92.02 Laparoscopic Weight Loss Surgery in the Elderly; An ACS NSQIP Study on the Effect of Age on Outcomes.

Posted on January 18, 2018

M. R. Arnold1, K. A. Schlosser1, J. Otero1, T. Prasad1, A. Lincourt1, B. T. Heniford1, P. D. Colavita1  1Carolinas Medical Center,General Surgery,Charlotte, NC, USA

Introduction:

Laparoscopic bariatric surgery is becoming increasingly common. In an era of rising obesity and an aging population, there is limited data regarding laparoscopic weight loss surgery in older Americans. The aim of this study is to characterize the short-term outcomes of laparoscopic weight loss surgery in the elderly.

Methods:
The American College of Surgeons National Surgical Quality Improvement Program database from 2010-2014 was queried for obese patients (BMI ≥35), age ≥40, who underwent laparoscopic roux-en-y gastric bypass or sleeve gastrectomy.  Patients were subdivided into age groups 40-49, 50-59, 60-64, 65-69, and ≥70 years old. Groups were compared in univariate and multivariate analysis.

Results:
53,533 patients underwent laparoscopic weight loss surgery between 2010 and 2014. Roux-en-y gastric bypass was performed in 57.5% of cases, and was more common in all age groups (p<0.05). Preoperative comorbidities that increased significantly with age are included in Table 1. Morbid obesity and smoking decreased with age (p<0.05). Univariate analysis demonstrated a significant increase in minor (4.6% vs. 9.1%; p<0.0001) and major complications (2.2% vs. 6.3%; p<0.0001), as well as an increase in 30-day mortality (0.1% vs. 0.5%; p=0.0001) between the 40-49 and ≥70 age groups. When multivariate analysis was performed to control for potential confounding variables, age was independently associated with increased complications.  Minor complications were more common in the ≥70 group(OR1.6, 95%CI 1.2-2.1). Major complications were independently impacted by age: groups 60-64 (OR1.6, 95%CI 1.1-1.7), 65-69 (OR1.4, 95%CI 1.1-1.8), and ≥70 (OR2.1, 95%CI 1.5-3.1). 30-day mortality was found to be increased in patients aged 60-64 (OR2.2, 95% CI 1.1-4.2), 65-69 (OR2.3, 95%CI 1.1-4.9), and ≥70 (OR4.3, 95%CI 1.6-11.7).

Conclusion:
The present study demonstrates increasing complications and mortality for older patients undergoing laparoscopic weight loss surgery. Elderly patients had significantly higher rates of many comorbidities compared to their younger counterparts. However, when controlling for comorbidities, age continued to impact major and minor complications, as well as mortality.
 

92.01 Short Term Outcomes of Esophagectomies in Octogenarians — An Analysis of ACS-NSQIP

Posted on January 18, 2018

J. Otero1, M. R. Arnold1, A. M. Kao1, K. A. Schlosser1, T. Prasad1, A. E. Lincourt1, B. T. Heniford1, P. D. Colavita1  1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction:   In the face of an increasing aged population, the surgical management of esophageal disease in the elderly will increase.  Little data exists regarding esophagectomy outcomes in the elderly.  The aim of this study was to assess the short-term outcomes of esophagectomies in octogenarians.

 

Methods:   National Surgical Quality Improvement Program database from 2005-2014 was queried for patients who underwent esophagectomy.  Preoperative, intraoperative, and postoperative variables were evaluated.  Patients ≥80 and <80 years old were compared in univariate and multivariate analysis controlling for obesity, smoking, functional status, dyspnea, chronic obstructive pulmonary disease, hypertension, steroid use, bleeding disorders, weight loss, and ASA.

 

Results:  Among 6454 esophagectomies, 290 (4.5%) were performed in patients ≥80 years of age.  Trans-thoracic esophagectomies predominated in both age groups (51% & 60%), with trans-hiatal being the next most common (36% & 27%).  Mean age for the younger group was 62, compared to 82 in the older group.  Octogenarians were more likely to enter surgery with comorbidities of HTN (70% vs 50%, p<0.0001), TIA (5.7% vs 1.9%, p=0.0024), and bleeding disorder (6.6% vs 3.8%, p=0.0164).  There were also increased frequency of prior cardiac procedures (PCI 13.5% vs 7.4%, p=0.0086 & cardiac surgery 15.6% vs 6.1%, p<0.0001).  Elderly patients were less likely to have independent functional status (94.1% vs 98.4%, p<0.0001), and had higher ASA (p=0.0186).  Operative time was shorter for the elderly (mean 320min vs 354min, p<0.0001).

No differences were noted in wound events (10% vs 11%, p=0.5772) and minor or major complications (33.7% vs 32.3%, p=0.6306 & 42.6% vs 38.5%, p=0.1718).  Postoperative sepsis occurred in 9% of patients in both groups (p=0.9672) while septic shock was noted in 8.6% of octogenarians and 6.5% of younger patients (p=0.1636).  Postoperative myocardial infarction occurred in 2% of elderly and 1% of younger patients (p=0.0624).  VTE rates were similar (DVT 2.4% vs 4%, p=0.7887 & PE 1% vs 2%, p=0.2477).  There was no difference in rates of return to the OR (14%, p=0.9848) between groups.  Amongst the different surgical approaches, trans-thoracic demonstrated increased rates of postoperative MI in the elderly (2.72% vs 0.86%, p=0.0469).  Using multivariate analysis, no difference in length of stay was noted between the two groups (p=0.2355).  Age was independently associated with worse outcomes in the elderly for postoperative respiratory complications (OR 1.39; CI 1.06-1.83), 30-day mortality (OR 1.73; CI 1.01-2.95), and discharge to facility other than home (OR 3.3698; CI 2.62-5.22).

 

Conclusion: Esophagectomies in the very elderly is feasible, with increased risk of postoperative respiratory complications, 30-day mortality, and discharge to a new facility for increased patient needs.  Cardiac outcomes with trans-thoracic approach may be worse in the elderly.

80.16 Development of Weight-loss Surgery Techniques in a Murine Model

Posted on January 18, 2018

H. A. Frohman1,2, P. G. Rychahou1,2, J. Li2, B. M. Evers1,2  1University Of Kentucky,Department Of Surgery,Lexington, KY, USA 2University Of Kentucky,Markey Cancer Center,Lexington, KY, USA

Introduction:  Roux-en-Y gastric bypass surgery (RYGB) has been shown to improve comorbidities such as diabetes and hypertension and lower the risk of obesity-related cancers. To better understand the physiologic and genetic influences of RYGB and sleeve gastrectomy (SG), a model is needed that can be extended to genetically engineered transgenic species. However, given the complexity of these procedures, few researchers have successfully implemented these techniques beyond larger rodent models. Therefore, the purpose of our current study was to develop a technically feasible and reproducible small animal model for RYGB and SG.

Methods:  Swiss-Webster mice were fed high-fat diet for 20 wks to induce morbid obesity. All mice received ciprofloxacin preoperatively. An injectable analgesic and subcutaneous fluids were provided following induction of anesthesia with inhaled Isoflurane. Sham surgeries consisted of enterotomies and gastrotomy followed by primary repair without resection or rerouting.

Results: Pre- and postoperative techniques that failed included: fasting mice for 12 h prior to operation, housing mice individually, use of bedding within 7 d of operation. Surgical techniques that failed included: end-to-side anastomosis of the jejunojejunostomy, running suture along the full length of the anastomoses, and creation of a gastric pouch less than 40% of stomach volume for RYGB surgery.

The pre- and postoperative techniques that improved mouse survival included conversion to liquid diet 72 h prior to surgery and resuming liquid diet for 7 d post-op without fasting, wire bottom cages, and housing mice with other mice – one of which received no surgery.

The surgical techniques that were successful for RYGB surgery consisted of intraoperative use of a far infrared heat source to increase deep tissue temperature, side-to-side functional end-to-side anastomoses, and running suture along the posterior wall of the anastomoses followed by approximation of the anterior walls with interrupted sutures. Furthermore, the surgical technique that resulted in the fewest SG complications was closure of the stomach in two layers, with the outer layer being an imbrication of gastric serosa.

Survival after incorporation of aforementioned techniques was 100% in the SG group, 67% in the sham-RYGB group, and 30% in the RYGB group at 1 month after surgery. Only 22% of RYGB mortality was attributed to leak, obstruction, or stricture. The remaining RYGB mortality was related to stress, dumping, or malnutrition.

 

Conclusion: Bariatric surgery in a mouse model is technically challenging but feasible. Much of the survival challenge for this surgery model is related to pre and post-operative mouse care, which is to be expected given their small stature and poor response to stress. Utilization of the surgical techniques described will produce similar results for researchers aiming to study effects of bariatric surgery.

72.09 Clinical Significance of NQO1 in Non-neoplastic Squamous Epithelium of Esophageal Cancer Patients

Posted on January 18, 2018

Y. Muneoka1, H. Ichikawa1, S. Kosugi2, T. Hanyu1, T. Ishikawa1, Y. Kano1, N. Sudo1, M. Nemoto1, Y. Shimada1, M. Nagahashi1, J. Sakata1, T. Kobayashi1, H. Kameyama1, T. Wakai1  1Niigata University Graduate School Of Medical And Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan 2Uonuma Institute Of Community Medicine, Niigata University, Medical And Dental Hospital,Department Of Digestive And General Surgery,Niigata, NIIGATA, Japan

Introduction:  NAD(P)H:quinone oxidoreductase-1 (NQO1) is an antioxidant protein. Low expression of NQO1 contributes to high response to anticancer agents, particularly to oxidative stress inducers such as cisplatin (CDDP) or 5-fluorouracil (5-FU) in malignant tumors. It was reported that NQO1 expression is constitutively reduced in non-neoplastic esophageal squamous epithelium of patients with single nucleotide polymorphism of NQO1 (C609T). The aim of this study is to elucidate the clinical significance of NQO1 expression in the non-neoplastic squamous epithelium of patients with esophageal squamous cell carcinoma (ESCC) who underwent preoperative chemotherapy with CDDP and 5-FU (CF) followed by a radical esophagectomy.

Methods:  We retrospectively analyzed the cases of 43 patients who underwent preoperative chemotherapy with CF followed by a radical esophagectomy for ESCC between 2001 and 2012. NQO1 expression in non-neoplastic squamous epithelium of the surgically resected specimens were examined by immunohistochemistry. The expression was defined as negative when basal cells and vascular endothelial cells were not stained with anti-NQO1 antibody. We analyzed the associations between NQO1 expression and the patient demographics, tumor characteristics, histological response to CF therapy, and relapse-free survival. The median follow-up period of the relapse-free patients was 51 months.

Results: Twenty-two patients (51%) had non-neoplastic squamous epithelium with negative NQO1 expression (NQO1-negative patients). No histological evidence of primary tumor or pathological T1 (pT1) tumor was more frequent in NQO1-negative patients than in NQO1-positive patients (41% vs. 5%; P < 0.01). Overall, downstaging of the primary tumor was achieved in 46% of NQO1-negative patients and in 10% of NQO1-positive patients (P = 0.02). There was no significant difference in the histological response to preoperative CF therapy between the two groups. The three-year relapse-free survival of NQO1-negative patients was significantly better than that of NQO1-positive patients (76% vs. 48%, P = 0.02). Other significant prognostic factors were pT, pN, and lymphovascular invasion in a univariate analysis. Multivariate analysis demonstrated that negative NQO1 expression (hazard ratio [HR], 0.30; 95% confidence interval [CI], 0.10-0.92; P = 0.04) and lymphovascular invasion (HR, 4.39; 95%CI, 1.43-13.5; P = 0.04) were independent prognostic factors.

Conclusion: NQO1 expression in non-neoplastic squamous epithelium of ESCC patients could be a promising biomarker to predict treatment outcomes after preoperative CF therapy followed by a radical esophagectomy.

 

72.08 Laparoscopic Gastropexy in Elderly Patients with Large Paraesophageal Hernias

Posted on January 18, 2018

A. D. Newton1, D. A. Herbst1, K. R. Dumon1, D. T. Dempsey1  1Hospital Of The University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction: The optimal technique for paraesophageal hernia (PEH) repair has been debated. For the past several years, our surgical treatment algorithm for elderly patients with large symptomatic PEH has been formal laparoscopic repair if gastroesophageal reflux (GER) symptoms predominate, and laparoscopic anterior gastropexy alone if mechanical symptoms predominate. Our goal was to evaluate outcomes with this approach.

Methods: We retrospectively reviewed all first-time operations for large PEH (40% or more intrathoracic stomach) in patients ≥ age 65 performed by a single attending surgeon from 2011-2016. Primary outcome measures were perioperative morbidity and mortality, presence of herniated stomach or GER on upper gastrointestinal radiograph (UGI) 3 months postop, and subjective symptom improvement.

Results:  A total of 83 patients (mean age 76.9 years, 84% female) had a primary laparoscopic operation for large PEH (type 3, n=75; type 4, n=8). Thirty patients had formal repair (sac removal, posterior crural repair, partial fundoplication, gastropexy) and 53 had gastropexy alone. There were no open or esophageal lengthening operations and one 30-day reoperation. Median intrathoracic stomach percentage was 50% vs. 90% for formal repair vs. gastropexy. Mean operative time was 161.7 vs. 100.6 minutes (P<0.0001) for formal repair vs. gastropexy, and mean postoperative length of stay was no different (2.6 vs. 2.8 days). ASA was ≥ 3 for 53% vs. 70% (P=0.133) for formal repair vs. gastropexy. Overall 90-day morbidity was 15.7% (16.7% with formal repair vs. 15.1% with gastropexy, P=0.85). There was one post-discharge 30-day mortality. On UGI 3 months postop, one patient (3%) had > 10% of stomach above the diaphragm after formal repair compared to 59% after gastropexy (P<0.001), and 69% had demonstrable GER on UGI after gastropexy compared to 24% after formal repair (P<0.001). However, 71% were asymptomatic and 98% had improvement in preop symptoms after gastropexy; 76% were asymptomatic and 92% had improvement in preop symptoms after formal repair.

Conclusion: Laparoscopic gastropexy alone is a reasonable treatment for large PEH in elderly patients with predominately mechanical symptoms while formal repair gives good results when GER symptoms predominate. Esophageal lengthening is unnecessary in most patients. Postop UGI findings often do not correlate with clinical symptoms in this group.

57.13 Simulation model for Laparoscopic and Robotic Foregut Surgery

Posted on January 18, 2018

F. Schlottmann1, N. S. Murty1, M. G. Patti1  1University Of North Carolina,Surgery,Chapel Hill, NC, USA

Introduction: The safe adoption of laparoscopic and robotic foregut surgery must maximize relevant training prior to transference to the clinical setting. A significant gap presently exists between box-lap and virtual-reality simulators and live surgery. Live animal and cadaver use have significant downsides. We have developed tissue-based simulator that allows for training in laparoscopic and robotic foregut operations.

Methods:  Our foregut surgery model is based on porcine tissue blocks that include lungs, heart, aorta, esophagus, diaphragm, stomach, duodenum, liver and spleen. Tissue is preserved in an alcohol based solution that retains fresh tissue characteristics for several weeks. The tissue block is mounted in a human mannequin and perfused with artificial blood. The anterior abdominal wall is constructed so as to allow for laparoscopic and robotic surgical training (Figure 1). Five expert attending foregut surgeons performed laparoscopic and robotic Heller myotomy, Nissen fundoplication and sleeve gastrectomy on the model. After completing the procedures, face validity was measured by surgeon responses to a questionnaire defining the perceived relationship to real surgery, ranging from really unrealistic to highly realistic.

Results: The initial cost of the simulator is $400. Once the initial expenses are covered (male torso mannequin and silicone based abdominal wall), the simulator cost is approximately $50 for each surgical training session (tissue block + artificial blood). The simulator was rated as highly realistic in terms of operative space, organs size and shape, and instrument usage for all three procedures in both laparoscopic and robotic surgery. In addition, all surgeons felt the model could significantly shorten the learning curve for performing these procedures.

Conclusion: The results of this study show that our model, based on animal tissue blocks, is economical, easy to use, and offers a very realistic representation of laparoscopic and robotic foregut operations, thus achieving a high level of face validity. Further validation studies are needed to assess if skills acquired by using our surgical simulator are transferable to the clinical setting

 

47.05 Bariatric Surgery Provider Perspectives On Barriers To Severe Obesity Care: A Qualitative Analysis

Posted on January 18, 2018

L. M. Funk1,2, S. A. Jolles1,2, R. L. Gunter2, C. I. Voils1,2  1William S. Middleton VA,Department Of Surgery,Madison, WI, USA 2University Of Wisconsin-Madison,Department Of Surgery,Madison, WI, USA

Background: Nearly 20% of U.S. Veterans are severely obese, yet less than 0.1% undergo the most effective treatment – bariatric surgery. The aim of our study was to assess perceived barriers to severe obesity care among bariatric surgeons and nutritionists who work with bariatric patients.

Methods: We conducted interviews with 16 providers, including 10 bariatric surgeons and 6 registered dieticians (RD) who provide severe obesity care to Veterans. At least two surgeons from each of the five national regions in the VA system participated. RDs were recruited from VA weight management programs in the Great Lakes Health Care System region. Using a semi-structured interview guide, an interviewer asked providers to describe the preoperative and postoperative processes of care and challenges to providing bariatric surgery care within the VA system. All interviews were audio-recorded and transcribed. A directed approach to content analysis was applied. Emergent themes were identified and finalized through a process of consensus among four coders. Participants also completed a demographic questionnaire upon the completion of each interview.

Results: The mean provider age was 42.1 (SD=9.8) years; 50% were male and 31% were non-white. The average number of years in practice was 13.7 (SD=8.0); 63% had a dual appointment at a University. Five general barriers to care were identified (Table 1): 1) primary care providers not supporting bariatric surgery; 2) difficulty accessing VA bariatric surgery programs; 3) difficulty meeting preoperative requirements (e.g. weight loss and smoking cessation); 4) difficulty coordinating postoperative care; and 5) patient apprehension about making postoperative lifestyle changes. Three facilitators of bariatric surgery care were identified: 1) patient motivation to improve their long-term quality of life; 2) having social support; and 3) utilizing telehealth.   

Conclusion: Educating referring providers about bariatric surgery options, expanding availability of bariatric surgery services, and standardizing preoperative criteria across centers may increase access and improve coordination of bariatric surgery care within the VA. Expanded use of telehealth also appears to support provision of bariatric surgery in the VA. Implementation and dissemination strategies focused on these areas will be key if bariatric surgery provision expands within the VA.     

 

 

 

36.05 An Analysis of Preoperative Weight Loss and Risk in Bariatric Surgery

Posted on January 18, 2018

L. Owei1, S. Torres Landa1, C. Tewksbury1, V. Zoghbi1, J. H. Fieber1, O. E. Pickett-Blakely1, D. T. Dempsey1, N. N. Williams1, K. R. Dumon1  1Hospital Of The University Of Pennsylvania,Gastrointestinal Surgery,Philadelphia, PA, USA

Introduction:

Preoperative weight loss theoretically reduces the risk of surgical complications following bariatric surgery. Current guidelines have focused on preoperative weight loss as an important element of patient care and, for some payers, a requirement for prior authorization. However, the association between preoperative weight loss and surgical complications remains unclear. The purpose of this study is to test the hypothesis that preoperative weight loss lowers operative risk in bariatric surgery.

Methods:

We conducted a retrospective analysis using the inaugural American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data -2015. Only patients who had primary laparoscopic gastric bypass, open gastric bypass and laparoscopic sleeve gastrectomy were included. Patients were stratified into 4 groups by percent preoperative total body weight (TBW) loss. Univariate analyses was performed. Logistic regression was also used to determine the association between preoperative weight loss and surgical outcomes (mortality, reoperation, readmission, and intervention) with adjustment for potential confounders.   

Results:

A total of 120,283 patients were included in the analysis, with a mean age of 44.6 (±12.0) and 78.7% were female. Procedures were laparoscopic sleeve gastrectomy (69.0%), laparoscopic gastric bypass (30.3%), and open gastric bypass (1.2%). Of the total number of patients, 25% had <1% preoperative TBW loss, 22% had 1 – 2.99%, 29% had 3 – 5.99%, and 24% had ≥6%. When stratified by percent TBW loss, significant differences were found in age, sex, race, co-morbidities, smoking, and ASA classification (p<0.05). Using the <1% preoperative total percent body loss group as a reference, logistic regression revealed that a TBW loss of ≥3% was associated with a significant decrease in operative (30 day) mortality (p = 0.012). Preoperative weight loss in excess of 6% TBW was not associated with a further decrease in operative mortality. There was no significant association between percent TBW loss and reoperation, readmission or intervention within 30 days of operation (Table 1). 

Conclusion:

A preoperative reduction of more than 3% of TBW is associated with a significant reduction in operative mortality following bariatric surgery. These results suggest that a modest preoperative weight loss may substantially reduce operative mortality risk in this population. Further studies are needed to elucidate the association between preoperative weight loss and other outcome measures (reoperation, readmission, intervention). 

 

**The ACS MBSAQIP and the centers participating are the source of the data, and are not responsible for the validity or the conclusions.
 

22.04 Novel Development of Gastric Cancer Organoids from Endoscopic Biopsy Tissues

Posted on January 18, 2018

M. Lin1, K. Hirai1, M. Choi1, D. Tzimas1, J. C. Bucobo1, J. Buscaglia1, G. V. Georgakis1, A. Sasson1, M. Gao1, J. Kim1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction:  Comprehensive testing of drugs for advanced gastric cancer is limited by the lack of models that recapitulate human disease. Patient-derived, 3-dimensional organoids have been developed and may accurately model in vivo disease. Diagnostic upper endoscopy is a potential avenue for gastric cancer tissue sampling and organoid creation. Here, we report the first successful creation of organoids from endoscopic biopsy in a patient with gastric adenocarcinoma.

Methods:  With IRB approval and written informed consent, upper endoscopy was performed on a patient with large gastric adenocarcinoma. Standard biopsy forceps were used to obtain tissue from three different tumor locations to create three sets of gastric organoids using a modified technique. Biopsy tissues were placed in prepared organoid medium, then washed and isolated to preserve glandular architecture. Gastric glands were collected and plated in 24-well plates. To confirm gastric origin, we performed immunofluorescent staining for LGR5 and TROY protein markers. To assess potential tumor heterogeneity within this patient’s tumor, we also created gastric cancer organoids from surgical resection tissues and obtained whole tumor lysates. We extracted DNA from all organoids and tissues and performed low-coverage, whole genome sequencing. 

Results: We successfully obtained upper endoscopy gastric cancer biopsy tissues for creation of organoids. Immediately following resection of the primary tumor, we also obtained tissues for organoid creation and genomic testing. For all organoids, we observed an initial coalescence of gastric glandular tissues into cystic structures. Some cysts developed into spheroids, whereas others remained cystic. Budding structures formed on the periphery of the spheroids after 5-7 days in culture. Gastric origin of the organoids was confirmed based on positive LGR5 and TROY stains. Comparison of whole genome sequencing between endoscopic derived and surgical organoids and whole tumor DNA assessed the tumor homogeneity. 

Conclusion: We report the first successful creation of organoids from endoscopic biopsy of gastric adenocarcinoma. The organoids appear to accurately portray human disease and have tremendous potential to be used for personalized drug testing. 

 

22.01 Sleeve Gastrectomy Reverses Obesity-Induced Intestinal Immune Dysfunction

Posted on January 18, 2018

D. A. Harris1, R. Subramaniam1, K. Heshmati1, A. Tavakkoli1, E. Sheu1  1Brigham And Women’s Hospital,General Surgery,Boston, MA, USA

Introduction: Obesity is associated with chronic inflammation driven in part by disruption in intestinal immune integrity leading to insulin resistance. Sleeve gastrectomy (SG) is the most performed bariatric surgery in the US, but its mechanisms remain incompletely defined. We hypothesized that SG improves glucose metabolism through normalization of obesity-induced immune dysregulation.

Methods:  C57Bl/6J mice were placed into four groups – normal chow diet (lean; n=6); high fat diet (Obese; n=6); Obese Sham (n=7); Obese SG (n=6).  Glucose tolerance, insulin tolerance, and immune phenotype were measured through 6 weeks. Liver, jejunum, and spleen were harvested for time of flight mass cytometry (CyTOF), which is a novel platform allowing quantitative immune profiling. A 24-antibody panel directed against key markers of innate and adaptive lymphocytes was developed. Visualization of stochastic neighbor embedding (ViSNE) was used for unbiased profiling. 

Results: Obese mice weighed more (40.7±2.4 vs 27.9±2.7g; p<0.001) and had worse fasting glycemia (139±14 vs 99±3 mg/dL; p<0.001) compared to Lean mice. CyTOF was used to compare splenic, hepatic, and jejunal immune populations in these groups. Obese mice have organ-specific perturbations of multiple immune populations compared to Lean mice such as changes in splenic B-cells, hepatic CD4+ TH1 cells, and jejunal CD8+CD103+ tissue resident memory (TRM) T-cells (p<0.05).

Obese SG mice exhibited significant weight loss, improved oral glucose tolerance (AUC, Obese Sham: 34693 [30338 to 39048], Obese SG: 25630 [21984 to 29257]), and increased insulin sensitivity (p<0.05 at 0, 15, 30 mins) compared to Obese Sham mice. Again, CyTOF was used to evaluate the impact of SG on splenic, hepatic, and jejunal immunity. Of the 40 distinct lymphocyte populations assessed, ViSNE revealed that only changes in jejunal CD8+CD103+ TRM correlated with improved weight and insulin sensitivity following SG (Figure 1A). TRM are responsible for rapid pathogen defense at mucosal surfaces. Obese mice have reduced jejunal TRM compared to Lean mice (85.2±7 vs 36.8±10, p=0.003, Figure 1B). SG repairs this obesity-induced mucosal immune defect by restoring jejunal TRM to levels seen in healthy, Lean mice (Figure 1B), a finding validated by flow cytometry. Changes in TRM were confined to jejunum and not seen in the liver or spleen.

Conclusion: Obesity is associated with a disruption in intestinal immunity leading to insulin resistance. SG reverses the deficit in jejunal TRM cells seen in obesity and thereby restores protective intestinal immune function, which may contribute to its metabolic benefits.
 

17.19 Double Percutaneous Transesophageal Gastrostomy for Pyloric Stenosis Due to Gastric cancer

Posted on January 18, 2018

R. Iwase1, Y. Suzuki2, E. Yamanouchi3, H. Odaira2, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Minato-ku, TOKYO, Japan 2International University Of Health And Welfare Hospital,Department Of Surgery,Nasushiobara, TOCHIGI, Japan 3International University Of Health And Welfare Hospital,Department Of Radiology,Nasushiobara, TOKYO, Japan

Introduction:

The management of gastric cancer causing pyloric stenosis and gastric dilatation must include decompression of the stomach and nutritional support. Percutaneous transesophageal gastrotubing (PTEG) is an effective technique for either gastric decompression or enteral nutrition. Here, we investigated the efficacy and safety of double PTEG, i.e., PTEG for both purposes for patients with gastric cancer.

Methods:
Eleven patients with pyloric stenosis due to gastric cancer were admitted to our hospital between January 2015 and March 2017 and enrolled in this study. Each patient underwent double PTEG as soon as possible. After double PTEG tubes were placed, gastric decompression was started immediately and enteral nutrition was started within one day. Feeding and decompression through the double tubes were continued until the day before operation. Using data from these patients, we investigated the efficacy and safety of double PTEG.

Results:
Double PTEG was performed successfully in all patients and no critical adverse effects were observed. Of the eleven patients, eight underwent radical or palliative resection. Decompression of the stomach was achieved and nutritional parameters improved significantly after the double PTEG in all patients.

Conclusion:
Double PTEG is a safe and effective management technique for patients with pyloric stenosis and gastric dilatation due to gastric cancer.

17.18 Postoperative Outcomes after Esophagectomy for Cancer in Elderly Patients

Posted on January 18, 2018

F. Schlottmann1, P. D. Strassle1, B. A. Cairns1, M. G. Patti1  1University Of North Carolina,Surgery,Chapel Hill, NORTH CAROLINA, USA

Introduction:  The progressing aging of the population in conjunction with the higher incidence of esophageal cancer will dramatically increase the number of elderly patients with esophageal cancer. We aimed to determine the postoperative outcomes after esophagectomy for cancer in elderly patients. 

Methods:  A retrospective, population-based analysis was performed using the National Inpatient Sample for the period 2000-2014. Adult patients (≥18 years old) diagnosed with esophageal cancer and who underwent esophagectomy during their inpatient hospitalization were included. Patients were categorized into <70 years old (yo) and ≥70 yo. Multivariable linear and logistic regression, adjusting for admit year, gender, race, comorbidities, primary insurance, household income, hospital region, hospital teaching status, and hospital size, were used to assess the potential effect of age on length of stay, hospital charges, and patient complications. The predicted probability of inpatient mortality was also estimated using multivariable logistic regression, where age was treated as a restricted cubic spline.

Results: Overall, 5,243 patients were included, with 3,699 (70.6%) <70 yo and 1,544 (29.5%) ≥70 yo. Elderly patients were more likely to be female and have comorbidities. The yearly rate of esophagectomies among patients ≥70 yo did not significantly changed during the study period (28.4% in 2000 and 26.3% in 2014, p=0.76). No significant differences in the incidence of postoperative venous thromboembolism, wound complications, infection, bleeding, renal failure, respiratory failure, shock, or average length of stay were seen. Elderly patients were significantly more likely have postoperative cardiac failure (OR 1.59, 95% CI 1.21, 2.09, p=0.0009) and postoperative mortality (OR 1.84, 95% CI 1.39, 2.45, p< 0.0001). The predicted probability of mortality also exponentially increased with age (1.5% in 40 yo, 2.5% in 50 yo, 3.6% in 60 yo, 5.4% in 70 yo, and 7.0% in 80 yo), Figure 1. Among elderly patients, hospital charges were, on average, $16,320 greater (95% CI $3,110, $29,530) than patients <70 yo, p=0.02. 

Conclusion: Elderly patients undergoing esophagectomy for cancer have a high risk of postoperative mortality and have a higher expense burden on the health care system. Elderly patients with esophageal cancer should be carefully selected for surgery.

 

17.17 Insurance Status Influences Cardiac Outcomes for Bariatric Surgery

Posted on January 18, 2018

N. Javadi1, L. Garcia1, D. Azagury1, H. Rivas1, J. M. Morton1  1Stanford University,Bariatric And Minimally Invasive Surgery,Palo Alto, CA, USA

Introduction: Medicaid status has been associated with increased risk-adjusted mortality for major surgical operations. While previous studies have documented that disparities in post-operative outcomes vary as a function of insurance status, the influence of insurance status on cardiac outcomes of patients after bariatric surgery remains unknown. We hypothesize that primary insurance status significantly affects the cardiac outcomes of patients after undergoing bariatric surgery.

Methods: Patient data were obtained retrospectively from a bariatric surgery database at a single academic institution in  California between 2009 and 2017. Patients who received either laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) were categorized into three categories based on insurance status: private insurance, Medicare, or Medi-Cal. Patient demographic characteristics, BMI, weight, percent excess weight loss (%EWL), waist circumference, systolic/diastolic blood pressure, total cholesterol, high-density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides (TG), fasting insulin, hemoglobin A1C (HbA1C), glucose, high sensitivity C-reactive protein (CRP), Lipoprotein(a) (Lp(a)), total plasma homocysteine (HmC), B-type natriuretic peptide (B-type BNP) and N-terminal pro b-type natriuretic peptide (NT-BNP) levels were collected at 6 and 12 months post-operatively. One-way analysis of variance (ANOVA), Kruskal-Wallis, and chi-square tests of association were conducted. 

Results:A total of 2482 patients were studied; 1697 patients had private insurance, 490 had Medi-Cal, and 295 had Medicare. Patients were predominantly female in every insurance group. Regardless of insurance group, most patients underwent LRYGB. At 12 months postoperatively, 541 privately insured patients, 218 Medicare patients and 218 Medi-Cal patients were lost to follow up. Significant differences were ascertained between private insurance and Medi-Cal groups in BMI, total cholesterol, and LDL cholesterol. Significant differences between private insurance and Medicare groups were observed in BMI, %EWL, and serum concentrations of homocysteine. Significant differences between Medicare and Medi-Cal were observed for total and LDL cholesterol. NT-BNP levels were statistically different between all three groups. 

Conclusion: This study demonstrates that differences in patient insurance influence cardiometabolic outcomes following bariatric surgery. These results indicate not only that, on average, Medicare and Medi-Cal patients have higher post-operative BMIs, but also that a lower proportion of patients with these forms of insurance attain a BMI within normal range 12 months after surgery relative to patients who are privately insured.

 

17.15 The Malnourished Obese Patient: A Unique Paradox in Bariatric Surgery

Posted on January 18, 2018

J. H. Fieber1, P. Dowzicky1, C. Wirtalla1, N. N. Williams1, D. T. Dempsey1, R. R. Kelz1  1University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction: Hypoalbuminemia is a known risk factor for poor outcomes after elective general surgery. Many obese patients concurrently suffer from modest to severe malnutrition. We seek to evaluate the impact of hypoalbuminemia on surgical outcomes in obese patients undergoing elective bariatric surgical procedures.

Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program for 2015 was queried for adult patients with body mass index [BMI] ≥ 35 undergoing bariatric surgery. Revision procedures and patients missing albumin values were excluded. The analysis was controlled for 12 potentially significant confounders. Low albumin was defined as albumin <3.5, <3.0, and <2.5. Independent logistic models were developed to estimate the adjusted odds of death/serious morbidity (DSM) or readmissions associated with hypoalbuminemia. A test for the interaction between 10% weight loss, measured in kilograms, and hypoalbuminemia was performed. Bonferroni correction was used to correct for multiplicity using 0.006 as the threshold for significance.

 

Results: A total of 106,577 patients were included in the study with a mean age of 44 years-old (IQ: 36-53), 78.9% female, and 74.8% White. By procedure, sleeve gastrectomy was most common (65%), followed by gastric bypass procedure (30.3%), laparoscopic band procedure (3%), and other bariatric procedures (1%). The majority of patients had a BMI of 40-49.9 (52.1%).  Among patients with low albumin, 6.3% (n=6,647) had albumin <3.5, 0.3% (n=350) had albumin <3, and 0.1% (n=94) had albumin <2.5. Patients with albumin <3.5 were 45% (OR: 1.45, CI: 1.25-1.67, p<0.001) more likely to have DSM following bariatric surgery. There was increasing likelihood of DSM with albumin <3 and albumin <2.5 [Table 1]. Patients with albumin <3.5 were 21% (OR: 1.21, CI: 1.09-1.35) more likely to require readmission. There was a significant interaction between 10% weight loss and low albumin for DSM when albumin was <3.0 (OR: 5.10, CI: 1.71-15.22, p=0.003).

Conclusion: Obesity is not uniformly associated with a well-nourished state. More than 5% of patients undergoing bariatric surgery have hypoalbuminemia.  Preoperative albumin is an important and modifiable risk factor for postoperative complications following bariatric surgery. Weight loss of 10% combined with hypoalbuminemia is synergistic for high complication rates and should be investigated before proceeding with elective bariatric surgery.
 

17.16 Comparative Analysis of Black Males vs. Black Females after Bariatric Surgery

Posted on January 18, 2018

E. S. Bauer4, M. S. Pichardo3,5, G. Ortega4, M. F. Nunez4, M. A. Spencer3, M. Wooten3, D. D. Tran2, T. M. Fullum2,4  2Howard University College Of Medicine,Department Of Surgery, Center For Wellness And Weight Loss Surgery,Washington, DC, USA 3Howard University College Of Medicine,Washington, DC, USA 4Howard University College Of Medicine,Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center,Washington, DC, USA 5Yale University,Department Of Chronic Disease Epidemiology,New Haven, CT, USA

Introduction:
As obesity rates grow, bariatric surgery continues to demonstrate itself as an effective treatment for long-term weight loss, contributing to improvements in obesity related diseases. While females make up 80% of all bariatric surgeries, studies show that males have comparable outcomes. Few studies focus solely on the outcomes of Black males and Black females after bariatric surgery. Our aim is to evaluate and compare the effectiveness of bariatric surgery on weight loss and resolution of co-morbidities among Black males and Black females at an urban institution.

Methods:
Retrospective study of patients who underwent bariatric surgery at a single urban academic institution between 2008 to 2016. Data retrieved from medical records included demographic, pre- and post-operative weight, height and co-morbidities (diabetes mellitus type II [DM], hypertension [HTN], and hypercholesterolemia [HC]), and surgical procedures (laparoscopic roux-en y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric band (LAGB)). All analysis compared males to females and stratified by surgical procedure. Primary outcomes interested were mean, weight loss, and BMI points loss by 12 months. Secondary outcomes were resolution of co-morbidities by 12 months. Adjusted multivariable regression analysis was performed to assess the relation between gender and outcomes of interest.

Results:
In an analytical sample of 422 black patients, 18% were male (n=74). Mean weight was 349 lbs (standard deviation (SD=76.19) for males and 290 lbs (SD=60.91) for females, and mean BMI for males was 50 kg/m2 (SD=9.21) and 48 kg/m2 (SD=8.99) for females. Among these patients, 43% of males and 32% of females had DM, 69% of males and 47% of females had HTN, and 32% of males and 28% of females had HC. At one year postoperatively, the mean BMI was 39 kg/m2 (SD=9.37) for males and 40 kg/m2 (SD= 4.92) for females. Among these patients, 15% of males and 9% of females had DM, 47% of males and females had HTN, 15% of males and 25% females had HC. There was no statistical significance between male and female outcomes in EWL% (OR=1.89, 95% CI=-6.78-4.46), BMI point difference (OR=3.60, CI=-19.03-26.23), resolution of DM (OR=1.55, CI=0.67-3.57), HTN (OR=1.13, CI=0.62-2.05), and HC (OR=1.87, CI=0.69-5.06).

Conclusion:

Our study demonstrates that there were no differences between Black males and Black females after bariatric surgery with respect to weight loss and resolution of co-morbidities.
 

17.14 National Trends in Gastrectomy for Cancer by Race: Insight into Changing Epidemiology

Posted on January 18, 2018

E. M. Groh1, N. Hyun2, D. Check2, H. Chinnasamy3, J. M. Hernandez1, B. I. Graubard2, J. L. Davis1  1National Cancer Institute,Thoracic And Gastrointestinal Oncology Branch,Bethesda, MD, USA 2National Cancer Institute,Division Of Cancer Epidemiology And Genetics,Bethesda, MD, USA 3National Cancer Institute,Surgery Branch,Bethesda, MD, USA

Introduction: The incidence of gastric cancer has declined in the United States over the last few decades, however race-specific trends in gastrectomy remain undefined. The goals of this study were to evaluate the annual rates and outcomes of gastrectomy for cancer stratified by race during a time of a changing US population. 

Methods: Data was queried from the Nationwide Inpatient Sample (NIS) from 1993 to 2013. All patients undergoing gastrectomy for cancer as defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure and diagnostic codes were identified. Multivariate analyses were performed on common covariates including sex, race, type of gastrectomy, comorbidity score and hospital characteristics. SAS® 9.4 Software was used for statistical analysis. 

Results: We identified a significant decline in the rates of gastrectomy for cancer between 1993 and 2013 (p<0.0001). In 1993, there were 9,879 gastric resections for cancer whereas in 2013, there were 7,270, representing a 26.4% decrease. Despite the decreasing frequency of operations undertaken for gastric cancer in the US, we identified a concomitant decrease  in the rates of in-hospital mortality during the study period (p=0.0002). Not surprisingly, in-hospital mortality was significantly lower at urban teaching hospitals as compared to rural or urban nonteaching hospitals (p=0.0217), where most resections were undertaken. In analyzing the rates of gastrectomy for cancer stratified by race, we identified a 32.5% decrease in operations undertaken in white patients, whereas a 39.5% increase in operations was observed in Hispanic patients. During this same time period the percent Hispanic U.S. population more than doubled. Multivariate analysis of patients undergoing gastrectomy for cancer revealed that Asian patients had significantly lower in-hospital mortality rates when compared to Whites (p=0.0041). However, there was no difference in in-hospital mortality when comparing African-American (AA) and Hispanic patients to White patients.

Conclusion: The annual rate of gastrectomy for cancer is declining in the U.S. in general, although race-specific changes may reflect changes in the population over the study period. Despite decreasing frequency of gastrectomy, mortality rates have also declined for patients undergoing gastrectomy for cancer. Rates of in-hospital mortality were worse in AA, Hispanic and White patients as compared to Asian patients for reasons that remained ill-defined. 

 

17.13 Ethnic Disparities in Diabetes Outcomes after Bariatric Surgery

Posted on January 18, 2018

A. Valencia1, L. Garcia1, D. Azagury1, H. Rivas1, J. M. Morton1  1Stanford University,Bariatric and Minimally Invasive Surgery,Palo Alto, CA, USA

Introduction: Previous studies have demonstrated that persons from lower socioeconomic and racial/ethnic minority backgrounds are more likely to qualify for bariatric surgery. Despite notable research regarding access to bariatric surgery, there remains a need to assess differences in metabolic outcomes among racial/ethnic groups and across time. This study assesses ethnic differences in diabetes outcomes following bariatric surgery. 

Methods: A retrospective analysis including 745 patients with type 2 diabetes (T2D) who underwent Roux-en-Y gastric bypass (RYGB) surgery was conducted to understand racial/ethnic disparities in metabolic outcomes over time. Data were collected from a bariatric database including patients treated at an academic medical center in  California. Non-Hispanic White (NHW), Hispanic, Black, Asian, and Pacific Islander racial/ethnic groups were identified using self-reported data. T2D was defined as having one of the following criteria: a fasting glucose concentration >125 mg/dL, HbA1c >6.5%, and taking one or more diabetic medications. Patients who had a fasting glucose <100 mg/dL, HbA1c <6.5%, and were not on diabetic oral medications were considered to have resolved T2D. Within-group comparisons were made using paired t-tests.

Results:Significant reductions in BMI, body weight, fasting glucose, and HbA1c were observed for all racial/ethnic groups six months after RYGB. However, whereas NHW, Hispanic, and Black patients benefited from an additional and statistically significant reduction in BMI 12 months after surgery, this effect was not observed among Asian or Pacific Islander patients. In addition, NHW and Hispanic cohorts experienced additional reductions in fasting glucose and HbA1c at 12 months of follow up, but there were no further improvements in glucose metabolism among the Black, Asian, or Pacific Islander groups. Significant improvements in triglycerides, total cholesterol, HDL-C, and LDL-C were observed for NHWs, Hispanics, and Blacks but not for Asians and Pacific Islanders. T2D was resolved in 94% of Hispanics, 94% of Asians, 89% of NHWs, 87% of Blacks, and 75% of Pacific Islanders. 

Conclusion: This study demonstrates that RYGB was an effective treatment for normalizing glucose metabolism among patients with type 2 diabetes, regardless of racial/ethnic group.  However, Asians and Pacific Islanders did not continue to benefit from improvements in BMI, fasting glucose concentrations, or HbA1c between 6 and 12 months after surgery. These results suggest the need to provide Asian and Pacific Islander patients with additional support for achieving similar longitudinal metabolic improvements as NHW and Hispanic counterparts.

 

17.12 Laparoscopic Revision of Roux-En-Y Gastric Bypass to Distal Bypass for Weight Regain: Midterm Outcomes

Posted on January 18, 2018

N. R. Changoor1, G. Ortega1, J. Kendall2, C. M. Smith2, K. Hughes1, T. M. Fullum1, D. Tran1  1Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 2Howard University College Of Medicine,Washington, DC, USA

Introduction:
Roux-en-Y gastric bypass (RYGB) is well known to be effective for the morbidly obese population. However, weight regain continues to be a significant problem for many patients. We report the outcomes of revision of RYGB to distal RYGB (DRYGB) in patients suffering from weight regain following their original procedure.

Methods:
A review of prospectively collected data was performed at a tertiary urban teaching hospital. Over a four-year period between March 2012 and March 2017, 21 patients underwent laparoscopic revision of RYGB to DRYGB. At the time of the original RYGB, the mean weight and body mass index (BMI) were 324.4 ± 60.8 lbs. and 52.2 ± 8.2 kg/m2, respectively. The interval between the original procedure and the revision was 120.1 ± 61.2 months.  Patients regained on average 70.2 ± 41.8 lbs, or a BMI gain of 11.4 ± 6.7 kg/m2. The mean weight at the time of revision was 277.5 ± 54.8 lbs. (BMI of 44.7 ± 6.9 kg/m2). All patients suffered from one or more obesity-related comorbidities.

Results:
The mean operative time was 157.4 ± 30.8 minutes. All patients were discharged on post-operative day 1, except for two who were discharged on post-operative day 2. There were no complications or mortalities within 30 days of surgery. The average weight (BMI) were 229.4 ± 53.6 lbs. (37.0 ± 6.0 kg/m2) at six months, 215.5 ± 46.5 lbs. (34.4 ± 5.8 kg/m2) at one year, 205.2 ± 28.9 lbs., (34.3 ± 4.0 kg/m2) at two years, 184.5 ± 44.9 lbs. (29.1 ± 7.5 kg/m2) at three years, and 177.4 +-42.6 lbs (27.9 +- 6.2 kg m/m2) at 4 years. We used percent excess BMI loss (%EBMIL) calculated as follows: (BMI at revision – BMI at 4 years)/(BMI at revision – ideal BMI) x 100. The %EBMIL at four years was 74.7 ± 35.2%. Four patients (19%) suffered from protein calorie malnutrition following the procedure, of which two required reversal. One patient died at four years from severe protein calorie malnutrition because of failure to follow up. Another patient, who was not malnourished, required reversal due to ischemic bowel secondary to adhesive bowel obstruction. Using paired t-test, significant difference was found between the BMI at revision and the BMI at four years post revision (p = .02).

Conclusion:
The options of surgical revision are limited for patients who regained weight after RYGB. In spite of higher risks of long term malnutrition, laparoscopic revision to DRYGB remains an effective procedure for these patients.
 

17.11 Esophageal Function and Obesity

Posted on January 18, 2018

J. U. Nguyen1, K. Feng1, J. P. Callaway2, B. L. Corey1, J. M. Grams1  1University Of Alabama at Birmingham,Division Of Gastrointestinal Surgery/Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Medicine,Birmingham, Alabama, USA

Introduction: Patients with obesity have been shown to have an increased intra-abdominal pressure and dysfunction of the gastroesophageal junction. We hypothesized that obesity would be associated with increased mean basal and residual lower esophageal sphincter (LES) pressures but also increased GERD.

Methods:  Retrospective review was performed on all adult patients undergoing high resolution manometry (HRM) and 24-hour pH monitoring at a single academic institution from 2014 to 2016. Exclusion criteria included a diagnosis of achalasia or hiatal hernia, and active acid suppression medications during testing. Patients were stratified by BMI (kg/m2): normal weight <25; overweight 25 to 29.9; class I, II, class III obesity at 30 to 34.9, 35-39.9, and ≥ 40, respectively. Statistical analyses were performed using Chi-square test, Kruskal-Wallis one-way analysis of variance, linear regression, or multiple regression as appropriate. Statistical significance was determined as p-value <0.05.

Results: A total of 507 patients were included in the study. After stratification, there were 149 (29.4%) patients who had normal weight, 159 (31.4%) overweight, 121 (23.9%) with class I obesity, 46 (9.1%) with class II obesity, and 32 (6.3%) with class III obesity. Mean basal LES pressure was significantly increased in patients with class III obesity (p=0.004), while mean residual LES pressure only trended toward being increased (p=0.060). There was no statistical difference in esophageal contraction vigor (Distal Contractile Integral, DCI) (p=0.43). In unadjusted linear regression models, there was a positive linear correlation between mean basal LES pressure and BMI (p<0.001) as well as between mean residual LES pressure and BMI (p<0.001). There was no association between DCI and BMI (p=0.425). These results persisted after adjustment for age. In subset analyses, 24-h pH monitoring was performed in 201 of these patients: normal weight 54 (26.9%), overweight 67 (33.3%), obesity 80 (39.8%). There were no significant differences among the groups in any esophageal acid exposure parameters or between any of the parameters of esophageal acid exposure and BMI when examined as a continuous variable.

Conclusion: In conclusion, these data suggest that obesity augments the basal resting and relaxation pressures of the LES but is not associated with changes in esophageal contractility. However, mean DCI values in obesity still remained within normal limits and standard criteria should be adequate to determine disease states. Obesity did not result in increased esophageal acid exposure.

 

17.10 Gender Discrepancies in Bariatric Procedures Despite Increased Qualification and Referrals

Posted on January 18, 2018

E. M. Masterson1, F. Halperin2, A. Tavakkoli2  1Wake Forest University School Of Medicine,Winston-Salem, NC, USA 2Brigham And Women’s Hospital,Boston, MA, USA

Introduction:
Despite increasing obesity rates in both males and females, females continue to participate in commercial weight loss programs, receive medical weight loss counseling, and undergo bariatric surgery procedures at disproportionately higher rates. Reasons for this are multifactorial and includes patient and provider biases. It is of interest to both physicians and surgeons to better understand these biases to help better serve this patient population, and increase the rate of bariatric surgery uptake from current 1-2%.

Methods:
The study retrospectively reviewed electronic health records and customized paper surveys for 300 new patients seen at our Center for Weight Management and Metabolic Surgery (CWMMS) . All new patients between July 2016 and February 2017 were included in the study. Data collected included patient demographics (age, BMI, gender, comorbidities), treatment (diet and exercise counseling, pharmacotherapy, bariatric referrals), and outcomes (weight loss, referrals, bariatric procedures). All patient data was input to and analyzed using REDCap an online, HIPPA-compliant database. 

Results:
79.3% (n=238) of patients seen were female. Based on BMI and comorbidities, 57.7% (n=173) of all patients qualified for bariatric surgery at their initial visit. Interestingly, a much higher percentage of male patients qualified for bariatric surgery than women (77.4% vs. 52.5% respectively; p<0.001). Of the 173 patients meeting surgical criteria, 26.0% (n=45) were referred for bariatric surgery consultation at an initial or follow-up visit, with no difference between male and female referral rates (31.3% vs. 24.0% respectively, p=0.33). Within the study time frame (July 2016- June 2017), a total of 14 patients underwent a bariatric procedure, representing 8.1% of qualified patients and 31.1% of referred patients. 78.6% of patients receiving a bariatric procedure were female.

Conclusion:

At an urban academic medical center, males referred for weight management consults were more likely to qualify for bariatric surgery at the initial visit. Although men were equally likely to be referred to bariatric surgery, they were less likely to undergo weight loss operations compared to females. These results highlight that (1) Males are referred to medical weight loss programs by primary care or specialty physicians at higher BMIs and (2) Males and females were equally likely to agree to referral to a bariatric clinic, but men were less likely to proceed with surgery. Studies with longer follow up time and sample population are necessary to extend these findings to other weight management centers, but these initial findings highlight gender discrepancies in medical weight management and bariatric surgery referrals and procedures.

 

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