Benefits of Bariatric Surgery Do Not Reach Obese Men

Background: Epidemiological studies have shown an equal gender distribution of obesity in the United States; however, literature suggests approximately 80% of patients undergoing bariatric surgery are female. The aim of this study is to identify factors that contribute to this gender disparity. Study Design: A retrospective analysis of the Nationwide Inpatient Sample was performed. Obese patients who underwent open or laparoscopic gastric bypass or sleeve gastrectomy were identified using International Classification of Diseases, 9th edition codes. Patients <18 years of age were excluded. Female gender was used as a dependent variable to determine factors that influence gender distribution. Multivariate analyses adjusted for age, race, state within the United States, Charlson Comorbidity Index, income level, and insurance status. Results: From 1998 to 2010, 190,705 patients underwent bariatric surgery (93% gastric bypass, 7% sleeve gastrectomy). Females made up 81.36% of the population. An 80% to 20% female to male distribution was maintained for every year (1998-2010) and was unchanged within individual states. Patients were more likely to be female if from a lower-income neighborhood or if African American or Hispanic (P<.05). Patients were less likely to be female with increasing age, more comorbidities, or private insurance (P<.05). Conclusions: The unequal gender distribution in bariatric surgery patients is influenced by demographic and socioeconomic factors. This disparity is narrowed in patients who are older and have more comorbidities, whereas the disparity is widened for certain races and lower incomes. Given the equal distribution of obesity in the United States, the widespread gender gap in bariatric surgery may suggest an underuse in obese men

Increasing the Value of Healthcare: Improving Mortality While Reducing Cost in Bariatric Surgery

Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased length of stay and decreased mortality, it is expected that costs should go down. The aim of this study is to analyze hospital charges, cost of care, and mortality in bariatric surgery over time. A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Adults with morbid obesity who underwent gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Multivariate analyses identified independent predictors of changes in hospital charges and in-hospital mortality. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open versus laparoscopic), hospital volume, and insurance status. In order to estimate baseline surgical inflation, changes in hospital charges over time were also calculated for appendectomy. From 1998 to 2011, 209,106 patients were identified who underwent bariatric surgery. Adjusted in-hospital mortality for bariatric surgery decreased significantly by 2003 compared to 1998 (p < 0.001, OR 0.47, 95 % CI 0.22-0.92) and remained significantly decreased for the remainder of the study period. As such, a 60-80 % decrease in mortality was maintained from 2003 to 2010 compared to 1998. After adjusting for inflation, the cumulative increase in hospital charges per day of a bariatric surgery admission was 130 % from 1998 to 2011. Charges per stay increased by 2.1 % annually for bariatric surgery compared to 5.5 % for appendectomy. In-hospital mortality rate following bariatric surgery underwent a ninefold decrease since 1998 while maintaining surgical inflation costs less than appendectomy. Innovation in bariatric surgical technique and technology has resulted in improvement of outcomes while providing overall cost savings

Variation of outcome and charges in operative management for diverticulitis

Outcomes after surgery for diverticulitis are of continued interest to improve quality of care. The aim of this study was to assess variations in mortality, length of stay, and patient charges between geographic regions of the United States. A retrospective analysis of the Nationwide Inpatient Sample database was performed. Adults with diverticulitis who underwent laparoscopic or open segmental colectomy were identified using ICD-9 codes. Subset analyses were performed by state and then compared. Outcomes included mortality, length of stay (LOS), and total charges. Results were adjusted for age, race, gender, findings of peritonitis, stoma placement, Charlson comorbidity index, and insurance status on multivariate analysis. 148,874 patients underwent segmental colectomy for diverticulitis from 1998 to 2010. Using California as the comparison state and after adjusting for covariates, in-hospital mortality was significantly higher in the State of New York (OR 1.32; 95 % CI 1.13-1.55; P 40 years, findings of peritonitis, and without private insurance had higher in-hospital mortality and longer length of stay. Average hospital charges differed dramatically between the states in the observation period. The highest hospital charges occurred in California, Nebraska, and Nevada while lowest occurred in Maryland, Wisconsin and Utah. Patients who undergo surgical treatment for diverticulitis in the United States have high geographic variation in mortality, LOS, and hospital charges despite adjusting for demographic and socioeconomic factors. Further analysis should be performed to identify the causes of outlier regions, with the goal of improving and standardizing best practices

Mortality after esophagectomy is heavily impacted by center volume: retrospective analysis of the Nationwide Inpatient Sample

The effects of hospital volume on in-hospital mortality after esophageal resection are disputed in the literature. We sought to analyze treatment effects in patient subpopulations that undergo esophagectomy for cancer based on hospital volume. We performed a retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using ICD-9 codes. Patients < 18 years and those with peritoneal disease were excluded. Multivariate logistic regression analyses were used with mortality as the independent variable to evaluate the effect of low (< 6), intermediate (6-19), and high (20) hospital volume of esophagectomies. These analyses were repeated in different subsets of patients to determine whether hospital volume affected mortality depending on the subpopulation evaluated. Subgroups were created depending on age, race, gender, operative approach, comorbidities, and tumor pathology. A total of 23,751 patients were included. The overall perioperative mortality rate was 7.7 % (low volume: 11.4 %; intermediate volume: 8.39 %, high volume: 4.01 %), and multivariate analysis revealed that high hospital volume had a protective effect (OR 0.54, 95 % CI 0.45-0.65). On subgroup analyses for low- and intermediate-volume hospitals, mortality was uniformly elevated for the subpopulations when comparing to high-volume hospitals (p < 0.05). There was no difference in mortality between low- and medium-volume hospitals and between subgroups. No lower mortality risk subgroup could be identified in this nationwide collective. This analysis emphasizes that perioperative mortality after esophagectomy for cancer is lower in high-volume hospitals

Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation

Background: Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage. Materials and Methods: We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality. Results: From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P<.05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P<.05). Conclusion: Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy

Foramen of Winslow hernia: a minimally invasive approach

Hernias through the foramen of Winslow comprise 8 % of all internal hernias and the majority contain incarcerated bowel. Clinical signs are often non-specific and delay in diagnosis associated with a mortality rate that approaches 50 %. Management is urgent surgical reduction with bowel decompression and resection of devitalized bowel. A foramen of Winslow hernia (FWH) has traditionally been managed via an exploratory laparotomy incision and the vast majority of cases describe an open approach. We describe a minimally invasive approach to the management of an incarcerated FWH requiring decompression and bowel resection

Patients with psychiatric comorbidity can safely undergo bariatric surgery with equivalent success

Introduction Patients with psychiatric disorder were reported to have a poor outcome in bariatric surgery. Few studies have examined the outcome of laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in patients with psychiatric history. We aimed to compare excess weight loss (%EWL) in patients with and without psychiatric comorbidities who underwent LSG or LAGB. Methods Patients undergoing LSG or LAGB were identified from our prospective database. A multidisciplinary team evaluated all patients preoperatively, including a psychological evaluation. Patients with the diagnosis of depression, anxiety, bipolar disorder, and schizophrenia were included in the psychiatric comorbidity group (PSY). Others were included in group NON-PSY. All patients were first screened to be psychologically stable to undergo surgery. Initial BMI and %EWL at 3, 6, and 12 months postoperatively were compared. Results A total of 590 patients (81.4 % women), with a median BMI of 43.8 kg/m(2) (range 30-99) who underwent LSG (n = 222) or LAGB (n = 368) from January 2006 to June 2013, were identified. Psychiatric comorbidities that were well controlled at the time of surgery were found in 188 patients (31.9 %). Diagnostic criteria for depression were met in 154 patients (26.1 %), 75 patients suffered from anxiety (12.7 %), 9 from bipolar disorder, and 4 from schizophrenia (0.7 %). Initial BMI was not different between the two groups. No significant difference in %EWL between the groups was found during follow-up (44.13 vs. 43.37 %EWL, respectively, at 1 year; p = 0.76). When LSG and LAGB patients were analyzed as subsets, again no difference in %EWL at 1 year was found for PSY vs. NON-PSY (LSG: 51.56 vs. 54.86 %EWL; LAGB: 38.48 vs. 38.45 %EWL, all p = ns). In multivariate analysis, the differences from unadjusted analysis persisted. Conclusion These findings demonstrate that a similar %EWL can be achieved in patients undergoing LSG or LAGB despite the presence of well-controlled psychiatric comorbidity