Publications by authors named "Zhamak Khorgami"

76 Publications

Postoperative sepsis after primary bariatric surgery: an analysis of MBSAQIP.

Surg Obes Relat Dis 2021 Apr 16;17(4):667-672. Epub 2020 Dec 16.

Department of Surgery, School of Community Medicine, University of Oklahoma, Tulsa, Oklahoma.

Background: Identifying patients at higher risk of postoperative sepsis (PS) may help to prevent this life-threatening complication.

Objectives: This study aimed to identify the rate and predictors of PS after primary bariatric surgery.

Setting: An analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015-2017.

Methods: Patients undergoing elective sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were included. Exclusion criteria were revisional, endoscopic, and uncommon, or investigational procedures. Patients were stratified by the presence or absence of organ/space surgical site infection (OS-SSI), and patients who developed sepsis were compared with patients who did not develop sepsis in each cohort. Logistic regression was used to identify independent predictors of PS.

Results: In total, 438,752 patients were included (79.4% female, mean age 44.6±12 years). Of those, 661 patients (.2%) developed PS of which 245 (37.1%) developed septic shock. Out of 892 patients with organ/space surgical site infections (OS-SSI), 298 (45.1%) developed sepsis (P <.001). Patients who developed PS had higher mortality (8.8% versus .1%, P < .001), and this was highest in patients without OS-SSI (11.8% versus 5%, P = .002). The main infectious complications associated with PS in patients without OS-SSI were pneumonia and urinary tract infection. Independent predictors of PS in OS-SSI included RYGB versus SG (OR, 1.8), and age ≥50 years (OR, 1.4). Independent predictors of PS in patients without OS-SSI were conversion to other approaches (OR, 6), operation length >2 hours (OR, 5.7), preoperative dialysis (OR, 4.1), preoperative therapeutic anticoagulation (OR, 2.8), limited ambulation most or all of the time (OR, 2.4), preoperative venous stasis (OR, 2.4), previous nonbariatric foregut surgery (OR, 2), RYGB versus SG (OR, 2), hypertension on medication (OR, 1.5), body mass index ≥50 kg/m(OR, 1.4), age ≥50 years (OR, 1.3), obstructive sleep apnea (OR, 1.3).

Conclusion: Development of OS-SSI after primary bariatric surgery is associated with sepsis and increased 30-day mortality. Patients without OS-SSI who develop PS have a significantly higher mortality rate compared with patients with OS-SSI who develop PS. Early identification and intervention in patients with PS, including those without OS-SSI, may improve survival in this high-risk group.
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http://dx.doi.org/10.1016/j.soard.2020.12.008DOI Listing
April 2021

Comments on the Use of Visceral Adiposity Index to Predict Diabetes Remission in Low BMI Chinese Patients after Bariatric Surgery.

Obes Surg 2021 05 19;31(5):2302-2303. Epub 2021 Jan 19.

Department of Surgery, School of Community Medicine, University of Oklahoma, Tulsa, OK, USA.

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http://dx.doi.org/10.1007/s11695-020-05194-9DOI Listing
May 2021

Metabolic bone changes after bariatric surgery: 2020 update, American Society for Metabolic and Bariatric Surgery Clinical Issues Committee position statement.

Surg Obes Relat Dis 2021 Jan 23;17(1):1-8. Epub 2020 Sep 23.

Department of Surgery, Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts.

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http://dx.doi.org/10.1016/j.soard.2020.09.031DOI Listing
January 2021

Comment on: Racial disparities in perioperative outcomes following metabolic and bariatric surgery: a case-control matched study.

Authors:
Zhamak Khorgami

Surg Obes Relat Dis 2020 10 9;16(10):e68-e69. Epub 2020 Jul 9.

University of Oklahoma School of Community Medicine, Tulsa, Oklahoma.

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http://dx.doi.org/10.1016/j.soard.2020.06.010DOI Listing
October 2020

Ethnic Disparities in Use of Bariatric Surgery in the USA: the Experience of Native Americans.

Obes Surg 2020 Jul;30(7):2612-2619

Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Institute of Clinical Sciences, Queen's University Belfast, Block B, Royal Victoria Hospital, Belfast, BT12 6BA, UK.

Purpose: To examine disparities in use of bariatric surgery in the USA with particular focus on the experience of Native Americans.

Materials And Methods: Multivariable logistic regression models were applied to the hospital discharge HCUP-NIS dataset (2008-2016) in order to examine the influence of ethnicity in use of bariatric surgery while controlling for aspects of need, predisposing and enabling factors. Separate models investigated disparities in length of stay, cost and discharge to healthcare facility among patient episodes for bariatric surgery.

Results: Full data for 1,729,245 bariatric surgery eligible participants were extracted from HCUP-NIS. The odds of Native Americans receiving bariatric surgery compared to White Americans were 0.67 (95% CI, 0.62-0.73) in a model unadjusted for covariates; 0.65 (95% CI, 0.59-0.71) in a model adjusted for demography and insurance; 0.59 (95% CI, 0.54-0.64) in a model adjusted for clinical variables; and 0.72 (95% CI, 0.66-0.79) in a model adjusted for demographic, insurance types and clinical variables. Native Americans who underwent surgery had significantly shorter lengths of stay, lower healthcare expenditures and lower likelihood of discharge to other healthcare facilities relative to White Americans (controlling for covariates).

Conclusion: Our study, the first study to examine this subject, showed apparent variations in receipt of bariatric surgery between Native Americans and White Americans even after a range of covariates were controlled. In addition, Native Americans have shorter lengths of stay and significantly lower expenditures.
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http://dx.doi.org/10.1007/s11695-020-04529-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7260278PMC
July 2020

Ten-Year Trends in Traumatic Cardiac Injury and Outcomes: A Trauma Registry Analysis.

Ann Thorac Surg 2020 09 4;110(3):844-848. Epub 2020 Feb 4.

Department of Surgery, College of Medicine, University of Oklahoma, Tulsa, Oklahoma.

Background: Cardiac injury is a significant cause of death in patients with traumatic injuries. The Oklahoma Trauma Registry collects data from acute care hospitals in Oklahoma. This study investigated the trends and outcomes of traumatic cardiac injury in Oklahoma over a 10-year period.

Methods: The Oklahoma Trauma Registry tracks patients with major severity and one of the following criteria: hospital stay 48 hours or longer, death on arrival or in the hospital, hospital transfer, intensive care unit admission, or surgery. Cardiac injuries were identified from data acquired 2005 to 2014. Characteristics, mechanisms of injury, associated injuries, and outcomes were analyzed. Results were further divided into blunt vs penetrating injuries and operative vs nonoperative management.

Results: Of 107,549 patients, 426 patients suffered cardiac injury, and 160 patients suffered penetrating trauma. Commonly associated injuries were rib fractures, pneumothorax, hemothorax, and intraabdominal injuries. Of blunt cardiac injuries, 26.7% had spinal fractures. Operative management occurred in 16.9%. Overall mortality rate was 35.7% (51.9% in penetrating and 26.3% in blunt injuries). Mortality was higher for patients who had operative management but was similar in penetrating and blunt cardiac injury. Over 10 years, the percentage of cardiac injury decreased. However, mortality in patients who suffered a cardiac injury increased, correlating with an increase in proportion of penetrating cardiac injury.

Conclusions: Traumatic cardiac injury, particularly penetrating injury, continues to be a significant source of mortality. Analysis of state-base trauma registries can identify trends in causes of injury and death, serving as a reference point for quality improvement, therapeutic triage, and preventative action plans.
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http://dx.doi.org/10.1016/j.athoracsur.2019.12.038DOI Listing
September 2020

Traumatized Residents - It's Not Surgery. It's Medicine.

J Surg Educ 2019 Nov - Dec;76(6):e30-e40. Epub 2019 Aug 31.

Methodist Dallas Medical Center, Department of Graduate Medical Education, Dallas, Texas.

Background: Post-traumatic stress disorder (PTSD) has been shown to be more common in surgical residents than the general population. This may be due to the rigors of a surgical residency. This study aims to compare the prevalence of screening positive for PTSD (PTSD+) among 7 medical specialties. Further, we intend to identify independent risk factors for the development of PTSD.

Methods: A cross-sectional national survey of residents (n = 1904) was conducted from September 2016 to May 2017. Residents were screened for PTSD. Traumatic stressors were identified in those who reported symptoms of PTSD. Potential risk factors for PTSD were assessed using multivariate regression analysis with stepwise backward elimination against 30 demographic, occupational, psychological, work-life balance, and work-environment variables.

Results: Residents from anesthesiology (n = 180), emergency medicine (n = 222), internal medicine (n = 473), general surgery (n = 464), obstetrics and gynecology (n = 226), psychiatry (n = 208), and surgical subspecialties (n = 131) were surveyed. No statistical difference was found in the prevalence of PTSD between specialties. Prevalence ranged from 14% to 23%. Eight independent risk factors for the development of PTSD+ were identified: higher postgraduate year, female gender, public embarrassment, emotional exhaustion, feeling unhealthy, job dissatisfaction, hostile hospital culture, and unsafe patient load.

Conclusions: The prevalence of PTSD in surgery residents was not statistically different when compared to those in other medical specialties. However, the overall prevalence of PTSD (20%) remains more than 3 times that of the general population. Overall, 8 risk factors for PTSD were identified. These risk factors varied by specialty. This may highlight the unique challenges of training in each discipline. Specialty specific interventions to improve resident wellness should be emphasized in the development of our young physicians.
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http://dx.doi.org/10.1016/j.jsurg.2019.08.002DOI Listing
December 2020

Banded versus nonbanded Roux-en-Y gastric bypass: a systematic review and meta-analysis of randomized controlled trials.

Surg Obes Relat Dis 2019 May 3;15(5):688-695. Epub 2019 Apr 3.

Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Bariatric surgery is remarkably effective in achieving weight loss and improving obesity-related co-morbidities; however, efforts still continue to improve its long-term outcomes. Particularly, banded Roux-en-Y gastric bypass (RYGB) has been scrutinized in comparison to standard (nonbanded) RYGB in terms of benefits and postoperative complications.

Objectives: This study aims to compare the safety and efficacy of banded versus nonbanded RYGB.

Setting: Meta-analysis of randomized controlled trials (RCTs).

Methods: A meta-analysis of high-quality studies that compared banded and nonbanded RYGB was conducted through February 2019 by systematically searching multiple electronic databases. Published RCTs comparing these 2 procedures were included to pool the data on excess weight loss, food tolerability, and postoperative complications.

Results: Three RCTs were eligible to be included in this meta-analysis, comprising a total of 494 patients (247 in each group). Two of the RCTs provided 2-year postoperative data, and 1 study reported 5-year outcome. Age ranged from 21 to 50 years, and body mass index ranged from 42 to 65 kg/m. Percentage of excess weight loss was significantly greater with banded RYGB than with nonbanded RYGB (mean difference 5.63%; 95% CI 3.26-8.00; P < .05). Postoperative food intolerance, emesis, and dysphagia were more common after banded RYGB (odds ratio 3.76; 95% CI 2.27-6.24; P < .001). Nevertheless, major postoperative complications did not significantly differ between the 2 groups.

Conclusion: Findings of this meta-analysis of RCTs indicate that in a medium-term follow-up, excess weight loss with banded RYGB would be 5% greater than that with the nonbanded RYGB (about 1 point difference in body mass index) at the expense of more food intolerance and postoperative vomiting; however, the frequency of postoperative complications would not be significantly different.
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http://dx.doi.org/10.1016/j.soard.2019.02.011DOI Listing
May 2019

Early cardiac complications after bariatric surgery: does the type of procedure matter?

Surg Obes Relat Dis 2019 Jul 23;15(7):1132-1137. Epub 2019 Mar 23.

Department of Surgery, College of Medicine, University of Oklahoma, Tulsa, Oklahoma.

Background: Major adverse cardiac events (MACE) can be a cause of postoperative mortality. This is specifically important in bariatric surgery due to obesity-related cardiovascular risk factors.

Objective: To assess postoperative cardiac adverse events after bariatric surgery and its independent predictors.

Setting: A retrospective analysis of 2011-2015 Healthcare Cost and Utilization Project-National Inpatient Sample.

Methods: Data on patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were retrieved. MACE was identified as a composite variable including myocardial infarction, acute ischemic heart disease without myocardial infarction, and acute heart failure. Dysrhythmia (excluding premature beats) was identified as a separate outcome. Multivariate regression analysis for MACE was performed using demographic factors, co-morbidities, and type of surgery.

Results: The analysis included 108,432 patients (SG: 54.6%, RYGB: 45.4%). MACE was found in 116 patients (.1%), and dysrhythmia occurred in 3670 patients (3.4%). Median length of stay in patients with MACE was 4.5 versus 2 days in others (P < .001). There were 43 deaths overall, and 31 were in patients with MACE or dysrhythmia (P < .001). Age ≥ 50 years, male sex, congestive heart failure, chronic pulmonary disease, ischemic heart disease, history of pulmonary emboli, and fluid or electrolyte disorders were independent predictors of MACE based on multivariate analysis. Type of surgery (SG versus RYGB) was not an independent predictor for MACE (odds ratio 1.41, 95% confidence interval: .77-2.55).

Conclusions: While cardiac complications are rare after bariatric surgery, their occurrence is associated with increased length of stay, hospital charges, and mortality. Older age, male sex, cardiopulmonary co-morbidities, and fluid or electrolyte disorders are predictive of MACE. RYGB does not increase the risk of MACE compared with SG.
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http://dx.doi.org/10.1016/j.soard.2019.03.030DOI Listing
July 2019

Impact of bariatric surgery on heart failure mortality.

Surg Obes Relat Dis 2019 Jul 22;15(7):1189-1196. Epub 2019 Mar 22.

Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: The impact of bariatric surgery on discrete cardiovascular events has not been well characterized.

Objectives: To assess the impact of prior bariatric surgery on mortality associated with heart failure (HF) admission.

Setting: A retrospective analysis of 2007-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample.

Methods: Participants including 2810 patients with a principal discharge diagnosis of HF who also had a history of prior bariatric surgery were identified. These patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Propensity scores, balanced on baseline characteristics, were used to assemble 2 control groups. Control group-1 included patients with obesity (body mass index [BMI] ≥35 kg/m) only. In control group-2, the BMI was considered as one of the matching criteria in propensity matching. Multivariate regression models were utilized to calculate the odds ratio (OR) and 95% confidence interval (CI) of mortality and length of stay (LOS).

Results: With well-balanced matching, 33,720 (weighted) patients were included in the analysis. In-hospital mortality rates after HF admission were significantly lower in patients with a history of bariatric surgery compared with control group-1 (0.96% versus 1.86%, OR .52, 95% CI .35-0.77, P = .0013) and control group-2 (0.96% versus 1.86%, OR .52, 95% CI .35-0.77, P = .0011). Furthermore, LOS was shorter in the bariatric surgery group compared with control group-1 (4.8 ± 4.4 versus 5.7 ± 5.7 d, P < .001) and control group-2 (4.8 ± 4.4 versus 5.4 ± 6.3 d, P < .001).

Conclusions: Our data suggest that prior bariatric surgery is associated with almost 50% reduction in in-hospital mortality and shorter LOS in patients with HF admission.
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http://dx.doi.org/10.1016/j.soard.2019.03.021DOI Listing
July 2019

Mortality in open abdominal aortic surgery in patients with morbid obesity.

Surg Obes Relat Dis 2019 Jun 4;15(6):958-963. Epub 2019 Apr 4.

Department of Surgery, College of Medicine, University of Oklahoma, Tulsa, Oklahoma.

Background: Open abdominal aortic surgery is among procedures with high morbidity and mortality. Adverse postoperative complications may be more common in morbidly obese patients.

Objectives: This study compared the outcomes of open abdominal aortic surgeries in patients with and without morbid obesity.

Setting: A retrospective analysis of 2007-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample.

Methods: We included patients who underwent open abdominal aortic aneurysm (AAA) repair or open aorta-iliac-femoral (AIF) bypass. Demographic factors, morbid obesity, co-morbidities, and emergent versus elective surgery were considered for univariate and multivariate analyses.

Results: A total of 29,340 patients (13,443 AAA repair and 15,897 AIF bypass) were included (age 66.3 ± 10.8 years, 65.7% male). The mortality was 9.1% in 536 patients with morbid obesity compared with 7.1% in patients without morbid obesity. Based on multivariate analysis, age, existing co-morbidities, emergent versus elective setting, and morbid obesity were found to be independent predictors of mortality. Patients with morbid obesity had an odds ratio of 3.61 (95% CI, 1.50-8.68; P = .004) for mortality, longer mean length of stay (11.2 versus 9.3 days, P < .001), and higher total hospital charges ($99,500 versus $73,700, P < .001).

Conclusions: Morbid obesity is an independent risk factor of mortality in patients undergoing open AAA repair and AIF bypass. Weight loss strategies should be considered for morbidly obese patients with an anticipation of open abdominal aortic procedures.
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http://dx.doi.org/10.1016/j.soard.2019.03.044DOI Listing
June 2019

Bariatric surgery is associated with a lower rate of death after myocardial infarction and stroke: A nationwide study.

Diabetes Obes Metab 2019 09 17;21(9):2058-2067. Epub 2019 Jun 17.

Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.

Aim: To assess the potential protective effect of bariatric surgery on mortality after myocardial infarction (MI) or cerebrovascular accident (CVA).

Materials And Methods: Using the National Inpatient Sample (2007-2014), 2218 patients with a principal discharge diagnosis of acute MI and 2168 patients with ischaemic CVA who also had history of prior bariatric surgery were identified. Utilizing propensity scores, these patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Control group-1 included participants with obesity (BMI ≥ 35 kg/m ) only and participants in control group-2 were matched according to post-surgery BMI with the bariatric surgery group. The primary and secondary endpoints were in-hospital all-cause mortality and length of hospital stay, respectively. Outcomes after MI and CVA were separately compared among groups in multivariate regression models.

Results: A total of 48 300 (weighted) participants were included in the analysis. The distribution of covariates was well balanced after propensity matching. Mortality rates after MI were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.85% vs 3.03%; odds ratio (OR), 0.61; 95% confidence interval (CI), 0.44-0.86; P = 0.004) and with control group-2 (2.00% vs 3.26%; OR, 0.62; 95% CI, 0.44-0.88; P = 0.008). Similarly, in-hospital mortality rates after CVA were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.43% vs 2.74%; OR, 0.54; 95% CI, 0.37-0.79; P = 0.001) and with control group-2 (1.54% vs 2.59%; OR, 0.61; 95% CI, 0.41-0.91; P = 0.015). Furthermore, length of stay was significantly shorter in the bariatric surgery group for all comparisons (P < 0.001).

Conclusion: Prior bariatric surgery is associated with significant protective effect on survival after MI and CVA.
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http://dx.doi.org/10.1111/dom.13765DOI Listing
September 2019

Comment on: "Racial disparities in perioperative outcomes after bariatric surgery".

Surg Obes Relat Dis 2019 05 20;15(5):804-805. Epub 2019 Mar 20.

Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.

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http://dx.doi.org/10.1016/j.soard.2019.02.008DOI Listing
May 2019

Predictors of discharge destination in patients with major traumatic injury: Analysis of Oklahoma Trauma Registry.

Am J Surg 2019 09 10;218(3):496-500. Epub 2018 Dec 10.

Department of Surgery, The University of Oklahoma, College of Medicine, Tulsa, OK, USA. Electronic address:

Background: The ability to predict the need for discharge of trauma patients to a facility may help shorten hospital stay. This study aimed to determine the predictors of discharge to a facility and develop and validate a predictive scoring model, utilizing the Oklahoma Trauma Registry (OTR).

Methods: A multivariate analysis of the OTR 2005-2013 determined independent predictors of discharge to a facility. A scoring model was developed, and positive and negative predictive values (PPV and NPV) were evaluated for 2014 patients.

Results: 101,656 patients were analyzed. The scoring model included age≥50 years, lower extremity fracture, ICU stay≥5 days, pelvic fracture, intracranial hemorrhage, congestive heart failure, cardiac dysrhythmia, history of CVA or TIA, and ISS≥15, spine fracture, diabetes mellitus, hypertension, ischemic heart disease, and chronic obstructive pulmonary disease. Applying the model to 2014 patients, PPV for predicting discharge to a facility was 84.9% for scores≥15, and NPV was 90.5% for scores<8.

Conclusion: A scoring model including age, trauma severity, types of injury, and comorbidities could predict discharge of trauma patients to a facility. Further studies are needed to refine the efficacy of the model.
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http://dx.doi.org/10.1016/j.amjsurg.2018.11.045DOI Listing
September 2019

Outcomes of Bariatric Surgery Versus Medical Management for Type 2 Diabetes Mellitus: a Meta-Analysis of Randomized Controlled Trials.

Obes Surg 2019 03;29(3):964-974

Department of Surgery, College of Medicine, University of Oklahoma, 4502 E 41st Street, Tulsa, OK, 74135, USA.

Introduction: Bariatric surgery improves type 2 diabetes (T2D) in obese patients. The sustainability of these effects and the long-term results have been under question.

Objective: To compare bariatric surgery versus medical management (MM) for T2D based on a meta-analysis of randomized controlled trials (RCTs) with 2 years of follow-up.

Material And Methods: Seven RCTs with at least 2-year follow-up were identified. The primary endpoint was remission of T2D (full or partial). Four hundred sixty-three patients with T2D and body mass index > 25 kg/m were evaluated.

Results: After 2 years, T2D remission was observed in 138 of 263 patients (52.5%) with bariatric surgery compared to seven of 200 patients (3.5%) with MM (risk ratio (RR) = 10, 95% CI 5.5-17.9, p < 0.001). Subgroup analysis of the Roux-en-Y gastric bypass (RYGB) showed a significant effect size at 2 years in favor of RYGB over MM for a higher decrease of HbA1C (0.9 percentage points, 95% CI 0.6-1.1, p < 0.001), decrease of fasting blood glucose (35.3 mg/dl, 95% CI 13.3-57.3, p = 0.002), increase of high-density lipoprotein (HDL) (12.2 mg/dl, 95% CI 7.6-16.8, p < 0.001), and decrease of triglycerides (32.4 mg/dl, 95% CI 4.5-60.3, p = 0.02). Four studies followed patients up to 5 years and showed 62 of 225 patients (27.5%) with remission after surgery, compared to six of 156 patients (3.8%) with MM (RR = 6, 95% CI 2.7-13, p < 0.001).

Conclusion: This meta-analysis shows a superior and persistent effect of bariatric surgery versus MM for inducement of remission of T2D. This benefit of bariatric surgery was significant at 2 years and superior to MM even after 5 years. Compared with MM, patients with RYGB had better glycemic control and improved levels of HDL and triglycerides.
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http://dx.doi.org/10.1007/s11695-018-3552-xDOI Listing
March 2019

Predictors of mortality after elective ventral hernia repair: an analysis of national inpatient sample.

Hernia 2019 10 3;23(5):979-985. Epub 2018 Nov 3.

Department of Surgery, College of Medicine, University of Oklahoma, 4502 E 41st Street, Tulsa, OK, 74135, USA.

Purpose: Deciding between surgery and non-operative management of a non-obstructive ventral hernia (VH) in a high-risk patient often poses a clinical challenge. The aim of this study is to evaluate a national series of open and laparoscopic ventral hernia repair (VHR), and to assess predictors of mortality after elective VHR.

Methods: A retrospective analysis of 2008-2014 data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample was performed. All patients with a primary diagnosis of abdominal wall hernia were included. Inguinal, femoral, or diaphragmatic hernias were excluded. Patients were stratified by elective versus emergent repair. Factors associated with mortality after elective VHR were analyzed.

Results: 103,635 patients were studied, including 14,787 (14.3%) umbilical, 63,685 (61.5%) incisional, and 25,163 (24.3%) other ventral hernias. Operative procedures included 59,993 (57.9%) elective and 43,642 (42.1%) emergent VHR. 21.3% elective VHRs were laparoscopic versus 13% in emergent cases (P < 0.001). Mesh was used in 52,642 (87.7%) elective versus 27,734 (63.5%) emergent VHR (P < 0.001). Median (interquartile range) length of stay was 2(3) days in laparoscopic and 3(3) days in open group (P < 0.001). Mortality was 0.2% (n = 135) in elective and 0.6% (n = 269) in emergent group (P < 0.001). In elective group, mortality rates were equal among laparoscopic and open VHR (0.2%), while in emergent group, it was lower in laparoscopic VHR (0.4% vs 0.6%, P = 0.028). Multivariate analysis of elective VHR showed that the following factors were associated with mortality during hospitalization: age > 50 years [Odds ratio (OR) = 1.96], male gender (OR = 2.37), congestive heart failure (OR = 2.15), pulmonary circulation disorders (OR = 5.26), coagulopathy (OR = 3.93), liver disease (OR = 1.89), fluid and electrolyte disturbances (OR = 8.66), metastatic cancer (OR = 4.66), neurological disorders (OR = 2.31), and paralysis (OR = 5.29).

Conclusions: VHR has a low mortality, especially when performed laparoscopically. In patients undergoing elective VHR, higher age and some comorbidities are predictors of mortality. These include congestive heart failure, pulmonary circulation disorders, coagulopathy, liver disease, metastatic cancer, neurological disorders, and paralysis. Conservative management should be considered for these high-risk subgroups in context of the overall clinical presentation.
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http://dx.doi.org/10.1007/s10029-018-1841-xDOI Listing
October 2019

The cost of robotics: an analysis of the added costs of robotic-assisted versus laparoscopic surgery using the National Inpatient Sample.

Surg Endosc 2019 07 16;33(7):2217-2221. Epub 2018 Oct 16.

Department of Surgery, College of Medicine, University of Oklahoma, Tulsa, OK, USA.

Background: Robotic-assisted surgery (RAS) with its advantages continues to gain popularity among surgeons. This study analyzed the increased costs of RAS in common surgical procedures using the National Inpatient Sample.

Methods: Retrospective analysis of the 2012-2014 Healthcare Cost and Utilization Project-NIS was performed for the following laparoscopic/robotic procedures: cholecystectomy, ventral hernia repair, right and left hemicolectomy, sigmoidectomy, abdominoperineal resection, and total abdominal hysterectomy (TAH). Patients with additional concurrent procedures were excluded. Costs were compared between the laparoscopic procedures and their RAS counterparts. Total costs and charges for cholecystectomy (the most common procedure in the dataset) were compared based on the payer and characteristics of hospital (region, rural/urban, bed size, and ownership).

Results: A total of 91,630 surgeries (87,965 laparoscopic, 3665 robotic) were analyzed. The average cost for the laparoscopic group was $10,227 ± $4986 versus $12,340 ± $5880 for the robotic cases (p < 0.001). The overall and percentage increases for laparoscopic versus robotic for each procedure were as follows: cholecystectomy $9618 versus $10,944 (14%), ventral hernia repair $10,739 versus $13,441 (25%), right colectomy $12,516 versus $15,027 (20%), left colectomy $14,157 versus $17,493 (24%), sigmoidectomy $13,504 versus $16,652 (23%), abdominoperineal resection $17,708 versus $19,605 (11%), and TAH $9368 versus $9923 (6%). Hysterectomy was the only procedure performed primarily using RAS and it was found to have the lowest increase in costs. Increased costs were associated with even higher increases in charges, especially in investor-owned private hospitals.

Conclusion: RAS is more costly when compared to conventional laparoscopic surgery. Additional costs may be lower in centers that perform a higher volume of RAS. Further analysis of long-term outcomes (including reoperations and readmissions) is needed to better compare the life-long treatment costs for both surgical approaches.
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http://dx.doi.org/10.1007/s00464-018-6507-3DOI Listing
July 2019

Clinical significance of perioperative hyperglycemia in bariatric surgery: evidence for better perioperative glucose management.

Surg Obes Relat Dis 2018 11 18;14(11):1725-1731. Epub 2018 Aug 18.

Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Uncontrolled hyperglycemia in patients undergoing surgery has been shown to be a risk factor for postoperative complications.

Objective: To assess the clinical significance of perioperative hyperglycemia on infectious complications and clinical outcomes in patients undergoing bariatric surgery.

Setting: Single academic center.

Methods: Retrospective chart review of all patients who underwent primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between 2013 and 2016 was performed. The association between any elevated perioperative glucose value (hyperglycemia: ≥126 mg/dL) and level of elevation (≥126 or ≥200 mg/dL) with 30-day infectious complications, reoperation, length of hospital stay, and readmission was assessed. Patients who developed early complications (within 3 d of surgery), which could potentially lead to immediate postoperative hyperglycemia, were not included in the analysis. Outcomes of patients with and without diabetes were separately analyzed.

Results: A cohort of 1981 patients was studied, including Roux-en-Y gastric bypass (n = 1171, 59%) and sleeve gastrectomy (n = 810, 41%) patients. In patients with diabetes (n = 751, 38%), perioperative hyperglycemia was independently associated with higher composite infectious complications (defined as presence of any of 6 infectious complications; odds ratio [OR] 3.1, 95% confidence interval [CI] 1.2-8.2, P = .018) and higher readmission rate (OR 2.2, 95% CI 1.1-4.6, P = .027). In patients without diabetes (n = 1230, 62%), 19.2% had perioperative hyperglycemia (≥126 mg/dL). Perioperative hyperglycemia in patients without diabetes was associated with higher composite infectious complications (OR 2.6, 95% CI 1.1-5.5, P = .018) and prolonged length of stay (OR 3.0, 95% CI 1.5-5.9, P = .001).

Conclusions: An elevated perioperative glucose value is adversely associated with infectious complications and key clinical outcomes after bariatric surgery. The increased risk is correlated with the extent of glucose elevation (dose-response relationship). Our findings highlight the importance of glucose control during the perioperative period in bariatric surgical patients.
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http://dx.doi.org/10.1016/j.soard.2018.07.028DOI Listing
November 2018

A Nationwide Safety Analysis of Discharge on the First Postoperative Day After Bariatric Surgery in Selected Patients.

Obes Surg 2019 01;29(1):15-22

Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, Desk M61, Cleveland, OH, 44195, USA.

Background: Enhanced recovery after surgery has led to early recovery and shorter hospital stay after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). This study aims to assess feasibility and outcomes of postoperative day (POD) 1 discharge after LRYGB and LSG from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset.

Methods: Patients who underwent elective LRYGB and LSG and were discharged on POD 1 and 2 were extracted from the MBSAQIP dataset. A 1:1 propensity score matching was performed between cases with POD 1 vs POD 2 discharge, and the 30-day outcomes of the cohorts were compared.

Results: A total of 80,464 patients met the study criteria: 8862 LRYGB and 31,370 LSG cases, which were discharged on POD 1, and matched 1:1 with those discharged on POD 2. Within the LRYGB cohort, patients discharged on POD 2 had higher all-cause morbidity (7.5% vs 6.1%; p < 0.001) and 30-day re-intervention (2.0% vs 1.5%; p = 0.004) in comparison with patients discharged on POD 1. There were no statistical differences with respect to serious morbidity (0.5% vs 0.4%; p = 0.15), 30-day readmission (4.9% vs 4.5%; p = 0.2), and 30-day reoperation (1.3% vs 1.2%; p = 0.7). Within the LSG cohort, patients discharged on POD 2 had higher all-cause morbidity (4.2% vs 3.4%; p < 0.001), serious morbidity (0.4% vs 0.3%; p < 0.001), 30-day re-intervention (1.0% vs 0.6%; p < 0.001), and 30-day readmission (2.9% vs 2.5%; p = 0.002) in comparison with patients discharged on POD 1.

Conclusions: Early discharge on POD 1 may be safe in a selective group of bariatric patients without significant comorbidities.
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http://dx.doi.org/10.1007/s11695-018-3489-0DOI Listing
January 2019

Ten-year trends in traumatic injury mechanisms and outcomes: A trauma registry analysis.

Am J Surg 2018 Apr 31;215(4):727-734. Epub 2018 Jan 31.

Department of Surgery, The University of Oklahoma, College of Medicine, Tulsa, OK, USA. Electronic address:

Background: The Oklahoma Trauma Registry (OTR) collects data from all state-licensed acute care hospitals. This study investigates trends and outcomes of trauma in Oklahoma using OTR.

Methods: 107,549 patients (2005-2014) with major severity and one of the following criteria were included: length of hospital stay ≥48 h, dead on arrival or death in the hospital, hospital transfer, ICU admission, or surgery on the head, chest, abdomen, or vascular system. Patient characteristics, mechanisms of injury, and outcomes of trauma were analyzed.

Results: Hospital admissions due to falls increased with an annual percent change of 4.0% (95%CI: 3.1%-4.9%) while hospital admissions due to motor vehicle crashes decreased. The number of overall deaths per year remained stable except for the fall-related deaths, which increased proportionate to the increase in the incidence of fall. Fall-related mortality was 4.2% and intracranial bleeding was present in 60% in these patients.

Conclusion: Falls are significantly increasing as a mechanism of trauma admissions and trauma-related deaths in Oklahoma. Analysis of state-based trauma registries can identify trends in etiologies of injuries and may indicate a reference point to prioritize preventive plans.
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http://dx.doi.org/10.1016/j.amjsurg.2018.01.008DOI Listing
April 2018

The Physician Attrition Crisis: A Cross-Sectional Survey of the Risk Factors for Reduced Job Satisfaction Among US Surgeons.

World J Surg 2018 05;42(5):1285-1292

Department of Graduate Medical Education, Methodist Dallas Medical Center, 1441 N. Beckley Avenue, Dallas, TX, 75203, USA.

Introduction: A physician shortage is on the horizon, and surgeons are particularly vulnerable due to attrition. Reduced job satisfaction leads to increased job turnover and earlier retirement. The purpose of this study is to delineate the risk factors that contribute to reduced job satisfaction.

Methods: A cross-sectional survey of US surgeons was conducted from September 2016 to May 2017. Screening for job satisfaction was performed using the abridged Job in General scale. Respondents were grouped into more and less satisfied using the median split. Twenty-five potential risk factors were examined that included demographic, occupational, psychological, wellness, and work-environment variables.

Results: Overall, 993 respondents were grouped into more satisfied (n = 502) and less satisfied (n = 491) cohorts. Of the demographic variables, female gender and younger age were associated with decreased job satisfaction (p = 0.003 and p = 0.008). Most occupational variables (specialty, experience, academics, practice size, payment model) were not significant. However, increased average hours worked correlated with less satisfaction (p = 0.008). Posttraumatic stress disorder, burnout, wellness, all eight work-environment variables, and unhappiness with career choice were linked to reduced job satisfaction (p = 0.001).

Conclusion: A surgeon shortage has serious implications for health care. Job satisfaction is associated with physician retention. Our results suggest women and younger surgeons may be at increased risk for job dissatisfaction. Targeted work-environment interventions to reduce work-hours, improve hospital culture, and provide adequate financial reimbursement may promote job satisfaction and wellness.
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http://dx.doi.org/10.1007/s00268-017-4286-yDOI Listing
May 2018

Pancreatic Head Actinomycosis.

Am J Med Sci 2017 Jul 3;354(1):64-65. Epub 2016 Oct 3.

Department of Surgery, College of Medicine, The University of Oklahoma, Tulsa, Oklahoma. Electronic address:

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http://dx.doi.org/10.1016/j.amjms.2016.09.015DOI Listing
July 2017

Cost of bariatric surgery and factors associated with increased cost: an analysis of national inpatient sample.

Surg Obes Relat Dis 2017 Aug 15;13(8):1284-1289. Epub 2017 Apr 15.

Department of Surgery, University of Oklahoma, College of Medicine, Tulsa, Oklahoma.

Background: In the current healthcare environment, bariatric surgery centers need to be cost-effective while maintaining quality.

Objective: The aim of this study was to evaluate national cost of bariatric surgery to identify the factors associated with a higher cost.

Setting: A retrospective analysis of 2012-2013 Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS).

Method: We included all patients with a diagnosis of morbid obesity (ICD9 278.01) and a Diagnosis Related Group code related to procedures for obesity, who underwent Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric banding (AGB) as their primary procedure. We converted "hospital charges" to "cost," using hospital specific cost-to-charge ratio. Inflation was adjusted using the annual consumer price index. Increased cost was defined as the top 20th percentile of the expenditure and its associated factors were analyzed using the logistic regression multivariate analysis.

Results: A total of 45,219 patients (20,966 RYGBs, 22,380 SGs, and 1,873 AGBs) were included. The median (interquartile range) calculated costs for RYGB, SG, and AGB were $12,543 ($9,970-$15,857), $10,531 ($8,248-$13,527), and $9,219 ($7,545-$12,106), respectively (P<.001). Robotic-assisted procedures had the highest impact on the cost (odds ratio 3.6, 95% confidence interval 3.2-4). Hospital cost of RYGB and SG increased linearly with the length of hospital stay and almost doubled after 7 days. Furthermore, multivariate analysis showed that certain co-morbidities and concurrent procedures were associated with an increased cost.

Conclusion: Factors contributing to the cost variation of bariatric procedures include co-morbidities, robotic platform, complexity of surgery, and hospital length of stay.
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http://dx.doi.org/10.1016/j.soard.2017.04.010DOI Listing
August 2017

Should recent smoking be a contraindication for sleeve gastrectomy?

Surg Obes Relat Dis 2017 Jul 9;13(7):1130-1135. Epub 2017 Mar 9.

Bariatric and Metabolic Institute, Department of Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: One of the ultimate goals of bariatric and metabolic surgery is to decrease cardiovascular morbidity and mortality. Obese individuals who smoke tobacco are at an increased risk of cardiovascular events and may benefit the most by positive effects of bariatric surgery on cardiometabolic risk factors. The safety profile of sleeve gastrectomy in patients who smoke has not yet been characterized.

Objectives: To investigate the independent effect of smoking on early postoperative morbidity and mortality of laparoscopic sleeve gastrectomy.

Setting: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

Methods: All patients undergoing primary laparoscopic sleeve gastrectomy from 2010 to 2014 were identified within the NSQIP database. Thirty-day postoperative outcomes for smokers, defined as patients who smoked within the year before surgery, were compared with nonsmokers.

Results: A total of 33,714 people underwent sleeve gastrectomy; 30,418 (90.2%) patients were nonsmokers, whereas 3296 (9.8%) patients smoked within a year before surgery. Among the 17 examined individual adverse events, patients who smoked were more likely to experience an unplanned reintubation (odds ratio [OR] = 1.88, 95% confidence interval [CI]: 1.01-3.50). Patients in the smoking group were significantly more likely to experience a composite morbidity event (4.3% versus 3.7%, P = .04), serious morbidity event (.9% versus .6%, P = .003), and 30-day mortality (0.2% versus .1%, P = .0004). The length of hospital stay, unplanned readmission, and readmission rates were comparable between the 2 groups. These differences in the composite morbidity event, serious morbidity event, and mortality persisted even when those patients with chronic obstructive pulmonary disease, used as a surrogate for end-stage pulmonary effects of smoking, were excluded from the analysis.

Conclusion: Sleeve gastrectomy is a well-tolerated procedure in nonsmokers and smokers. However, patients who have smoked within a year before sleeve gastrectomy are at an increased, albeit still very low, risk for 30-day morbidity and mortality compared with nonsmokers. Additional studies are needed to determine if long-term improvement in co-morbidities can offset this initial modest increased perioperative risk.
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http://dx.doi.org/10.1016/j.soard.2017.02.028DOI Listing
July 2017

Efficacy and Safety of the Over-the-Scope Clip (OTSC) System in the Management of Leak and Fistula After Laparoscopic Sleeve Gastrectomy: a Systematic Review.

Obes Surg 2017 09;27(9):2410-2418

Bariatric and Metabolic Institute, Department of Surgery, The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, Brooklyn, NY, USA.

Background: Endoscopic management of leaks/fistulas after laparoscopic sleeve gastrectomy (LSG) is gaining popularity in the bariatric surgery.

Objectives: This study aimed to review the efficacy and safety of over-the-scope-clip (OTSC) system in endoscopic closure of post-LSG leak/fistula.

Methods: PubMed/Medline and major journals of the field were systematically reviewed for studies on endoscopic closure of post-LSG leaks/fistula by means of the OTSC system.

Results: A total of ten eligible studies including 195 patients with post-LSG leaks/fistula were identified. The time between LSG and leak/fistula ranged from 1 day to 803 days. Most of the leaks/fistula were located at the proximal staple line, and they sized from 3 to 20 mm. Time between leak diagnosis and OTSC clipping ranged from 0 to 271 days. Thirty-three out of 53 patients (63.5%) required one clip for closure of the lesion. Regarding the OTSC-related complications, a leak occurred in five patients (9.3%) and OTSC migration, stenosis, and tear each in one patient (1.8%). Of the 73 patients with post-LSG leak treated with OTSC, 63 patients had an overall successful closure (86.3%).

Conclusion: OTSC system is a promising endoscopic approach for management of post-LSG leaks in appropriately selected patients. Unfortunately, most studies are series with a small sample size, short-term follow-up, and mixed data of concomitant procedures with OTSC. Further studies should distinguish the net efficacy of the OTSC system from other concomitant procedures in treatment of post-LSG leak.
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http://dx.doi.org/10.1007/s11695-017-2651-4DOI Listing
September 2017

Concurrent ventral hernia repair in patients undergoing laparoscopic bariatric surgery: a case-matched study using the National Surgical Quality Improvement Program Database.

Surg Obes Relat Dis 2017 Jun 6;13(6):997-1002. Epub 2017 Jan 6.

Bariatric and Metabolic Institute, Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: There is no consensus regarding the optimal management of ventral hernias encountered during bariatric surgery.

Objectives: To compare early patient morbidity and mortality between those patients undergoing laparoscopic bariatric surgery only and those patients undergoing laparoscopic bariatric surgery with concomitant ventral hernia repair.

Setting: American College of Surgeons National Surgical Quality Improvement Program Database (NSQIP).

Methods: All patients undergoing laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy from 2012-2013 were identified within the NSQIP database. Those patients undergoing concomitant ventral hernia repair were compared with patients undergoing bariatric surgery only using a 1:1 matched analysis. Primary outcomes of interest included differences in 30-day composite adverse events, unplanned 30-day reoperation, and unplanned 30-day readmission to the hospital.

Results: A total of 27,608 patients underwent laparoscopic bariatric surgery during the study period; 988 (3.6%) patients underwent concomitant ventral hernia repair. After 1:1 matching, 1976 patients were evaluated. In terms of 30-day patient morbidity, patients who underwent concomitant ventral hernia were significantly more likely to experience all primary outcomes of interest, including composite adverse events (P = .01), a higher rate of unplanned return to the operating room (P<.001), and a higher 30-day readmission rate (P = .01).

Conclusion: Although we were unable to assess specific hernia characteristics from the NSQIP database, patients who underwent concomitant ventral hernia repair with laparoscopic bariatric surgery experience increased 30-day morbidity. Optimal management of concurrent ventral hernias and timing of repair in bariatric surgical patients requires further investigation.
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http://dx.doi.org/10.1016/j.soard.2017.01.007DOI Listing
June 2017

Trends in utilization of bariatric surgery, 2010-2014: sleeve gastrectomy dominates.

Surg Obes Relat Dis 2017 May 25;13(5):774-778. Epub 2017 Jan 25.

Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Bariatric surgery is the most effective treatment for morbid obesity. Furthermore, the proportion of various types of bariatric procedures has significantly changed over the last two decades. Sleeve gastrectomy (SG) has been increasingly chosen as a primary bariatric procedure in recent years.

Objectives: This study aimed to analyze the changing pattern of bariatric surgery utilization from 2010 to 2014.

Settings: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014.

Method: We identified patients aged≥18 years with a body mass index (BMI)≥35 kg/m undergoing primary bariatric surgery. The trend of surgical procedures was analyzed from 2010 to 2014.

Results: A total of 93,328 patients were included (age of 44.6±11.8 years and BMI of 46.2±7.9 kg/m). Roux-en-Y gastric bypass (RYGB), adjustable gastric band, and SG comprised 58.4%, 28.8%, and 9.3% of the procedures in 2010 which changed to 37.6%, 3.1%, and 58.2% in 2014, respectively. Baseline BMI of SG patients decreased from 47.5 to 45.6 kg/m (P< .001). The proportion of diabetic patients undergoing RYGB increased (30.4% to 33.2%, P<.001) but decreased among those having SG (26.6% to 22.8%, P = .001). The proportion of patients with hypertension having RYGB remained unchanged while decreased among SG patients (56.2% to 47.6%, P<.001). Female patients among the SG group increased from 73.2% to 77.7% (P< .001).

Conclusion: SG has been increasingly performed in the United States superseding adjustable gastric band and RYGB. The trend is in favor of females, lower BMI, and lower ratio of patients with diabetes and hypertension. More data are needed on outcomes of SG to assess its long-term effectiveness and credibility.
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http://dx.doi.org/10.1016/j.soard.2017.01.031DOI Listing
May 2017

Who Should Get Extended Thromboprophylaxis After Bariatric Surgery?: A Risk Assessment Tool to Guide Indications for Post-discharge Pharmacoprophylaxis.

Ann Surg 2017 01;265(1):143-150

*Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH †Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.

Objective: To determine the risk factors for 30-day postdischarge venous thromboembolism (VTE) after bariatric surgery and to identify potential indications for extended pharmacoprophylaxis.

Background: VTE is among most common causes of death after bariatric surgery. Most VTEs occur after hospital stay; still a few patients receive extended pharmacoprophylaxis postdischarge.

Methods: From American College of Surgeons-National Surgical Quality Improvement Program, we identified 91,963 patients, who underwent elective primary and revisional bariatric surgery between 2007 and 2012. Regression-based techniques were used to create a risk assessment tool to predict risk of postdischarge VTE. The model was validated using the 2013 American College of Surgeons-National Surgical Quality Improvement Program dataset (N = 20,575). Significant risk factors were used to create a user-friendly online risk calculator.

Results: The overall 30-day incidence of postdischarge VTE was 0.29% (N = 269). In those experiencing a postdischarge VTE, mortality increased about 28-fold (2.60% vs 0.09%; P < 0.001). Among 45 examined variables, the final risk-assessment model contained 10 categorical variables including congestive heart failure, paraplegia, reoperation, dyspnea at rest, nongastric band surgery, age ≥60 years, male sex, BMI ≥50 kg/m, postoperative hospital stay ≥3 days, and operative time ≥3 hours. The model demonstrated good calibration (Hosmer-Lemeshow goodness-of-fit test, P = 0.71) and discrimination (c-statistic = 0.74). Nearly 2.5% of patients had a predicted postdischarge VTE risk >1%.

Conclusions: More than 80% of post-bariatric surgery VTE events occurred post-discharge. Congestive heart failure, paraplegia, dyspnea at rest, and reoperation are associated with the highest risk of post-discharge VTE. Routine post-discharge pharmacoprophylaxis can be considered for high-risk patients (ie, VTE risk >0.4%).
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http://dx.doi.org/10.1097/SLA.0000000000001686DOI Listing
January 2017

Fast track bariatric surgery: safety of discharge on the first postoperative day after bariatric surgery.

Surg Obes Relat Dis 2017 Feb 2;13(2):273-280. Epub 2016 Feb 2.

Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Fast track recovery pathways have resulted in a multidisciplinary approach to enhance postoperative recovery.

Objectives: To assess feasibility and outcome of early discharge after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

Setting: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to identify patients with body mass index≥35 kg/m who underwent LSG or LRYGB in 2012 and 2013.

Methods: Patients were allocated to early discharge (ED) when discharged on postoperative (POD) 1 and late discharge (LD) when discharged on POD 2 or 3. Baseline characteristics and 30-day outcomes were compared between the 2 groups.

Results: Records of 15,468 LSG and 16,483 LRYGB patients were analyzed; 5220 patients with LSG (33.7%) and 2960 patients with LRYGB (18%) were discharged on POD 1. The early discharge group had significantly fewer co-morbidities and lower rate of complications and readmission. Thirty-day readmission rate in LSG was 2.8% in ED versus 3.6% in LD (P = .008), and in LRGYB, it was 4.3% in ED versus 5.8% in LD (P = .001). Based on multivariate analysis, early discharge was not an independent risk factor for a higher readmission rate after LSG or LRYGB. Predictors of late discharge were age>50 years, body mass index>50 kg/m, Hispanic or non-Hispanic black race/ethnicity, impaired functional status, diabetes on insulin, chronic steroid/immunosuppressant use, bleeding disorder, being on dialysis, chronic obstructive pulmonary disease, albumin<3.5 mg/dL, longer operative time, and concurrent cholecystectomy.

Conclusion: Discharge on POD 1 after LSG and LRYGB is feasible in a considerable proportion of patients. In this subgroup, early discharge is well tolerated and may be associated with lower complication and readmission rates.
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http://dx.doi.org/10.1016/j.soard.2016.01.034DOI Listing
February 2017

A Randomized Controlled Trial Comparing Laser Intra-Hemorrhoidal Coagulation and Milligan-Morgan Hemorrhoidectomy.

J Invest Surg 2017 Oct 2;30(5):325-331. Epub 2016 Nov 2.

a Department of Surgery , Shariati Hospital, Tehran University of Medical Sciences , Tehran , Iran.

Purpose: To compare laser intra-hemorrhoidal coagulation with Milligan-Morgan (MM) hemorrhoidectomy.

Method: Patients with symptomatic grade II or III internal hemorrhoids according to the Goligher's classification (refractory to medical treatment) were enrolled in this double-blinded randomized controlled trial study. In the laser group, hemorrhoidal columns were coagulated using a 980-nanometer (nm) radial laser emitting fiber (three, 15-W pulses of 1.2 s each, with 0.6-s intervals). Operative time, postoperative pain and complications, and recovery or resolution of symptoms were measured. Patients were followed up for at least one year for evaluating healing, resolution of symptoms, and late complications.

Results: Postoperative pain scores (at 12, 18, and 24 hr after surgery) were significantly lower in the laser group compared with the MM group (p <.01). The operative time and intra-operative blood loss were more in the MM group (p <.001). The administration of analgesics was significantly reduced in the laser group (p <.05). Two patients in the laser group were presented with thrombosis of external hemorrhoid 7-10 days after the procedure, which was resolved with medical treatment, but no patients in the MM group developed hemorrhoidal thrombosis (p >.05). One-year follow-up showed comparable results in terms of the resolution of symptoms and sustainable cure.

Conclusions: Intra-hemorrhoidal coagulation with 980-nm diode laser reduces postoperative pain, intra-operative bleeding, and administered analgesics with a comparable resolution rate of hemorrhoid symptoms. However, for the patients who experience complications, such as hemorrhoidal thrombosis, the overall pain may be equivalent to or even worse than conventional hemorrhoidectomy.
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http://dx.doi.org/10.1080/08941939.2016.1248304DOI Listing
October 2017