18.04 Academic Surgery or Community Practice: What's Driving Decision Making and Career Choices?

Posted on January 18, 2018

B. J. Goudreau1, T. E. Hassinger1, A. Schroen1, T. L. Hedrick1, C. L. Slingluff1, L. T. Dengel1  1University Of Virginia,General Surgery,Charlottesville, VA, USA

Introduction: Identifying factors that impact progression of surgical trainees into academic versus non-academic (community, private) practices may permit selecting residency candidates and tailoring residency experiences to promote academic careers. 

Methods:  An anonymous survey was distributed directly to surgeons graduating from a single academic institution from 1965-2016, excluding those currently in fellowship training or with inactive email addresses. Questions pertaining to practice type, research productivity, work-life balance, mentorship, and overall sentiment toward research and academic surgery were included. A five-point Likert scale measured responses on career satisfaction and influence of factors in practice setting choice. Responses were analyzed by academic versus non-academic practice settings. 

Results:  Of 147 survey recipients, 54 responded, 8 were ineligible (overall response rate= 37%).  Of 46 with known current practice type, 29 are in academic (63%) and 17 in non-academic practice (37%). Compared to non-academic surgeons, academic surgeons are more likely to have participated in dedicated research time during training (86% vs 53%, p < 0.01), and reported more publications at the conclusion of training (58% with >10 publications vs.18%, p<0.01).  45% of academic surgeons reported >$100,00 in student debt at time of graduation compared to 29% of non-academic surgeons, though this difference was not noted to be statically significant.  Factors encouraging an academic career were similar for both types of surgeons, including involvement in education of trainees and access to mentorship (Table 1).  Both groups were discouraged from an academic practice by grant writing requirements and funding responsibilities.  When queried as to professional satisfaction, 94% of all respondents (93% in academic practice and 88% in non-academic practice) reported they were satisfied or very satisfied professionally, and 88% would recommend surgery as a career to a current medical student (100% in academic practice, 67% in non-academic practice).   

Conclusion: Surgeons, particularly those in academic practice, report high satisfaction rates with their career choices.  Supporting funding mechanisms and grant writing programs while encouraging mentorship and participation in trainee education may encourage current surgical trainees to participate in academic medicine. 
 

18.01 A Competency-Based Curriculum to Teach and Assess the Fundamental Skills of Open Surgery (FSS)

Posted on January 18, 2018

J. W. Menard1, F. Shariff1, W. Goering1, A. Deladisma1, R. Damewood2, D. S. Lind1  1University Of Florida-Jacksonville,General Surgery,Jacksonville, FL, USA 2Wellspan Health York Hospital,General Surgery,York, PA, USA

Introduction: While modular curricula exists to teach/assess the fundamentals of laparoscopic (FLS) and endoscopic (FES) surgery, no similar curriculum exists for the fundamental skills of open surgery (FSS). Therefore, we describe our efforts to create, validate and distribute a competency-based curriculum to teach/assess the basics skills of open surgery.

Methods: Using a modified Delphi approach, we created a 15-point binary checklist for the steps required to open and close an abdomen. Construct validity was then determined by videotaped assessment of novice and experts performing a laparotomy on a simulated model (Simulab Corporation, Seattle, WA). We then developed a comprehensive, competency-based curriculum regarding the knowledge/skills required for open surgery. Finally, to facilitate distribution, we employed an innovative, web-based platform (ApprenNet) to provide learners with on-line content, video-based evaluation and expert feedback (see Figure 1).

Results: Using a 15-point binary checklist, experts performed significantly better than novices on the simulated abdomen (0.88 vs. 0.27; p=0.06). The FSS curriculum has been successfully implemented in 7 general surgery residency programs at the PGY1/2 level (N=110). For distant learning, we effectively employed an app-based, educational platform (ApprenNet). Learners used the app to record/submit their simulated laparotomy using their personal smart-devices. 

Conclusion: We have successfully created, validated and distributed a competency-based curriculum to teach/assess the fundamental skills of open surgery (FSS). Similar to FLS/FES, general surgery training programs should require all residents to successfully complete the FSS curriculum.

 

17.20 Multidisciplinary Approach For Management Of Necrotizing Pancreatitis: A Case Series

Posted on January 18, 2018

P. SENTHIL-KUMAR1, W. Alswealmeen1, Q. Yan1, P. O’Moore1, T. Braun1, D. Ringold1, O. Kirton1, T. Vu1  1Abington Memorial Hospital,Surgery,Abington, PA, USA

Introduction:

 Necrotizing pancreatitis is often a devastating sequelae of acute pancreatitis. Historically several approaches have been described with variable outcome. Open necrosectomy is associated with higher morbidity (95%) and mortality (25%). Endoscopic necrosectomy often is tolerated well but associated with stent migration and multiple procedures. Video-assisted retroperitoneal debridement is tolerated well but associated with severe bleeding if adjacent blood vessels are injured during the procedure leading to severe complications

Methods:
In our series. We perform a step up approach by Involvement of a multidisciplinary group consisting of general surgeons, gastroenterologists, Infectious disease physicians, critical care internalist, interventional radiologist and nutritional services to formulate a management plan. The necrotized pancreas is initially drained with an IR guided drain, fluid cultures sent for microbiology and treatment with appropriate antibiotics if deemed necessary. The drain is gradually upsized to a 24 Fr sized drain to form a well-defined tract for surgical debridement; A pre-operative CT scan of the abdomen with IV contrast to access the location and proximity of the vasculature around the necrotized pancreas. A collaboration with the interventional radiologist to discuss possible IR embolization of splenic artery prior to surgical debridement. The patient would then undergo video assisted retroperitoneal pancreatic necrosectomy and a sump drain left in-situ at the pancreatic fossa. Post-operative management in the surgical ICU would be lead by the critical care internalist.

Results:
Three patients were managed by this multidisciplinary approach with excellent outcomes. One patient underwent preoperative IR embolization followed by surgical debridement; second patient underwent embolization immediately following debridement; one patient did not require any embolization but had IR on standby if needed to intervene. Post-operatively all three patients recovered well. They all were tolerating good oral intake and were discharged to rehabilitation facilities.

Conclusion:

As this series show an early plan and collaboration with various subspecialities will produce an optimal outcome. It will lead us to a pragmatic and successful approach to this potentially catastrophic condition.

 

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.

 

17.18 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.

 

17.19 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.

17.15 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.
 

17.13 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.

 

17.14 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. 

 

17.11 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.

 

17.12 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.
 

17.10 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.

 

17.08 Tipping the Scales: Results of Bariatric Surgery by Socioeconomic Status in Black Patients

Posted on January 18, 2018

S. Timberline7, M. S. Pichardo6,7, G. Ortega5, M. F. Nunez8, E. S. Bauer5, E. Smith7, J. Tordecilla7, T. M. Fullum10, D. D. Tran10  5Howard University College Of Medicine,Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center,Washington, DC, USA 6Yale University,New Haven, CT, USA 7Howard University College Of Medicine,Washington, DC, USA 8Howard University College Of Medicine,Department Of Medicine,Washington, DC, USA 10Howard University College Of Medicine,Department Of Surgery, Center For Wellness And Weight Loss Surgery,Washington, DC, USA

Introduction:
Research suggests that individuals of racial/ethnic minority groups and of low socioeconomic status (SES) experience worse outcomes after weight loss surgery compared to their White and higher SES counterparts, respectively. Our objective is to examine the association between socioeconomic characteristics and post-operative outcomes by 12 months in Black patients from a single academic center.

Methods:
A retrospective study of Black patients who underwent bariatric surgery from 2008 to 2013 was performed. Median Household Income (MHI), obtained from census-tract level neighborhood SES data, was a proxy for patients’ SES and categorized into tertiles: $42,595-$76,674, $76,969-$100,652, and $100,704-$205,980. Insurance status at time of surgery was defined as public or private insurance. Outcomes of interest included mean weight loss, body mass index (BMI) points loss, percent excess weight loss (%EWL), and resolution of comorbidities (hypertension, diabetes, hypercholesterolemia). Adjusted multivariable regression analysis was performed to assess the association between SES characteristics and the outcomes of interest.

Results:
Of 422 Black patients, most were female (82%) and had private insurance (73.9%). The mean preoperative BMI was 48.9 kg/m2. At baseline, about half of the patients had hypertension (51.1%), and one third had diabetes (34.4%) and hypercholesterolemia (28.2%). Postoperatively, there were no statistical significant differences in %EWL (β= 0.17, 95%CI= -1.95 – 2.28), mean weight loss (β= 5.37, 95%CI=-3.88 – 14.62), BMI point difference (β= 5.39, 95%CI= -13.47 – 24.24), resolution of hypertension (OR= 1.57, 95%CI= 0.88 – 2.80), diabetes (OR= 1.29, 95%CI= 0.63 – 2.62), and hypercholesterolemia (OR= 0.81, 95%CI= 0.36 – 1.81) by insurance status. Median household income categories did not statistically differ in %EWL, mean weight loss, BMI point difference, or resolution of co-morbidities (Table 1).

Conclusion:
Among Black patients who underwent bariatric surgery, median household income level and type of insurance used was not associated with a difference in weight loss or resolution co-morbidity outcomes by 12 months post-operatively.

17.09 Readmission Following Laparoscopic Bariatric Surgery Using the MBSAQIP Database

Posted on January 18, 2018

K. Feng1, J. S. Richman1, B. L. Corey1, R. D. Stahl1, J. M. Grams1  1University Of Alabama at Birmingham,Division Of Gastrointestinal Surgery/Department Of Surgery,Birmingham, Alabama, USA

Introduction: Laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most common bariatric operations. As both have low reported morbidity and mortality rates, readmission rates are increasingly utilized as a measure of quality. Identifying patients at risk will allow for targeted interventions to decrease readmissions. The purpose of this study was to evaluate national readmission rates and the associated risk factors related to RYGB and SG.

Methods:  Data from patients undergoing SG or RYGB were identified from the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Chi-square test and logistic regression were used to examine patient characteristics and 30-day readmission rates. Patients were also stratified by bariatric procedure. 

Results: A total of 144,459 patients were included RYGB (30.44%) and SG (69.56%). The overall 30-day readmission rate was 3.45% (n=4,991). SG patients had a lower readmission rate compared to RYGB (2.73% vs. 5.10%; p<0.001). The most common causes of readmission were nausea, vomiting, or dehydration (RYGB 26.83%, SG 32.32%); and abdominal pain (RYGB 14.55%, SG 11.71%). Unadjusted analyses showed that readmitted patients had higher body mass index (BMI), longer operation times, and more often had length of stay (LOS) >4 days (all p< 0.001). When stratified by operation, readmitted SG patients were more likely to have hypertension, hyperlipidemia, obstructive sleep apnea, and diabetes, while readmitted RYGB patients had longer operation time and more post-operative complications (all p< 0.001). Adjusted analyses (Table 1) showed that factors associated with readmission for both procedures included being African-American (SG OR=1.46, RYGB OR=1.24), LOS>4 (SG OR=3.63, RYGB OR=2.09), postoperative inpatient complications (SG OR=23.03, RYGB OR=9.21), all p<0.001. 

Conclusion: Readmission after bariatric surgery was associated with race, BMI, diabetes, LOS, and inpatient postoperative complications. Further studies should focus on understanding these risk factors to reduce readmission rates. 
 

17.06 Pre-Operative Weight-loss on a Liver Shrink Diet Predicts Early Weight-loss after Bariatric Surgery

Posted on January 18, 2018

A. D. Jalilvand1, J. Sojka1, K. Shah1, B. J. Needleman1, S. F. Noria1  1Ohio State University,General And Gastrointestinal Surgery,Columbus, OH, USA

Introduction:  The surgical weight loss program at our institution requires patients to comply with a liver-shrink diet (LSD) 1-3 weeks prior to bariatric surgery (BS) in order to facilitate liver retraction during surgery. However, the effect of LDS-induced weight-loss on weight-loss after BS is unclear. The primary objective of this study was to examine the correlation between LSD-induced weight-loss and post-operative weight loss outcomes. Secondary objectives included identifying other factors that correlated to improved weight-loss after surgery.

Methods:  All patients who underwent primary laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (LRNYGB) between July 2014 and June 2016 were retrospectively reviewed at a single academic institution. Baseline demographic and operative data was obtained using the electronic medical record. The LSD consisted of a partial-liquid, low carbohydrate, high protein diet that utilized 4 protein shakes and 1 low carbohydrate meal/day. Percent excess body weight-loss (EBWL) was calculated for each patient on LSD (EBWL-LSD), as well as at 2, 8, and 24 weeks after BS. Student’s t-test, Mann-Whitney-U, Chi squared, and Fisher’s Exact were utilized to calculate significance. Multivariate linear regressions were conducted to determine independent predictors of weight-loss. A p-value of <0.05 was considered significant. 

Results: During the study period, 588 patients underwent primary BS, of which 57.14% had LSG and 42.86% underwent LRNYGB. Of these, 78.91% (464) were female, and the mean preoperative BMI was 48.8 ± 8.95 kg/m2. The mean time spent on the LSD was 18.21 ± 7.32 days, and median EBWL-LSD was 4.7% (1.73-7.61). Greater EBWL-LSD was observed in patients who were on the LSD for > 2 weeks (5.35% vs 3.09%, p<0.0005), and in men (median of 6.2% vs 4.23%, p=0.0001). Significant independent predictors of EBWL 2 weeks post-operatively included EBWL-LSD (p<0.0005) and male sex (p<0.0005), when adjusting for surgery type, baseline EBW, and age. Patients who achieved at least the median EBWL at 2 weeks (15.4%) had greater EBWL-LSD than those who did not (5.7% vs 4%, p<0.0005). The only significant predictor of EBWL at 2 months was 2-week EBWL (p <0.0005), when adjusting for EBWL-LSD, surgery type, and gender. At 24 weeks, significant independent predictors for EBWL included EBWL at 2 and 8 weeks (p=0.001, p<0.0005), and LRNYGB (p=0.002).

Conclusion: Greater EBWL-LSD is associated with male gender and longer duration on the LSD. EBWL-LSD was a significant independent predictor of EBWL at 2 weeks, while EBWL at 2 and 8 weeks were independent predictors for weight loss at 24 weeks. Patients who reached at least 5.7% EBWL-LSD were in the 50th percentile of EBWL at 2 weeks. This suggests that EBWL-LSD can predict optimal early weight loss outcomes after BS and be used to guide expectations both in preparation for, and after bariatric surgery. 

 

17.07 Type of Fundoplication Is Not Associated with Persistent Dysphagia Following Antireflux Surgery

Posted on January 18, 2018

K. Vande Walle1, L. M. Funk1, Y. Xu1, J. Greenberg1, A. Shada1, A. Lidor1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:  Laparoscopic fundoplication is the gold standard operation for control of gastroesophageal reflux disease. It has been suggested that persistent postoperative dysphagia is increased in Nissen fundoplication compared to partial fundoplication (Toupet, Dor). We aimed to determine risk factors for persistent postoperative dysphagia, specifically examining type of fundoplication, to inform operative planning. 

Methods:  Patients experiencing gastroesophageal reflux symptoms who underwent laparoscopic Nissen, Toupet, or Dor fundoplication between January 2009 and July 2016 were identified from our single academic institutional foregut surgery database. A dysphagia score was obtained by administering a standardized quality of life survey in clinic or by telephone. Persistent dysphagia was defined as a difficulty swallowing score ≥ 1 (noticeable) on a scale from 0 (no symptoms) to 5 (incapacitating) at least one year postoperatively. Adjusted odds ratios (OR) of persistent dysphagia among those who underwent Nissen compared to partial fundoplication with 95% confidence intervals (CI) were calculated in multivariate logistic regression models. The multivariate logistic regression model was adjusted for sex, age, body mass index (BMI), and redo operation.

Results: Of 441 patients in the database who met the inclusion criteria, 255 had at least one year of follow-up (response rate = 57.8%). The median follow-up interval was 3 years. 45.1% of patients underwent Nissen fundoplication and 54.9% underwent partial fundoplication. Persistent postoperative dysphagia was present in 25.9% (n=66) of patients. On adjusted analysis, there was no statistically significant association between the type of fundoplication (Nissen vs. partial) and the likelihood of dysphagia (Table 1).

Conclusion: The likelihood of persistent dysphagia was not associated with the type of fundoplication (Nissen vs. partial). While many surgeons believe partial fundoplication decreases the risk of persistent postoperative dysphagia compared to Nissen fundoplication, our study demonstrated equivalent rates of persistent postoperative dysphagia. This suggests that in patients who are equivalent candidates for either a Nissen or partial fundoplication, Nissen fundoplication is a sound choice for an antireflux operation.
 

17.05 Stratification by Age Improves Accuracy of ACS Risk Calculator for Paraesophageal Hernia Repair

Posted on January 18, 2018

A. D. Jalilvand1, M. Al-Mansour1, K. A. Perry1  1Ohio State University,General And Gastrointestinal Surgery,Columbus, OH, USA

Introduction: The ACS-NSQIP Surgical Risk Calculator (ANS-RC) predicts 30-day complication rates for specific surgical procedures. The goal of this study was to assess the accuracy of the ANS-RC for predicting 30-day complication rates in a cohort of patients undergoing laparoscopic paraesophageal hernia repair (LPEHR) in a large academic medical center.

Methods: One hundred seventy-seven patients underwent primary LPEHR between 2011 and 2016 and were included in the study. Using the definitions in the ANS-RC, risk factors and 30-day post-operative complications were obtained for all patients from the electronic medical record. Predicted complication rates were calculated for each patient. Data are presented as incidence (%), mean ± SD, or median (IQ range). Comparisons between predicted and observed complication rates were made using one sample proportion or Wilcoxan paired signed rank tests. A p-value of <0.05 was considered statistically significant.

Results: During the study period, LPEHR was performed for 177 patients with a mean age of 66.2 ± 14.0 years and BMI of 30.2± 6.1 kg/m2. Seventy-three percent (n=156) were female and most patients had an ASA score of 2 (n=47, 26.6%) or 3 (n=122, 68.9%). Compared to the ANS-RC general population, this cohort had higher risks for serious complications (7.0% vs 5.7%), cardiac complication (0.4% vs 0.2%), reoperation (2.3% vs 2.1%), and readmission (6.5% vs 5.2%). Overall, the observed complication rates for any complication (13.6% vs 7.7%, p<0.01), serious complication (11.4% vs 7%, p=0.02), death (1.7% vs 0.3%, p<0.01), reoperation (6.8% vs 2.3%, p<0.01), and readmission (11.3% vs 6.5%, p<0.01) were higher than those predicted by the ANS-RC. The median hospital length of stay (LOS) was significantly shorter than predicted (2 vs 2.5, p<0.01). When stratified for patients with ASA scores of 2 or 3, the calculator more accurately predicted the observed complication rates, although reoperation (p=0.02) for ASA 2, and reoperation (p=0.04), SNF placement (p=0.03) and readmission rates (p=0.04) for ASA 3 were higher than predicted by the ANS-RC. The calculator most accurately predicted complication rates when patients were stratified by age group (<65, 65-79, 80+). Predicted values were lower than observed rates for reoperation in patients <65 (p=0.01) and 65-79 (p<0.01), readmission for patients <65 (p<0.01), and any or serious complications for patients >80 years of age (p=0.01). ANS-RC significantly overestimated LOS for patients <65 (p<0.01) and 65-79 years (p<0.01).

Conclusion: While the ANS-RC provides a useful tool for guiding preoperative discussions, this cohort comprised primarily of elderly patients with significant medical comorbidities had significantly higher than predicted complication rates compared to the general NSQIP population. However, stratifying patients by age and ASA improves the accuracy of the ANS-RC for LPEHR.

17.02 New Onset Alcohol Use Disorder Following Bariatric Surgery

Posted on January 18, 2018

C. Holliday1, M. Sessine1, N. Ibrahim1, M. Alameddine1, J. Brennan1, A. A. Ghaferi1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:

Bariatric surgery is the most effective treatment for morbid obesity; however, there may be significant unanticipated psychosocial effects after surgery. Prior work identified a three-fold increase in the incidence of alcohol use disorder (AUD) after surgery in patients who underwent Roux-en-Y gastric bypass (RYGB). The landscape of bariatric surgery has changed, with sleeve gastrectomy (SG) now comprising over 50% of primary bariatric operations. However, the degree to which patients who undergo SG develop AUD remains unknown. Therefore, we sought to characterize the incidence of AUD in patients who have undergone SG compared to RYGB and potential predisposing patient factors.

Methods:

This study used prospectively collected, patient-reported data from a state-wide quality collaborative. Presence of AUD was determined using the validated Alcohol Use Disorders Identification Test for Consumption (AUDIT-C), with a score ≥4 in men and ≥3 in women suggestive of AUD. We used bivariate chi-square tests for categorical variables and independent samples t-tests for continuous variables. We used multivariable logistic regression to identify patient characteristics that may predispose patients to development of AUD at 1 and 2 years after surgery.

Results:

The prevalence of AUD in all patients who underwent bariatric surgery in our population was 9.6% preoperatively (n=5724), 8.5% at 1 year postoperatively (n=5724), and 14.0% at 2 years postoperatively (n=1381). The preoperative, 1 year, and 2 year prevalence of AUD for SG were 10.1%, 9.0%, and 14.4%, respectively. The preoperative, one year, and two year postoperative prevalence of AUD for RYGB were 7.6%, 6.3%, and 11.9%, respectively. The rate of new onset AUD in the first year following SG and RYGB were 0.75% and 0.54%, respectively. However, in year two, there was a significant increase in the incidence of new onset AUD—8.5% for SG and 7.2% for RYGB (Figure). Predisposing patient factors to AUD development included higher educational level (p<0.01) and higher household income (p<0.01).

Conclusions:

This is the first large, multi-institutional study of AUD in sleeve gastrectomy patients. The prevalence of alcohol use disorder in patients undergoing SG and RYGB was similar pre- and post-operatively. While there was only a slight increase in the incidence of new onset AUD in the first postoperative year, there was a marked increase in new onset AUD in the second year after both SG and RYGB. Understanding the timing and incidence of alcohol use disorder in patients undergoing sleeve gastrectomy—the most commonly performed bariatric operation in the United States—is critical to providing appropriate counseling and treatment. 

17.03 Discrepancies Between Physician and Midlevel Provider Attitudes on Bariatric Surgery

Posted on January 18, 2018

S. M. Wrenn1, V. Shah1, P. W. Callas1, W. Abu-Jaish1  1University Of Vermont College Of Medicine / Fletcher Allen Health Care,Burlington, VT, USA

Introduction: Bariatric surgery (BS) remains a mainstay of treatment for severe obesity and/or diabetes mellitus. Referral for BS is predominantly dictated by primary care practitioners consisting of physicians and midlevel providers. Provider perceptions and knowledge related to these procedures influences treatment decisions, surgical volume, and ultimately patient outcomes.

 

Methods: We constructed a novel electronic survey and dispersed it to all physician and midlevel providers (n=1169) at a single academic medical center and its affiliated external sites.  Responders were queried for demographic information, baseline perception regarding BS, and given the option to view short informational surgical videos on four procedures (sleeve gastrectomy, roux-en-y gastric bypass, laparoscopic gastric band, and duodenal switch). Their perceptions were reassessed following the viewing of these videos. Responses were given on a Likert scale (1=very positive/very likely, 5=very negative/very unlikely) or multiple-choice response. Statistical analysis was performed with two sample t-test and Fisher’s exact test. Multivariate analysis adjusted for gender, specialty (primary care vs. specialist), practice, and education level (MD/DO vs. midlevel).

 

Results: Total respondents (n) included 114 physicians and 26 midlevel providers (12% response rate). Midlevel providers preferred weight loss medication (mean 3.3 vs 2.6, p =.005) for the treatment of diabetes and were less likely to recommend a randomized trial of weight loss surgery (mean 2.1 vs. 1.6, p=0.003). Midlevel providers also had a less favorable opinion overall of BS than physicians (mean likert scale response 2.4 vs. 1.9, p=0.003), including its ability to treat diabetes mellitus (mean 2.4 vs 2.0, p=0.02). Midlevel providers believed there was an increased likelihood of death from all 4 surgeries. Providers who watched an educational video on sleeve gastrectomy trended towards more likely to recommend the procedure (p=.07) than those who had not. After adjustment, there was no difference between genders or between specialists and generalists. After reviewing the educational material, 60% of all providers stated they had a more favorable opinion of BS and midlevel providers were just as likely to recommend BS (1.7 vs. 1.9, p=0.26).

 

Conclusions: Midlevel providers overall had significantly more negative perceptions of BS than physicians and perceived it to be of higher risk. This was at least partially alleviated by viewing educational videos.  More continued educational interventions geared toward primary care practitioners, particularly midlevel providers, may improve perceptions and increase referrals. 

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