidence interval: 1.06-1.41). Veterans undergoing laparoscopic sleeve gastrectomy had higher CPOU incidence 1 to 5 years after surgery (hazard ratio = 1.28; 95% confidence interval: 1.05-1.56) than nonsurgical controls.

Conclusions: Bariatric surgery was associated with greater risk of CPOU incidence in patients without baseline CPOU but was not associated with greater CPOU persistence.
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http://dx.doi.org/10.1016/j.soard.2020.04.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7423624PMC
August 2020

Prospective comparison of longitudinal change in hepatic proton density fat fraction (PDFF) estimated by magnitude-based MRI (MRI-M) and complex-based MRI (MRI-C).

Eur Radiol 2020 Sep 21;30(9):5120-5129. Epub 2020 Apr 21.

Liver Imaging Group, Department of Radiology, University of California - San Diego, San Diego, CA, USA.

Purpose: To compare longitudinal hepatic proton density fat fraction (PDFF) changes estimated by magnitude- vs. complex-based chemical-shift-encoded MRI during a weight loss surgery (WLS) program in severely obese adults with biopsy-proven nonalcoholic fatty liver disease (NAFLD).

Methods: This was a secondary analysis of a prospective dual-center longitudinal study of 54 adults (44 women; mean age 52 years; range 27-70 years) with obesity, biopsy-proven NAFLD, and baseline PDFF ≥ 5%, enrolled in a WLS program. PDFF was estimated by confounder-corrected chemical-shift-encoded MRI using magnitude (MRI-M)- and complex (MRI-C)-based techniques at baseline (visit 1), after a 2- to 4-week very low-calorie diet (visit 2), and at 1, 3, and 6 months (visits 3 to 5) after surgery. At each visit, PDFF values estimated by MRI-M and MRI-C were compared by a paired t test. Rates of PDFF change estimated by MRI-M and MRI-C for visits 1 to 3, and for visits 3 to 5 were assessed by Bland-Altman analysis and intraclass correlation coefficients (ICCs).

Results: MRI-M PDFF estimates were lower by 0.5-0.7% compared with those of MRI-C at all visits (p < 0.001). There was high agreement and no difference between PDFF change rates estimated by MRI-M vs. MRI-C for visits 1 to 3 (ICC 0.983, 95% CI 0.971, 0.99; bias = - 0.13%, p = 0.22), or visits 3 to 5 (ICC 0.956, 95% CI 0.919-0.977%; bias = 0.03%, p = 0.36).

Conclusion: Although MRI-M underestimates PDFF compared with MRI-C cross-sectionally, this bias is consistent and MRI-M and MRI-C agree in estimating the rate of hepatic PDFF change longitudinally.

Key Points: • MRI-M demonstrates a significant but small and consistent bias (0.5-0.7%; p < 0.001) towards underestimation of PDFF compared with MRI-C at 3 T. • Rates of PDFF change estimated by MRI-M and MRI-C agree closely (ICC 0.96-0.98) in adults with severe obesity and biopsy- proven NAFLD enrolled in a weight loss surgery program. • Our findings support the use of either MRI technique (MRI-M or MRI-C) for clinical care or by individual sites or for multi-center trials that include PDFF change as an endpoint. However, since there is a bias in their measurements, the same technique should be used in any given patient for longitudinal follow-up.
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http://dx.doi.org/10.1007/s00330-020-06858-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495399PMC
September 2020

Bariatric Surgery and Diabetes Treatment-Finding the Sweet Spot.

JAMA Surg 2020 05 20;155(5):e200088. Epub 2020 May 20.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison.

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http://dx.doi.org/10.1001/jamasurg.2020.0088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483969PMC
May 2020

Early-phase study of a telephone-based intervention to reduce weight regain among bariatric surgery patients.

Health Psychol 2020 May 30;39(5):391-402. Epub 2020 Jan 30.

William S. Middleton Memorial Veterans Hospital.

Objective: This study describes early-phase development of a behavioral intervention to reduce weight regain following bariatric surgery. We utilized the Obesity-Related Behavioral Intervention Trials model to guide intervention development and evaluation. We sought to establish recruitment, retention, and fidelity monitoring procedures; evaluate feasibility of utilizing weight from the electronic medical record (EMR) as an outcome; observe improvement in behavioral risk factors; and evaluate treatment acceptability.

Method: The intervention comprised 4 weekly telephone calls addressing behavior change strategies for diet, physical activity, and nutrition supplement adherence and 5 biweekly calls addressing weight loss maintenance constructs. Veterans ( = 33) who received bariatric surgery 9-15 months prior consented to a 16-week, pre-post study. Self-reported outcomes were obtained by telephone at baseline and 16 weeks. Clinic weights were obtained from the EMR 6 months pre- and postconsent. Qualitative interviews were conducted at 16 weeks to evaluate treatment acceptability. We aimed to achieve a recruitment rate of ≥ 25% and retention rate of ≥ 80%, and have ≥ 50% of participants regain < 3% of their baseline weight.

Results: Results supported the feasibility of recruiting (48%) and retaining participants (93% provided survey data; 100% had EMR weight). Pre-post changes in weight (73% with < 3% weight regain) and physical activity (Cohen's ds 0.38 to 0.52) supported the potential for the intervention to yield clinically significant results. Intervention adherence (mean 7.8 calls of 9 received) and positive feedback from interviews supported treatment acceptability.

Conclusions: The intervention should be evaluated in an adequately powered randomized controlled trial. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/hea0000835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219473PMC
May 2020

Weight Loss for Patients With Obesity: An Analysis of Long-Term Electronic Health Record Data.

Med Care 2020 03;58(3):265-272

Departments of Surgery, University of Wisconsin School of Medicine and Public Health.

Background: Numerous studies have reported that losing as little as 5% of one's total body weight (TBW) can improve health, but no studies have used electronic health record data to examine long-term changes in weight, particularly for adults with severe obesity [body mass index (BMI) ≥35 kg/m].

Objective: To measure long-term weight changes and examine their predictors for adults in a large academic health care system.

Research Design: Observational study.

Subjects: We included 59,816 patients aged 18-70 years who had at least 2 BMI measurements 5 years apart. Patients who were underweight, pregnant, diagnosed with cancer, or had undergone bariatric surgery were excluded.

Measures: Over a 5-year period: (1) ≥5% TBW loss; (2) weight loss into a nonobese BMI category (BMI <30 kg/m); and (3) predictors of %TBW change via quantile regression.

Results: Of those with class 2 or 3 obesity, 24.2% and 27.8%, respectively, lost at least 5% TBW. Only 3.2% and 0.2% of patients with class 2 and 3 obesity, respectively, lost enough weight to attain a BMI <30 kg/m. In quantile regression, the median weight change for the population was a net gain of 2.5% TBW.

Conclusions: Although adults with severe obesity were more likely to lose at least 5% TBW compared with overweight patients and patients with class 1 obesity, sufficient weight loss to attain a nonobese weight class was very uncommon. The pattern of ongoing weight gain found in our study population requires solutions at societal and health systems levels.
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http://dx.doi.org/10.1097/MLR.0000000000001277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7218679PMC
March 2020

Bariatric Surgery Trends in the U.S.: 1% is the Loneliest Number.

Ann Surg 2020 02;271(2):210-211

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

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http://dx.doi.org/10.1097/SLA.0000000000003714DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7474975PMC
February 2020

Accuracy of common proton density fat fraction thresholds for magnitude- and complex-based chemical shift-encoded MRI for assessing hepatic steatosis in patients with obesity.

Abdom Radiol (NY) 2020 03;45(3):661-671

Liver Imaging Group, Radiology, University of California-San Diego, 9500 Gilman Drive, San Diego, CA, 92037, USA.

Purpose: MRI proton density fat fraction (PDFF) can be calculated using magnitude (MRI-M) or complex (MRI-C) MRI data. The purpose of this study was to identify, assess, and compare the accuracy of common PDFF thresholds for MRI-M and MRI-C for assessing hepatic steatosis in patients with obesity, using histology as reference.

Methods: This two-center prospective study included patients undergoing MRI-C- and MRI-M-PDFF estimations within 3 days before weight loss surgery. Liver biopsy was performed, and histology-determined steatosis grades were used as reference standard. Using receiver operating characteristics (ROC) analysis on data pooled from both methods, single common thresholds for diagnosing and differentiating none or mild (0-1) from moderate to severe steatosis (2-3) were selected as the ones achieving the highest sensitivity while providing at least 90% specificity. Selection methods were cross-validated. Performances were compared using McNemar's tests.

Results: Of 81 included patients, 54 (67%) had steatosis. The common PDFF threshold for diagnosing steatosis was 5.4%, which provided a cross-validated 0.88 (95% CI 0.77-0.95) sensitivity and 0.92 (0.75-0.99) specificity for MRI-M and 0.87 sensitivity (0.75-0.94) with 0.81 (0.61-0.93) specificity for MRI-C. The common PDFF threshold to differentiate steatosis grades 0-1 from 2 to 3 was 14.7%, which provided cross-validated 0.86 (95% CI 0.59-0.98) sensitivity and 0.95 (0.87-0.99) specificity for MRI-M and 0.93 sensitivity (0.68-0.99) with 0.97(0.89-0.99) specificity for MRI-C.

Conclusion: If independently validated, diagnostic thresholds of 5.4% and 14.7% could be adopted for both techniques for detecting and differentiating none to mild from moderate to severe steatosis, respectively, with high diagnostic accuracy.
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http://dx.doi.org/10.1007/s00261-019-02350-3DOI Listing
March 2020

Long-term dysphagia resolution following POEM versus Heller myotomy for achalasia patients.

Surg Endosc 2020 04 10;34(4):1704-1711. Epub 2019 Jul 10.

Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Ave, CSC H4/728, Madison, WI, 53792, USA.

Background: Heller myotomy (HM) has historically been considered the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM) is a less-invasive procedure and offers a quicker recovery. Although some studies have compared short-term outcomes of HM and POEM, predictors of long-term dysphagia resolution remain unclear. The objective of this study was to evaluate patient-reported outcomes for achalasia patients who underwent either POEM or HM over a 9-year period.

Methods: Data from our single academic institutional foregut database were used to identify achalasia patients who underwent HM or POEM from 2009 to 2018. Electronic health record data were reviewed to obtain patient characteristics and operative data. Achalasia severity stages were established for each patient using esophagram findings from an attending radiologist blinded to the procedure type. Postoperative outcomes were assessed via telephone for patients with at least 9 months of follow-up using Eckardt dysphagia scores. Patient age, sex, type of operation, and duration of follow-up were included in a multivariable linear regression model with Eckardt score as the outcome.

Results: Our cohort included 141 patients (97 HM and 44 POEM). Eighty-two patients completed a phone survey at the 9 months or greater time interval (response rate = 58%). Mean Eckardt scores were 2.98 and 2.53 at a median follow-up of 3 years and 1 year for HM and POEM patients, respectively (an Eckardt score ≤ 3 is considered a successful myotomy). Lower stages of achalasia on esophagram (e.g., Stage 0 vs. Stage 4) were associated with greater dysphagia improvement. On multivariable analysis, operative approach was not associated with a statistically significant difference in dysphagia outcomes.

Conclusions: POEM and HM were associated with similar rates of dysphagia resolution for achalasia patients at a median of 2 years of follow-up. Both procedures appear to be durable options for achalasia treatment.
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http://dx.doi.org/10.1007/s00464-019-06948-yDOI Listing
April 2020

30-Day Outcomes After Intraoperative Leak Testing for Bariatric Surgery Patients.

J Surg Res 2019 10 8;242:136-144. Epub 2019 May 8.

Department of Surgery, University of Wisconsin, Madison, Wisconsin; William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin. Electronic address:

Background: Intraoperative testing of anastomoses and staples lines is commonly performed to minimize the risk of postoperative leaks in bariatric surgery, but its impact is unclear. The aim of this study was to determine the association between leak testing and 30-d postoperative leak, bleed, reoperation, and readmission rates for patients undergoing laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB).

Methods: This is a retrospective observational study utilizing 2015-2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Postoperative outcomes were compared using χ test. Multivariable logistic regression was used to identify factors associated with 30-d outcomes.

Results: We included 237,081 patients. Leak testing was performed on 73.0% and 92.1% of LSG and RYGB patients, respectively. LSG was associated with lower rates of leak, bleed, reoperation, and readmission than RYGB. On multivariable analysis, intraoperative leak testing was associated with increased rates of postoperative leak for LSG and RYGB (OR 1.48 and 1.90, respectively) and lower rates of bleed for LSG (OR 0.76). There were no significant associations between leak testing and rates of reoperation or readmission.

Conclusions: Use of intraoperative leak testing was not associated with improved outcomes for either LSG or RYGB. A prospective trial investigating leak testing is warranted to better elucidate its impact.
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http://dx.doi.org/10.1016/j.jss.2019.04.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679992PMC
October 2019

Motivations of Males with Severe Obesity, Who Pursue Medical Weight Management or Bariatric Surgery.

J Laparoendosc Adv Surg Tech A 2019 Jun 24;29(6):730-740. Epub 2019 Apr 24.

1 Department of Surgery, William S. Middleton Memorial VA, Madison, Wisconsin.

Both medical weight management (MWM) and bariatric surgery are significantly underutilized by patients with severe obesity, particularly males. Less than 30% of participants in MWM programs are male, and only 20% of patients undergoing bariatric surgery are men. To identify motivations of males who pursue either MWM or bariatric surgery. Interviews with males with severe obesity (body mass index ≥35 kg/m), who participated in a Veteran Affairs weight loss program in the Midwest. Participants were asked to describe their experiences with MWM and bariatric surgery. Interviews were audio-recorded, transcribed, and uploaded to NVivo for data management and analysis. Five coders iteratively developed a codebook using inductive content analysis to identify relevant themes. We utilized theme matrices organized by type of motivation and treatment pathway to generate higher-level analysis and generate themes. Twenty-five males participated. Participants were 58.7 (standard deviation 8.6) years old on average, and 24% were non-white. Motivations for pursuing MWM or surgery included a desire to improve physical or psychological health and to enhance quality of life. Patients seeking bariatric surgery were motivated by the fear of death and felt that they had exhausted all other weight loss options. MWM patients believed they had more time to pursue other weight loss options. The opportunity to improve health, optimize quality of life, and lengthen lifespan motivates males with severe obesity to pursue weight loss treatments. These factors should be considered when providers educate patients about obesity treatment options and outcomes.
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http://dx.doi.org/10.1089/lap.2019.0219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6940588PMC
June 2019

Healthcare spending and utilization following antireflux surgery: examining costs and reasons for readmission.

Surg Endosc 2020 01 5;34(1):240-248. Epub 2019 Apr 5.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Background: While clinical outcomes have been reported for anti-reflux surgery (ARS), there are limited data on post-operative encounters, including readmission, and their associated costs. This study evaluates healthcare utilization during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal hernia (PEH) repair.

Methods: Data were analyzed from the Truven Health MarketScan Databases. Patients older than 16 years with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS and a primary diagnosis of GERD during 2012-2014 were selected. Healthcare spending and utilization on emergency department (ED) visits, performance of outpatient endoscopy, and readmission were examined. Reasons for readmission were classified based on ICD-9 code.

Results: A total of 40,853 patients were included in the cohort with a mean age of 49 years and females comprising 76.0%. Mean length of stay was 1.4 days, and 93.0% of patients underwent a laparoscopic approach. The mean cost of the index surgical admission was $24,034. Readmission occurred in 4.2% of patients, and of those, 26.3% required a surgical intervention. Patients requiring one or more related readmissions accrued additional costs of $29,513. Some of the most common reasons for readmission were related to nutritional, metabolic, and fluid and electrolyte disorders. Presentation to the ED occurred in 14.0% of patients, and outpatient upper endoscopy was required in 1.5% of patients, but with much lower associated costs as compared to readmission ($1175).

Conclusion: The majority of patients undergoing ARS do not require additional care within 90 days of surgery. Patients who are readmitted accrue costs that almost double the overall cost of care compared to the initial hospitalization. Measures to attenuate potentially preventable readmissions after ARS may reduce healthcare utilization in this patient population.
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http://dx.doi.org/10.1007/s00464-019-06758-2DOI Listing
January 2020

Persistent Dysphagia Rate After Antireflux Surgery is Similar for Nissen Fundoplication and Partial Fundoplication.

J Surg Res 2019 03 23;235:52-57. Epub 2018 Oct 23.

Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin. Electronic address:

Background: Laparoscopic fundoplication is the gold standard operation for treatment of gastroesophageal reflux disease (GERD). It has been suggested that persistent postoperative dysphagia is increased following Nissen fundoplication compared to partial fundoplication. This study aimed to determine risk factors for persistent postoperative dysphagia, specifically examining the type of fundoplication.

Methods: Patients experiencing GERD symptoms who underwent laparoscopic Nissen, Toupet, or Dor fundoplication from 2009 to 2016 were identified from a single-institutional database. A dysphagia score was obtained as part of the GERD health-related quality of life questionnaire. Persistent dysphagia was defined as a difficulty swallowing score ≥1 (noticeable) on a scale from 0 to 5 at least 1 y postoperatively. Odds ratios of persistent dysphagia among those who underwent antireflux surgery were calculated in a multivariate logistic regression model adjusted for fundoplication type, sex, age, body mass index, and redo operation.

Results: Of the 441 patients who met inclusion criteria, 255 had ≥1 y of follow-up (57.8%). The median duration of follow-up was 3 y. In this cohort, 45.1% of patients underwent Nissen fundoplication and 54.9% underwent partial fundoplication. Persistent postoperative dysphagia was present in 25.9% (n = 66) of patients. On adjusted analysis, there was no statistically significant association between the type of fundoplication (Nissen versus partial) and the likelihood of postoperative dysphagia.

Conclusions: Persistent postoperative dysphagia after antireflux surgery occurred in approximately one-quarter of patients and did not differ by the type of fundoplication. These findings suggest that both Nissen and partial fundoplication are reasonable choices for an antireflux operation for properly selected patients.
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http://dx.doi.org/10.1016/j.jss.2018.09.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6368386PMC
March 2019

Monitoring Fatty Liver Disease with MRI Following Bariatric Surgery: A Prospective, Dual-Center Study.

Radiology 2019 03 18;290(3):682-690. Epub 2018 Dec 18.

From the Departments of Radiology (B.D.P., C.N.W., A.M., N.S.A., S.B.R.), Medical Physics (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and General Surgery (L.M.F., J.A.G.), University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252; Madison Radiologists, SC, Madison, Wis (B.D.P.); Department of General Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wis (L.M.F.); Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tenn (N.S.A.); Departments of Radiology, Liver Imaging Group (A.S., Y.C., J.H., C.B.S.), Pediatrics, Section of Gastroenterology (J.B.S.), General Surgery (G.J., S.H.), and Computational and Applied Statistics Laboratory (T.W., A.C.G.), University of California, San Diego, Calif; and Department of Surgery, Virginia Commonwealth University, Richmond, Va (G.M.C.).

Purpose To longitudinally monitor liver fat before and after bariatric surgery by using quantitative chemical shift-encoded (CSE) MRI and to compare with changes in body mass index (BMI), weight, and waist circumference (WC). Materials and Methods For this prospective study, which was approved by the internal review board, a total of 126 participants with obesity who were undergoing evaluation for bariatric surgery with preoperative very low calorie diet (VLCD) were recruited from June 27, 2010, through May 5, 2015. Written informed consent was obtained from all participants. Participants underwent CSE MRI measuring liver proton density fat fraction (PDFF) before VLCD (2-3 weeks before surgery), after VLCD (1-3 days before surgery), and 1, 3, and 6-10 months following surgery. Linear regression was used to estimate rates of change of PDFF (ΔPDFF) and body anthropometrics. Initial PDFF (PDFF), initial anthropometrics, and anthropometric rates of change were evaluated as predictors of ΔPDFF. Mixed-effects regression was used to estimate time to normalization of PDFF. Results Fifty participants (mean age, 51.0 years; age range, 27-70 years), including 43 women (mean age, 50.8 years; age range, 27-70 years) and seven men (mean age, 51.7 years; age range, 36-62 years), with mean PDFF ± standard deviation of 18.1% ± 8.6 and mean BMI of 44.9 kg/m ± 6.5 completed the study. By 6-10 months following surgery, mean PDFF decreased to 4.9% ± 3.4 and mean BMI decreased to 34.5 kg/m ± 5.4. Mean estimated time to PDFF normalization was 22.5 weeks ± 11.5. PDFF was the only strong predictor for both ΔPDFF and time to PDFF normalization. No body anthropometric correlated with either outcome. Conclusion Average liver proton density fat fraction (PDFF) decreased to normal (< 5%) by 6-10 months following surgery, with mean time to normalization of approximately 5 months. Initial PDFF was a strong predictor of both rate of change of PDFF and time to normalization. Body anthropometrics did not predict either outcome. Online supplemental material is available for this article. © RSNA, 2018.
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http://dx.doi.org/10.1148/radiol.2018181134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394737PMC
March 2019

Deficiencies in postoperative surveillance for veterans with gastrointestinal cancer.

J Surg Oncol 2019 Mar 16;119(3):273-277. Epub 2018 Dec 16.

Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.

Background And Objectives: National guidelines for gastrointestinal (GI) cancers offer surveillance algorithms to facilitate detection of recurrent disease, yet adherence rates are unknown. We sought to characterize postoperative surveillance patterns for veterans with GI cancer at a tertiary care Veterans Affairs Hospital.

Methods: A single-center retrospective cohort study identified patients who underwent surgical resection for colorectal, gastroesophageal or hepatopancreaticobiliary malignancy from 2010-2016. We calculated the annual rate of cancer-directed clinic visits and abdominal imaging and used National Comprehensive Cancer Network guidelines as a benchmark by which to assess adequate surveillance.

Results: Ninety-seven patients met inclusion criteria. Median surveillance time was 1203 days. Overall, 44% of patients had insufficient surveillance. Specifically, 11% received no postoperative imaging and 7% had no cancer-directed clinic visits. An additional 30% received less than recommended surveillance imaging and 12% attended fewer than recommended clinic visits. By disease site, insufficient imaging was most common for patients with hepatopancreaticobiliary cancer (63%), while inadequate clinic follow-up was highest for colorectal cancer (24%).

Conclusion: A significant proportion of veterans with GI cancer received either inadequate postoperative surveillance based on national guidelines. This deficiency represents an opportunity for improvement through targeted efforts, including telemedicine and education of patients and providers.
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http://dx.doi.org/10.1002/jso.25333DOI Listing
March 2019

Geographic Variation in Obesity, Behavioral Treatment, and Bariatric Surgery for Veterans.

Obesity (Silver Spring) 2019 01 13;27(1):161-165. Epub 2018 Nov 13.

Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.

Objective: This study aims to describe geographic variation in veterans' prevalence of obesity, participation in Veterans Health Administration's behavioral weight management program (MOVE!), and receipt of bariatric surgery in fiscal year (FY) 2016.

Methods: In this retrospective cohort study of veterans with obesity who received Veterans Health Administration care in FY2016, electronic health record data were obtained on weight, height, outpatient visits to the MOVE! program, and bariatric surgeries. For each Veterans Integrated Service Network (VISN) region, the prevalence rate of veterans with obesity (BMI ≥ 30 kg/m ), MOVE! participation rates, and bariatric surgery rates are presented.

Results: The prevalence of obesity in veterans ranged from 30.5% to 40.5% across VISNs in FY2016. MOVE! participation among veterans with obesity was low (2.8%-6.9%) across all VISNs, but veterans with class II and III obesity (BMI ≥ 35) had higher MOVE! participation rates (4.3%-10.8%) than veterans with class I obesity. There was 20-fold variation across VISNs in receipt of bariatric surgery among veterans with BMI ≥ 35, ranging from 0.01% to 0.2%. Among veterans with BMI ≥ 35 participating in MOVE!, there was 46-fold variation in bariatric surgery provision, ranging from 0.07% to 3.27%.

Conclusions: Despite veterans' high prevalence of obesity, behavioral and surgical weight management participation is low and varies across regions.
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http://dx.doi.org/10.1002/oby.22350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309247PMC
January 2019

Wisconsin's Enterra Therapy Experience: A multi-institutional review of gastric electrical stimulation for medically refractory gastroparesis.

Surgery 2018 10 30;164(4):760-765. Epub 2018 Jul 30.

Department of Surgery, Division of General Surgery, Medical College of Wisconsin, Milwaukee; and. Electronic address:

Background: Gastric electrical stimulation is a treatment for symptoms of diabetic or idiopathic gastroparesis refractory to medical management. We sought to evaluate the outcomes of gastric electrical stimulation in the state of Wisconsin during a more than 10-year period.

Methods: Data were collected prospectively from patients undergoing implantation of the gastric electrical stimulation to initiate gastric electrical stimulation therapy at two Wisconsin institutions from 2005-2017. The Gastroparesis Cardinal Symptom Index was administered during clinical encounters and over the phone preoperatively and postoperatively.

Results: A total of 119 patients received gastric electrical stimulation therapy (64 diabetic and 55 idiopathic). All devices were placed laparoscopically. Mean follow-up was 34.1 ± 27.2 months in diabetic and 44.7 ± 26.2 months in idiopathic patients. A total of 18 patients died during the study interval (15.1%). No mortalities were device-related. Diabetics had the greatest rate of mortality (25%; mean interval of 17 ± 3 months post implantation). GCSI scores improved, and prokinetic and narcotic medication use decreased significantly at ≥1 year. Satisfaction scores were high.

Conclusion: Gastric electrical stimulation therapy led to the improvement of symptoms of gastroparesis and a better quality of life. Patients were able to decrease the use of prokinetic and narcotic medications and achieve long-term satisfaction. Diabetic patients who develop symptomatic gastroparesis have a high mortality rate over time.
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http://dx.doi.org/10.1016/j.surg.2018.04.043DOI Listing
October 2018

Relationship Status After Bariatric Surgery: It's Complicated.

JAMA Surg 2018 07;153(7):661-662

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison.

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http://dx.doi.org/10.1001/jamasurg.2018.0216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953603PMC
July 2018

Bariatric surgery barriers: a review using Andersen's Model of Health Services Use.

Surg Obes Relat Dis 2018 03 10;14(3):404-412. Epub 2017 Nov 10.

Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), University of Wisconsin-Madison, Madison, Wisconsin; William S. Middleton Veterans Memorial Hospital, Madison, Wisconsin. Electronic address:

Severe obesity affects nearly 20 million adults in the United States and is associated with significant morbidity and mortality. Bariatric surgery is the most effective treatment for weight loss and resolution of obesity-related co-morbidities. Of adults with severe obesity,<1% undergo bariatric surgery annually. Both contextual (health system, clinicians, and community) and individual factors contribute to the underutilization of bariatric surgery. In this review, we summarize potential barriers to undergoing bariatric surgery within the framework of Andersen's Behavioral Model of Health Services Use.
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http://dx.doi.org/10.1016/j.soard.2017.11.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039385PMC
March 2018

How bariatric surgery affects liver volume and fat density in NAFLD patients.

Surg Endosc 2018 04 7;32(4):1675-1682. Epub 2017 Dec 7.

Division of Minimally Invasive Surgery, Department of Surgery, University of California, San Diego, 9500 Gilman Drive MC 0740, San Diego, CA, 92093, USA.

Introduction: Nonalcoholic fatty liver disease (NAFLD) is an epidemic in the obese population. Bariatric surgery is known to reverse multiple metabolic complications of obesity such as diabetes, dyslipidemia, and NAFLD, but the timing of liver changes has not been well described.

Materials And Methods: This was an IRB-approved, two-institutional prospective study. Bariatric patients received MRIs at baseline and after a pre-operative liquid diet. Liver biopsies were performed during surgery and if NAFLD positive, the patients received MRIs at 1, 3, and 6 months. Liver volumes and proton-density fat fraction (PDFF) were calculated from offline MRI images. Primary outcomes were changes in weight, body mass index (BMI), percent excess weight loss (EWL%), liver volume, and PDFF. Resolution of steatosis, as defined as PDFF < 6.4% based on previously published cutoffs, was assessed. Secondarily, outcomes were compared between patients who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB).

Results: From October 2010 to June 2015, 124 patients were recruited. 49 patients (39.5%) completed all five scans. EWL% at 6 months was 55.6 ± 19.0%. BMI decreased from 45.3 ± 5.9 to 34.4 ± 5.1 kg/m and mean liver volume decreased from 2464.6 ± 619.4 to 1874.3 ± 387.8 cm with a volume change of 21.4 ± 11.4%. PDFF decreased from 16.6 ± 7.8 to 4.4 ± 3.4%. At 6 months, 83.7% patients had resolution of steatosis. Liver volume plateaued at 1 month, but PDFF and BMI continued to decrease. There were no statistically significant differences in liver volume or PDFF reduction from baseline to 6 months between the LSG versus LRYGB subgroups.

Conclusion: Patients with NAFLD undergoing bariatric surgery can expect significant decreases in liver volume and hepatic steatosis at 6 months, with 83.7% of patients achieving resolution of steatosis. Liver volume reduction plateaus 1-month post-bariatric surgery, but PDFF continues to decrease. LSG and LRYGB did not differ in efficacy for inducing regression of hepatosteatosis.
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http://dx.doi.org/10.1007/s00464-017-5846-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6690434PMC
April 2018

Patient-reported quality of life after bariatric surgery: a single institution analysis.

J Surg Res 2017 10 15;218:117-123. Epub 2017 Jun 15.

Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin; Department of Surgery, William S. Middleton Veterans Hospital, Madison, Wisconsin. Electronic address:

Background: Bariatric surgery is an effective weight loss and comorbidity treatment among severely obese patients. However, there are limited data describing its impact on patient-reported quality of life (QoL). We examined patient-reported QoL after bariatric surgery and analyzed variables associated with higher postoperative QoL.

Methods: Patient demographics, comorbidities, and weight loss data were obtained from our institutional database for patients who underwent bariatric surgery from January 2010 to December 2012. QoL scores were obtained during preoperative and postoperative visits (2, 6, 12, 24, 52, and 104 wk) from the Moorehead-Ardelt Quality of Life Questionnaire II. Multivariable logistic regression was performed to generate odds ratios for variables hypothesized a priori to be associated with higher postoperative QoL.

Results: A total of 209 patients were included in the study. Patients lost an average of 59.1% (±19.0) of excess body weight 1 y after surgery. One-year postoperative QoL scores were available for 42% of patients. Mean QoL scores improved from 0.82 preoperatively to 1.66 1 y postoperatively (P = 0.004). Patients scored higher in all individual areas of Moorehead-Ardelt Quality of Life Questionnaire II: self-esteem (0.22 versus 0.36), physical activity (0.11 versus 0.31), social life (0.28 versus 0.36), work ability (0.07 versus 0.22), sexual functioning (0.04 versus 0.16), and approach to food (0.11 versus 0.26; all P values <0.05). On multivariable analysis, higher QoL was associated with private insurance/self-pay versus Medicare (odds ratio 4.20 [95% confidence interval 1.39-12.68]).

Conclusions: Bariatric surgery patients experienced significant improvement in QoL 1 y after surgery. Identifying modifiable predictors of high QoL after bariatric surgery requires additional investigation.
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http://dx.doi.org/10.1016/j.jss.2017.05.068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6919965PMC
October 2017

Concurrent bariatric surgery and paraesophageal hernia repair: comparison of sleeve gastrectomy and Roux-en-Y gastric bypass.

Surg Obes Relat Dis 2018 01 29;14(1):8-13. Epub 2017 Jul 29.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background: Paraesophageal hernia (PEH) is a common condition that bariatric surgeons encounter. Expert opinion is split on whether bariatric surgery and PEH repair should be completed concurrently or sequentially. We hypothesized that concurrent bariatric surgery and PEH repair is safe.

Objectives: We examined 30-day outcomes after concomitant PEH repair and bariatric surgery.

Setting: National database, United States.

Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database (2011-2014), we identified patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) with or without PEH repair. A propensity score-matching algorithm was used to compare patients who underwent either LRYGB or LSG with PEH repair. The primary outcome was overall morbidity. Secondary outcomes included mortality, serious morbidity, readmission, and reoperation.

Results: Of the 76,343 patients in this study, 5958 (7.80%) underwent PEH repair concurrently with bariatric surgery. The frequency of bariatric operations that included PEH repair increased over time (2.14% in 2010 versus 12.17% in 2014, P<.001). The rate of PEH/LSG was higher than PEH/LRYGB in 2014 (8.9 % versus 3.2%). There were no significant differences in outcomes between the matched cohort of PEH and non-PEH patients. Subgroup analysis showed significantly greater rates of morbidity (6.20% versus 2.69%, P<.001), readmission (6.33% versus 3.06%, P<.001), and reoperation (3.00% versus 1.05%, P<.001) for PEH/LRYGB versus PEH/LSG.

Conclusions: A PEH repair at the time of bariatric surgery does not appear to be associated with increased morbidity or mortality. A concurrent approach to treat patients with severe obesity and PEH appears safe.
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http://dx.doi.org/10.1016/j.soard.2017.07.026DOI Listing
January 2018