62.06 Surgical Coaching for Advancement of Global Surgical Skills and Capacity: a Systematic Review

Posted on January 31, 2019

D. El-Gabri1, A. D. McDow1, S. R. Pavuluri Quamme2, C. C. Greenberg3, K. L. Long1  1University Of Wisconsin,Division Of Endocrine Surgery/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 2University Of Wisconsin,Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 3University Of Wisconsin,Division Of Surgical Oncology/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA

Introduction:
Surgical coaching is an emerging concept of education and collaboration demonstrated to improve surgical performance, perceptions and attitudes of practicing surgeons. Continued surgical education in low-resource settings remains a challenge due to confounding barriers of access, resources, and sustainability. Despite early successes of surgical coaching in academic institutions, to our knowledge, no formal assessments of coaching as a means to improve surgical quality in low-middle income countries (LMICs) exist. The purpose of this review is to explore if surgical coaching is an effective method of fostering continued medical education and promoting advancement of surgical skills for established surgeons in low resource settings.

Methods:
We conducted a systematic literature search through PubMed, Scopus, Web of Science, and CINAHL in July 2018. Included studies were in English, peer-reviewed, and met pre-established study criteria. Studies must have assessed surgical coaching- specifically defined as a means to establish continuous professional growth of trainees and practicing surgeons. Additionally, we conducted a reference and citation analysis as well as a data quality assessment on included studies.

Results:
Our search produced 1377 results and 151 were selected for full text analysis, of which 23 met inclusion criteria for summary analysis. While the majority of the articles (13/23) evaluated coaching of trainees, 10 articles assessed or evaluated coaching surgeons in established careers. Of the articles that discussed skill acquirement (18/23), 3 assessed non-technical skills alone, and 14 assessed technical skills or both technical and non-technical skills. In studies that assessed skill performance after a coaching intervention (9/23), all of them (9/9) demonstrated skill improvement compared to a control. The idea of remote or cross-institutional coaching was explored in 8 of the 23 studies. None of the studies reviewed discussed or evaluated coaching in LMICs.

Conclusion:
Coaching is a widely applicable method of teaching surgeons at multiple stages of a career with clear educational benefits. The explored advantages of surgical coaching in academic institutions may be applied to continuous performance improvement and collaboration with surgeons in LMICs. Furthermore, coaching may aid in assessment of the well-established Lancet Global Surgery Indicators thereby improving surgical capacity in LMICs.
 

62.05 Evaluating an Evidenced-Based Guideline to Reduce Excessive Prescription of Post-Operative Opioid

Posted on January 31, 2019

M. R. Freedman-Weiss1, A. S. Chiu1, D. R. Heller1, V. Kurbatov1, P. S. Yoo1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:
Prescription opioids are a main contributor to the current opioid epidemic as leftovers often get diverted for non-medical use.  Surgeons are known to dispense far more opioid pills than are needed to treat pain.  In academic institutions, junior residents (PGY-1, 2) write most postoperative prescriptions.  Few residents receive education on opioids, but trainees who did, cited opioid dosage recommendations as the most useful educational point.  Utilizing publsihed data on actual postoperative opioid use, we developed a card of recommendations for surgical residents to use when prescribing postoperative analgesia.  We studied the impact of this initiative and the value of the card, paying particular interest in junior resident use.

Methods:
A pocket-sized postoperative analgesia guideline card was developed, comprising specific recommended opioid doses for common general-surgical procedures, general guidelines for postoperative analgesia, instructions for Narcan use, an equianalgesic opioid chart, and smartphrases in the electronic medical record for use as patient instructions on opioid use, safety, and disposal.  The specific recommended doses were based on published data on actual postoperative opioid use and were approved by experienced surgeons from each included specialty.  The tool was distributed to all general surgery housestaff at a university-affiliated hospital.  Following the distribution of the card, an anonymous electronic survey (Qualtrics Survey Software) regarding its use and impact was distributed.  Descriptive statistics were used for all analyses.

Results:
Of 85 trainees, 62 (72.9%) responded to the survey in full.  Fifty respondents (80.6%) received the opioid guideline card, including 16 PGY-1’s and 10 PGY-2’s.  Of responding PGY-1 and PGY-2 trainees who received the card, 75% and 60% respectively use it, with 46% of responding junior residents accessing the tool on a daily-to-weekly basis.  Overall, 81.6% of included residents reported changing their opioid prescribing practices because of this intitative and 89.8% believe the card should continue to be distributed and used. The most valuable aspects of the card were the specific dosage recommendations (53.1%), the guidelines for analgesia after inpatient stays (40.8%), and the smartphrases for patient discharge instructions (28.6%).

Conclusion:
An evidenced-based guideline for postoperative analgesia, including specific recommendations for opioid doses after common surgical procedures, is useful for surgical residents, specifically junior residents.  Nearly all residents who received this card report that is has influenced their prescribing practices and advise its continued distribution and use.  A comprehensive guideline for postoperative analgesia should be considered for wide-use, specifically among junior residents at training hospitals.  Its impact on offsetting the over-prescription of postoperative opioids should be studied further.
 

62.04 Provider Education Decreases Opioid Prescribing After Pediatric Umbilical Hernia Repair

Posted on January 31, 2019

K. Piper1, K. J. Baxter1, M. Wetzel3, C. McCracken3, C. Travers3, B. Slater4, S. B. Cairo5, D. H. Rothstein5,9, R. Cina6, M. Dassinger7, P. Bonasso7, A. M. Lipskar8, N. Denning8, K. F. Heiss1, M. V. Raval2  1Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 2Feinberg School Of Medicine – Northwestern University,Department Of Surgery, Division Of Pediatric Surgery, Ann & Robert H. Lurie Childen’s Hospital Of Chicago,Chicago, IL, USA 3Emory University School Of Medicine,Department Of Pediatrics, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 4The University of Chicago Medical Center,Department Of Pediatric Surgery,Chicago, IL, USA 5John R. Oishei Children’s Hospital of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA 6Medical University Of South Carolina,Division Of Pediatric Surgery,Charleston, SC, USA 7University of Arkansas for Medical Sciences,Department Of Pediatric Surgery,Little Rock, AR, USA 8Zucker School of Medicine at Hofstra/Northwell,Division Of Pediatric Surgery, Department Of Surgery, Cohen Children’s Medical Center,New Hyde Park, NY, USA 9University at Buffalo Jacobs School of Medicine,Department Of Surgery,Buffalo, NY, USA

Introduction:  Surgical procedures early in life may serve as an initial contact with opioids and contribute to the current opioid epidemic in the United States.  Educating adult surgical providers about their opioid prescribing practices has been shown to reduce overprescribing following a variety of procedures.  Our objective was to improve opioid stewardship for umbilical hernia repair in children. 

Methods:  An educational presentation intervention was conducted at 6 centers with 52 surgeons.  The presentation highlighted the importance of opioid stewardship, demonstrated practice variation, provided prescribing guidelines, encouraged non-opioid analgesics and limiting doses/strength if opioids were prescribed. Three months of pre- and post-intervention prescribing practices for umbilical hernia repair were compared. 

Results: A total of 224 patients were identified in the pre-intervention cohort (median age = 5 years) and 218 in the post-intervention cohort (median age = 5 years).  Baseline opioid use varied from 22% of patients to 100% across the 6 centers.  Overall, the percent of patients receiving narcotics at discharge decreased after the intervention from 73.2% to 45.4% (p < 0.001).  After adjusting for age, sex, umbilicoplasty, and hospital site, the odds ratio for opioid prescribing in the post-intervention period versus the pre-period was 0.28 (p < 0.001; 95% confidence interval (CI) = 0.18-0.45). There was no evidence for the intervention having hospital-specific effects (p = 0.77). All hospitals demonstrated improved opioid stewardship with the magnitude of the decrease in percent of patients prescribed opioids ranging from 24% to 100% (Figure).  Among patients receiving narcotics, the number of doses prescribed decreased slightly after the intervention (median doses 12.4 to 10, p = 0.002), and the morphine equivalents per kg per dose decreased (median 0.14 to 0.10, p < 0.001).  Among the entire cohort of patients, the total number of doses prescribed decreased by 50% when compared with the number that would have been prescribed before the educational intervention.  No patients required a refill (pre- or post-intervention) and there were no differences in returns to clinic or emergency departments or hospital readmissions.

Conclusion: Opioid stewardship can be improved after pediatric umbilical hernia repair using a low-fidelity educational intervention.  Pediatric surgeons appear receptive to these efforts supporting expansion to more procedures and populations.

 

62.03 Gender Differences within Surgical Fellowship Program Directors

Posted on January 31, 2019

C. Shaw1, C. Le1, T. Loftus1, A. Filiberto1, G. A. Sarosi1, A. Iqbal1, S. Tan1  1University Of Florida,Department Of Surgery,Gainesville, FL, USA

Introduction: The role of gender-specific mentorship in career choice for women has been well documented. Although women are increasingly represented in American surgery, national data on fellowship program leadership are unknown.  The academic rank and gender of surgical fellowship Program Directors (PDs) were analyzed with the null hypothesis that women and men would be equally represented and hold similar academic ranks among various fellowship programs.

Methods: Demographics and academic ranks for fellowship PDs, Associate Program Directors (APDs), and department faculty were collected for 811 surgical fellowship programs across 14 specialties in the United States.  The academic rank and gender of PDs were compared by Fisher’s Exact test. Proportions of women PDs and fellows were then compared to median compensation for the specialty.

Results: Women represented 23% of all departmental faculty, 18% of all fellowship PDs, and 14% of all APDs.  Fifteen percent of all PDs were Assistant Professors (20% women vs. 13% men, p=0.052), 29% were Associate Professors (32% women vs. 29% men, p=0.367), 37% were Professors (30% women vs. 39% men, p=0.038), and academic rank was unknown for 19%.  The percentage of women PDs was highest in Breast Surgery (65%), Endocrine Surgery (35%), Burn Surgery (25%), and Acute Care Surgery (25%), and lowest in Thoracic Surgery (6%), Minimally Invasive Surgery (6%), Vascular Surgery (11%), and Plastic Surgery (13%). This largely paralleled the percentage of women fellows within these programs with women being overrepresented in subspecialties with lower compensation.

Conclusion: Women surgeons are underrepresented among surgical fellowship PDs, especially in high-income specialties.  It remains unclear whether women surgeons achieve PD appointments at lower academic ranks, or if promotion of fellowship PDs is influenced by gender. Lack of same-sex mentorship could be a component of the difficulty in attracting women to high-paying subspecialties, further widening the gender pay gap among surgeons and perpetuating the lack of women in the pipeline to leadership within these fields.

62.02 Gender Gap amid Moderators, Speakers, Oral and Poster Presenters at National Surgical Conferences

Posted on January 31, 2019

A. L. Hoffman1, R. Ghoubrial1, P. Matemavi1, A. Langnas1, W. Grant1  1University Of Nebraska College Of Medicine,Surgery,Omaha, NE, USA

Introduction:

Discussions about gender representation in high profile positions at surgical conferences have been informal.  The objective of our study is to examine trends at four large United States surgical conferences which represent a variety of surgical specialties.

Methods:
We retrospectively collected data from publicly accessible programs on moderators, invited speakers, abstract and poster presenters at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Society of Surgical Oncology (SSO), American Pediatric Surgical Association (APSA), and American Society of Transplant Surgeons (ASTS) between 2012-2017. Gender representation of society membership is not public record and was not available at our request.

Results:

In all four conferences over the 5-year period:

·  223 (21.9%) of 1,016 moderators were female.

·  1,294 (25.2%) of 5,119 invited speakers were female.

·  1,828 (27.1%) of 6,738 oral and abstract presenters were female.

The largest gender gap was observed at SAGES and ASTS for all categories whereas the APSA and SSO oral and poster presenters neared gender parity at the end of the review period.

During the review period, the percentage of female:

·  moderators increased from 19.5% to 26.7%.

·  invited speakers increased from 23.25% to 32.7%. 

·  abstract presenters increased from 17.8% to 27.3% and

· poster presenters increased 24.5% to 36.9%.

 

Conclusion:

Over the last five years, there has been an increased proportion of women in medical school and general surgery residency. Currently women make up 48.4% of medical students and 38.4% of surgery residents. The percentage of female representation at surgical meetings does not yet parallel trends in training. Though, shifts towards gender parity are seen in some areas, women are still under-represented in many aspects of surgical meetings.

62.01 Trends in Gender Representation at the Academic Surgical Congress

Posted on January 31, 2019

A. R. Wilcox1,2, S. L. Wong1,2  1Dartmouth-Hitchcock Medical Center,Department Of Surgery,Lebanon, NH, USA 2Dartmouth Medical School,Lebanon, NH, USA

Introduction: A growing body of data demonstrates persistent disparities in gender representation at scientific and medical meetings. It is also well established that women are underrepresented in positions of highest academic achievement in surgery. As visibility and active participation at national meetings contribute to career advancement, it is important to understand the gender parity of national surgical meetings. Our objective was to evaluate trends in the proportion of women panelists and moderators at the Academic Surgical Congress (ASC) meetings.

Methods: This was a retrospective analysis for which we manually extracted data from the ASC meeting programs for 2014-2018, which are publicly available on the meeting website. We performed an internet search of surgeons listed in the program to determine gender. We then performed counts and calculated proportions of surgeons by gender who were listed as panelists and moderators (including moderators for all oral, plenary, poster, and panel sessions). We also compiled data on the Association for Academic Surgery (AAS) and Society of University Surgeons (SUS), focusing on the composition of the ASC Program Committee, which is comprised of members of the AAS Program Committee and SUS Publications Committee.

Results: 20% of panels (12/59) at the ASC over the past 5 years did not include a woman panelist. 2016 was the most unequal year, as 55% of panels (6/11) did not include a woman panelist at all and only 23% of panelists overall (9/39) were women. In contrast, all panels in 2017 included at least 1 woman panelist. In 2018, although there were 2 panels without a woman, the proportion of woman panelists overall was 43% (24/56). (FIGURE)

Over the 5 years studied, 30% of moderators were women (280/945). 2016 had the lowest representation of women moderators at 25% (43/172). In turn, the Program Committee had the lowest representation of women in 2015 & 2016 (13/58 & 13/59, respectively, or just 22%). Interestingly, in 2016 both of the Program Committee chairs were men, whereas there was 1 man and 1 woman in each of the remaining four years analyzed. Women comprised 30% of the Program Committee in 2017 (17/57) and 29% in 2018 (19/65).

Conclusion: In the past 5 years, and most notably in 2016, women were underrepresented compared to men as panelists and moderators at ASC meetings. The lowest proportion of women on the Program Committee (including chairs) was seen in 2016, which is consistent with trends in the literature showing that representation of women on program committees correlates to the proportion of women speakers at meetings. However, there has been evidence of growing equity in the past 2 years, possibly reflective of increasing awareness of these disparities.
 

61.20 Cost Efficiency of a Comprehensive ASC Evaluation for Patients with GERD in a Rural Surgical Clinic.

Posted on January 31, 2019

A. Miller1,2, M. Bempah1, S. Clarke1, C. Cruz Pico1,2, A. Postoev1,2, C. Ibikunle1,2  1Medical College Of Georgia,Surgery,Augusta, GA, USA 2Augusa State University,Surgery,Augusta, GA, USA

Introduction:
An estimated prevalence of GERD is 59% in the US, with more than 7,067,209 annual visits and more than $10 billion of annual treatment cost. GERD has multifactorial pathophysiology requiring several diagnostic procedures as esophagogastroduodenal endoscopy (EGD), Ph probe, Manometry, and Biopsy for correct diagnostics and prevention of Barrett's esophagus and cancer. Objectives of the study is to examine cost efficiency of a comprehensive evaluation for the patient with GERD in one visit by an Ambulatory Surgical Center (ASC) evaluation protocol (EGD, Ph probe, Manometry, Cellvisio) at a rural ambulatory surgical center.

Methods:
We examined retrospectively AthenaHealthNet electronic medical records of patients evaluated by ASC protocol with procedure codes: “43239 EGD Transoral biopsy single/multiple”, “91010 Manometry Esophagus motility study”, “91035 Bravo Esoph/Gastroesoph reflux test”, “43252 Cellvizio w/mucous telemetry Ph electrode place/Rec/Interp” from 08/22/2017 to 08/22/2018.

Results:
We evaluated total 344 patients, with average age 51.47 (range 19-87). The most common diagnostic codes applied were: 120 (34.8%) “K219: Gastroesophageal reflux disease without esophagitis”; 65 (18.9%) “K2270: Barrett's esophagus without dysplasia”; 42 (12.2%) “K635: Polyp of colon”; 38 (11.0%) “E6601: Morbid (severe) obesity due to excess calories”; 29 (8.4 %) “K449: Diaphragmatic hernia without obstruction or gangrene”; 19 (5.5 %) “K2970: Gastritis, unspecified, without bleeding”;13 (3.8 %) “R1310: Dysphagia, unspecified”;12 (3.5 %) “R109: Unspecified abdominal pain”. Total annual cumulative billed chargers for all procedures were $ 807,784, comprising charges for EGD/Biopsy ($ 467,935), EGD Flex Biopsy ($ 126,492), Manometry Motility study ($ 126,492), Bravo Reflux test ($ 156,024). Annual billed charges for total evaluation protocol applied in one visit ranged from $ 3,927 to $ 4,763 in contrast to applied in two visits ranged from $ 6,081 to $ 7,820.   

Conclusion:
ASC evaluation protocol (EGD, Ph probe, Manometry, Cellvizio) is more cost efficient in complex evaluation of patients at one visit.
 

61.19 Laparoscopic Esophagomyotomy with Concomitant Paraesophageal Hernia Repair

Posted on January 31, 2019

K. A. Schlosser1, S. R. Maloney1, T. Prasad1, B. T. Heniford1, P. D. Colavita1  1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction:

The successful management of achalasia can be complicated by the presence of paraesophageal hernias, a combination that is felt to be uncommon.  This study examines short term outcomes Laparoscopic Heller Myotomy(LHM) with or without concomitant paraesophageal hernia repair (PEHR).

Methods:

The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent LHM with or without PEHR (2010-2016). Concomitant bariatric procedures were excluded. Demographics, operative approach, and outcomes were compared over time and by procedure group. Overall complication rate was defined as Clavien-Dindo ≥1, while major complication was defined as Clavien-Dindo ≥ 3.

Results:

3,579 patients underwent LHM from 2010-2016. 8.0% of procedures included PEHR, and 1.2% included PEHR with mesh placement. LHM with concomitant PEHR accounts for 1.3% of all PEHR in this time period (286 of 20,798 PEHR). Mean age of LHM was 52.6±16.3yr, mean BMI was 27.6±6.5m2/kg, 50.2% were female, 9.9% had diabetes, and 15.8% were active smokers. Most cases were elective (94.5%). When compared to LHM, patients undergoing open LHM with PEHR were older (58.2±16.3 vs 52.1±16.2yr, p<0.0001), more often inpatients (77.0 vs. 88.1%, p<0.0001) and had higher rates of hypertension (31.1% vs. 45.5% p<0.0001) and long-term steroid use (2.4 vs 4.9%, p=0.01). LHM with PEHR patients had higher rates of reoperation, mortality, overall complications, and major complications (1.5 vs. 3.6%, 3.5 vs. 4.7%, 3.8 vs. 9.1%, respectively; p<0.0009 all values). Over time, the frequency of LHM performed with concomitant PEHR increased from 2.3% of all LHM in 2006 to 10.7% in 2016 (p<0.0001).

Multivariate analysis was used to control for multiple potential confounding factors including concomitant PEHR, age, BMI, steroid use, and hypertension. PEHR with LHM was associated with double the rate of reoperation (OR 2.3, CI 1.1-4.7), and double the overall and major complication rate (OR 2.0, CI 1.2-3.1; OR 2.0, CI 1.1-3.6, respectively). Chronic steroid use was associated with increased length of stay (+2.8d, SE 0.4, p<0.0001), with readmission (OR 3.2, CI 1.6-6.7), and with overall complication rate (OR 3.0, CI 1.6-5.8). Hypertension treated by medications was also associated with increased length of stay (+0.4d, SE 0.15, p=0.01), overall complication rate (OR 1.8, CI 1.2-2.7), and major complications (OR 2.1, CI 1.3-3.7).

 

Discussion:

The performance of LHM with concomitant PEHR has increased in frequency from 2010 to 2016 for unclear reasons. While patients who have LHM with PEHR have higher complication rates, multivariate analysis demonstrates equivalent short-term outcomes when controlling for confounding factors. 

61.18 Experience with IVC Filters for Robotic Gastric Bypass Procedures

Posted on January 31, 2019

M. Aman1, G. AlAwwa1, L. Flores1, P. Haser1, A. J. Tortolani1, M. Khalil1, N. J. Gargiulo1  1The Brookdale University Hospital and Medical Center,Vascular,Brooklyn, NEW YORK, USA

Introduction: It has been previously suggested that inferior vena cava (IVC) filter placement at the time of open gastric bypass in patients with a body mass index (BMI) > 55 kg/m2 reduces both the pulmonary embolism rate and perioperative mortality.  This has not been observed in patients undergoing laparoscopic gastric bypass.  Little is known regarding the necessity of IVC filter placement in patients undergoing robotic gastric bypass surgery.

Methods:   Over a 3 year period, 51 morbid obese patients have undergone robotic gastric bypass procedures, and 37 (72.5%) had a BMI > 55 kg/m2.  All 51 patients had routine preoperative subcutaneous lovenox injections and systemic compression devices prior to the administration of general anesthesia.  Robotic gastric bypass was completed utilizing the da Vinci system.

Results:  Fifty of 51 (98%) patients remained free of thrombo-embolic phenomena over the 3 year period (range 6 months-3 years) following successful robotic gastric bypass with the da Vinci system.  One patient (2%) with a BMI > 55 kg/m2 developed a pulmonary embolism (PE) 1 month post procedure.  She was treated  successfully with intravenous heparin and had complete resolution of the PE.  She was incidentally diagnosed with a Factor V Leiden deficiency and placed on long-term oral anticoagulation. 

Conclusion:  It appears that IVC filter placement at the time of robotic gastric bypass is not required even in patients with a BMI > 55 kg/m2.  A note of caution should be exerted in those obese patients who have a hypercoagulable disorder.  An aggressive posture should be advocated in this small sub-group of morbid obese patients which may consist of immediate anticoagulation (when it is deemed safe) following their procedures.   

 

61.17 Obesity Years: Clinical Variation by Age Pre/Post Biliopancreatic Diversion/Duodenal Switch (BPD/DS)

Posted on January 31, 2019

M. L. Gott1, P. R. Osterdahl2, G. J. Slotman1  1Inspira Health Network,Department Of Surgery,Vineland, NEW JERSEY, USA 2Inspira Health Network,Department Of Obstetrics/Gynecology,Vineland, NEW JERSEY, USA

Introduction:

Pre-operative conditions and bariatric surgery outcomes of Medicare patients vary significantly versus other insurances, with Medicare often faring worse than others.  However, since some morbidly obese Medicare insured are younger patients on disability, whether or not obesity effects vary strictly by age is unknown.  

Objective:

Identify clinical variation by age of pre/post BPD/DS.

Methods:

Using the BOLD database, 1673 BPD/DS patients were analyzed retrospectively in 6 age groups: <30(177), 30-40(456), 40-50(486), 50-60(407), 60-70(138), >70(9). Data: Demographics, Pre-/Post-op BMI and 33 obesity co-morbidities. Statistics: ANOVA and General Linear Models including pre- and post-operative data modified for binomial distribution of dichotomous variables.

Results:

Pre-op BMI varied inversely by age, from <30 (55+-10) to >70 (44+-8) p<0.01, as did 12 month BMI <30 (32+-6) to 60-70 (31+-5) p<0.05. Female/male %:<30 (76/24) to >70 (44/56) p<0.05, Race and health insurance (Medicaid, Medicare, Private, Self-Pay) varied widely (p<0.0001). Panniculitis, alcohol/substance use, asthma, obesity hypoventilation, PVD, back pain, fibromyalgia, mental health diagnosis, depression, psychological impairment, pseudotumor cerebri, irregular menses, DVT/PE did not vary by age. Gout varied directly by age and tobacco abuse varied inversely at baseline. 12 month liver disease and pulmonary hypertension varied directly by age. Hernia, cholelithiasis (Chole), CHF, impaired function (IFS), diabetes, hypertension (HTN), dyslipidemia (Lipids), lower extremity edema (LEE), somatic pain (MS pain), angina, sleep apnea (OSA), stress urinary incontinence (SUI) all varied directly by age pre-op, and their increased persistence correlated with increasing age at 12 months. In the 60-70 and >70 sets angina, MS pain, LEE and SUI increased from baseline: see Table.

Conclusion:

In spite of lower pre-operative BMI in older age groups, the incidence of serious obesity co-morbidities varied directly with age among BPD/DS patients. In addition, while BMI for all age groups at 12 months after BPD/DS was clinically identical, post-operative improvement in 12 weight-related medical derangements was inversely proportional to age. Only diabetes resolved more completely among older patients. Although BOLD did not record the duration of each patient’s obesity, these findings suggest the concept of “obesity years”, meaning that those who have obesity the longest accumulate more co-morbidities and are less likely to resolve them than those who have obesity a shorter length of time. This advance knowledge may assist patient selection for BPD/DS. Data-informed planning could yield superior BPD/DS outcomes.
 

61.16 Blockade of the TCA Cycle in Type 2 Diabetes and the Metabolic Syndrome

Posted on January 31, 2019

W. Pories1, T. E. Jones1, J. Houmard1, C. J. Tanner1, D. Zeng1, K. Zou3, P. M. Coen2, B. H. Goodpaster4, W. E. Kraus2, J. Yang1, G. L. Dohm1, W. Pories1  1East Carolina University,Brody School Of Medicine,Greenville, NC, USA 2Duke,Metabolism,Durham, NC, USA 3Boston University,Biochemistry,Boston, MA, USA 4Sanford Bunham Prebys Medical Discovery Institute,Orlando, FL, USA

Introduction:
Blood lactate, an indicator of metabolic failure in critical care, indicates dependence on the anaerobic partitioning of glucose, reflected by increased lactate production. In this study, we explored basal lactate levels in normal individuals and preoperative patients with the metabolic syndrome, before and after correction of glucose metabolism, with surgery and with exercise.

Methods: Fasting lactate levels and insulin sensitivity were determined during IVGTT in non-obese subjects and patients with metabolic disease prior to Roux-en-Y gastric bypass as well as 1 week, 1-3 months, 7-9 months and more than 12 months following RYGB.  Subjects with the metabolic syndrome were also studied at baseline and after 9 months of exercise.

Results: Subjects with the metabolic syndrome have higher lactate (1.67 +/- 0.11 mM) than non-obese controls (1.06 +/- 0.05 mM, P< .001) and respond to a glucose/insulin challenge with higher lactates.  Lactate concentrations, including basal levels, were significantly reduced a week after RYGB and remained at levels like non-obese for more than a year.  The greatest improvement in fasting lactate occurred in those who were most metabolically impaired (highest lactate). Fasting lactate was also reduced by exercise in metabolically impaired subjects (by 0.21 mM, p = 0.028) (Figure 1).

Conclusion: Elevated blood lactate levels reflect metabolic impairment, correctible in the severely obese with the gastric bypass and/or exercise.  These data suggest that the metabolic syndrome is caused by a signal, perhaps from the foregut, which limits entry of pyruvate into the TCA cycle.

 

61.15 Factors Associated with Excess Weight Loss Percent Among Adolescent Bariatric Surgery Patients

Posted on January 31, 2019

E. C. Victor1,2, N. V. Mulpuri3, L. S. Burkhalter1, M. Lott2, F. G. Qureshi1,3  1Children’s Medical Center,Division Of Pediatric Surgery,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Department Of Psychiatry,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA

Introduction: Adolescent bariatric surgery is associated with significant weight loss with a reduction in medical comorbidities and improved psychological functioning. To date, there has been limited research exploring individual medical, demographic, and family factors associated with excess weight loss percent (EWL%) postoperatively in adolescents.

Methods: A retrospective chart review of adolescents who underwent sleeve gastrectomy between 2015 and 2018 was performed. A series of forward stepwise linear regressions at 6 weeks, 3 and 6 months postop were conducted to examine medical, family, and demographic factors associated with EWL%. IRB approval was obtained.

Results:47 patients were identified (age 17.6±1.16, body mass index(BMI) 50.71±7.50kg/m2). At 6 weeks, males (M EWL% = 17.68,p=.017) had a greater EWL% than females (M EWL% = 16.52) . Patients with lower BMIs at first surgical appointment (p < .001) also had a greater EWL%. Patients referred from primary care providers and/or a pediatric high-risk obesity clinic (M EWL% = 17.72,p= .003) had a greater EWL% compared to patients referred from a specialty care clinic (M EWL% = 12.30).  EWL% at 6 weeks was the greatest predictor of EWL% at 3 months (p<.001) and 6 months (p<.001) post-op. Interestingly, patients with higher BMIs at first surgical appointment, had higher EWL% at 6 months (p<.001).  At all post-operative time points, there were no differences in EWL% outcomes with regard to race, ethnicity, age at surgery intake appointment, medical diagnoses (obstructive sleep apnea, hypertension, hyperlipidemia, non-alcoholic fatty liver disease, or type 2 diabetes), mental health diagnosis, insurance type, family  history of weight loss surgery, or family members’ successful weight loss maintenance post-op.

Conclusion:For adolescents undergoing bariatric surgery, greatest EWL% at 3 and 6 months post-op was most associated with the amount of weight a patient is able to lose in their first 6 weeks following surgery. Boys also had greater EWL% and BMI at first surgical appointment impacted EWL% differently at 6 weeks and 6 months, perhaps reflecting different rates of weight loss.  Additional longitudinal data will be required to validate these findings.

 

61.14 Skeletal muscle loss in laparoscopic gastrectomy: differences between laparoscopic procedures.

Posted on January 31, 2019

Y. Yamazaki1, S. Kanaji1, G. Takiguchi1, H. Hasegawa1, M. Yamamoto1, Y. Matsuda1, K. Yamashita1, T. Oshikiri1, T. Matsuda1, T. Nakamura1, S. Suzuki1, Y. Kakeji1  1Kobe University Graduate School Of Medicine,Division Of Gastrointestinal Surgery, Department Of Surgery, Kobe University Graduate School Of Medicine,Kobe, HYOGO, Japan

Introduction:
Gastrectomy is an essential treatment for gastric cancer. However, it is well known that gastrectomy causes not only body weight loss (BWL) but also skeletal muscle loss (SML), which can impair quality of life of the patients. Several reports showed the type of open gastrectomy had an effect on BWL and SML. However, the difference in SML between types of laparoscopic gastrectomy and correlation between BWL and SML are still unclear. The aim is to reveal the differences in SML between laparoscopic procedures for gastric cancer and to identify the risk factors for SML.

Methods:
We retrospectively obtained data of 207 consecutive patients who underwent laparoscopic gastrectomy for gastric cancer between March 2011 and May 2017. Out of the patients, 157 patients underwent laparoscopic distal gastrectomy (LDG group) and 50 patients underwent laparoscopic total gastrectomy (LTG group). We analyzed psoas major muscle area (PMA) of the L3 for evaluation of skeletal muscle mass using CT image taken before the surgery and at 1 postoperative year and compared PMA change between the laparoscopic procedures. Comparisons of BW and PMA were performed between the types of laparoscopic procedures including LDG (Billroth 1), LDG (Roux en Y) and LTG. Univariate and multivariate analysis to identify risk factors for PMA rate of less than 90% were performed for LDG group. Further, we performed the same analysis for the population whose BW was relatively preserved.

Results:
 There was no significant difference in the characteristics. Longer operative time and more blood loss were observed in LTG group. Pathological findings showed more advanced diseases in LTG group, which resulted in more adjuvant chemotherapy undergone. Anastomotic leakage in LTG group was more frequent, while the overall complications rate was not different. The median PMA rate (1POY / Pre) was 94.0% in LDG (B-1), 95.2% in LDG (R-Y) and 84.4% in LTG group respectively. BW and PMA were preserved significantly better in both LDG subgroups. Univariate analysis showed that high BMI (25 or above) and postoperative complications were significantly associated with more PMA loss, while multivariate analysis identified only postoperative complications as an independent risk factor in LDG group. BW and PMA rate were well correlated in overall patients, and PMA rate of 90% was equivalent to BW rate of 88%. Out of 118 patients whose BW rates was 88% or above, 29 patients had their PMA rate fall below 90%. Univariate and multivariate analysis showed that LTG was the independent risk factor for PMA rate less than 90 % in patients whose BW rate was 88% or larger.
 

Conclusion:
 We showed that postoperative PMA loss occurred in laparoscopic gastrectomy as well as previous reported open surgery. Postoperative complications were harmful for SML after LDG. Because LTG can cause great PMA loss even when BW are relatively preserved, SML should be cared especially after LTG.

 

61.13 Effect of Distance from Surgical Center on Bariatric Postsurgical Outcomes and Follow-up Compliance

Posted on January 31, 2019

S. Monfared1, D. Selzer1, A. Butler1  1Indiana University School Of Medicine,Bariatric And Minimally Invasive Surgery,Indianapolis, IN, USA

Introduction:
Patients seeking bariatric surgery are traveling longer distances to reach Metabolic and Bariatric Centers of Excellence. The purpose of this study was to evaluate the impact of travel distance on adherence to follow up and outcomes after bariatric surgery.

Methods:
A retrospective review of all consecutive patients who had undergone bariatric surgery at a Center of Excellence from June 1, 2013 to May 30, 2014 was performed. The patients were divided into two groups: those who traveled 50 miles or less and those who traveled more than 50 miles. Demographic data was obtained including age, gender, initial body mass index (BMI), type of surgery and insurance type. Primary outcome assessed was the influence of distance on postoperative weight loss over 4-year follow up period. Secondary outcomes assessed were follow-up compliance, length of stay (LOS), 30-day complication and readmission rates.

Results:
A total of 231 patients underwent bariatric surgery at our institution during that year with 4 years of follow up available. Of these, 147 patients traveled 50 miles or less and 84 patients traveled greater than 50 miles. Patient demographics were similar between the two groups. There was no difference in percent excess weight loss at each follow visit between the two cohorts (Figure 1). Furthermore, there was no difference in readmission rates (2% in ≤50 mile group vs 5% in > 50 mile group), minor complications rates (13% vs 10%), major complications rates (3% vs 2%) and LOS (2.6 vs 2.6 days). Over the four year period, patients who lived within 50 miles of the surgery center followed up an average of 5.6 out of 9 required visits which was statistically greater than an average of 4.6 visits for those who lived greater than 50 miles away.

Conclusion:
As expected, distance impacted long term follow up, but despite longer travel, there was no difference in bariatric patients’ postoperative weight loss success, length of stay, 30-day complication or readmission rates. Travel distance should not be a significant factor to providing patients with access to bariatric surgery at a Center of Excellence.
 

61.12 Postoperative Urinary Retention After Bariatric Surgery: An Institutional Analysis

Posted on January 31, 2019

D. F. Roadman1, M. Helm1, M. Goldblatt1, T. Kindel1, J. Gould1, R. Higgins1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  Postoperative urinary retention (POUR) can significantly impact quality outcomes, leading to urinary tract infections, longer lengths of stay, and increased healthcare costs. The incidence of POUR in bariatric patients has limited information in the literature. The primary objective of this study was to determine the incidence of and risk factors contributing to POUR in primary bariatric surgery patients. 

Methods:  A retrospective chart review was performed of patients who underwent a laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) at a single institution from 2013 to 2017. POUR was defined as the inability to urinate postoperatively requiring urinary straight or indwelling catheterization prior to discharge. Univariate analyses were performed on perioperative variables and their correlation with POUR. 

Results: In total, 603 patients underwent primary bariatric surgery during the study period: 317 (52.6%) LSG and 286 (47.4%) LRYGB. Overall, 49 (8.1%) patients developed POUR with a mean volume at time of urinary catheter intervention of 682.5 ± 319.7 mL. There were no significant differences in pre-operative demographics between patients with and without POUR. Patients who underwent a LSG had an increased incidence of POUR at 11.4% compared to 4.5% after LRYGB (p=0.002). Additionally, POUR was significantly associated with decreased neostigmine usage, isolated non-depolarizing muscle relaxant usage, and reduced intraoperative fluid administration (Table 1). Female patients with POUR had a significantly longer length of stay at 2.14 ± 1.17 days compared to those without POUR at 1.71 ± 1.25 days (p=0.046). There was no significant difference in length of stay for male patients. 

Conclusion: Risk factors associated with POUR after primary bariatric surgery include LSG, less intraoperative neostigmine and intravenous fluids, as well as isolated non-depolarizing muscle relaxants. Female patients who developed POUR had a longer length of stay. These risk factors can be used to educate patients, as well as identify quality initiatives that focus on perioperative and anesthetic management. Creating a standardized protocol for the management of urinary retention in these patients could also impact its effect on length of stay. 

 

61.11 Lack of Lymphocyte Recovery After Esophagectomy Predicts Mortality and Recurrence

Posted on January 31, 2019

B. M. Hall1, T. Geraci1, J. Machan1, S. Milman1, W. Cioffi1, T. Ng1, S. Monaghan1  1Warren Alpert Medical School of Brown University,Department Of Surgery,Providence, RI, USA

Introduction:
Esophagectomy performed for esophageal cancer is a relatively high morbidity and mortality operation.  The immediate morbidities have been shown to have major impacts on patient’s long term survival.  Prior research at our institution has found decreased lymphocyte counts to be an independent predictor of mortality in some populations.  We hypothesized the lymphocyte count postoperatively would predict outcomes in esophagectomy patients as well.

Methods:
A retrospective review was performed of all esophagectomies for adenocarcinoma performed over 13 years at our center by a single surgeon.  The routinely obtained postoperative lymphocyte counts were analyzed for their trend, separating patients into three groups: never low, low with by recovery, and low without recovery.  Resolution of lymphopenia was assessed at postoperative day four.  Outcomes between these groups were then compared, with the primary end points being all cause mortality and recurrence analyzed with Kaplan Meier curves.

Results:
In total, 207 patients were included in the review with a minimum one year follow up.  Our 5 year mortality and recurrence rates were 49% and 44% respectively.  Recurrence was significantly higher in patients in patients with persistent lymphopenia [41% (64/158)] compared to those who did recover [13% (5/39)] (p = 0.0019) and those whose counts never dropped [10% (1/10)] (p = 0.0024).  For mortality, the persistent lymphopenia group was significantly higher [54% (85/158)] as compared to the two other groups combined [33% (16/49)] (p = 0.0225).  There was no significant difference in immediate complications including leak rate and infections, nor hospital length of stay.  There were more patients with persistent lymphopenia who had a higher clinical stage (36 vs 13% p = 0.0051) and received neoadjuvant chemotherapy (86% vs 28% p < 0.0001).  However, neither of these preoperative factors were predictive of mortality.

Conclusion:
There is a significant increase in the mortality and cancer recurrence rates in those patients whose lymphocyte count drops without recovery following their esophagectomy.  These data imply differences in immune responses to the stress of surgery that that can be measured and are indicative of overall outcomes.  As a portion of already routine postoperative labs, consideration of lymphocyte trends would an early indicator of potential poor outcomes in these patients.  
 

61.10 Treatments Modalities for Esophageal Adenocarcinoma in the US: Trends and Survival Outcomes

Posted on January 31, 2019

M. Di Corpo1, F. Schlottmann1, P. D. Strassle2, C. Gaber2, M. G. Patti1,2  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Department Of Medicine,Chapel Hill, NC, USA

Introduction:  The rise in incidence of esophageal adenocarcinoma in the United States over the last decade has been well documented; however, data on trends in use of different therapies and their impact on long-term survival are lacking. We aimed to: a) assess the national trends in the use of different treatment modalities; and b) compare survival outcomes among the different treatment strategies. 

Methods:  A retrospective, population-based analysis was performed using the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program registry for the period 2004-2014. Adult patients (>18 years old) diagnosed with esophageal adenocarcinoma were eligible for inclusion. Treatments of interest included chemoradiation, esophagectomy, and chemoradiation plus esophagectomy. The yearly incidence of each treatment strategy was calculated using Poisson regression. A weighted Cox regression model was used to assess the overall effect of each treatment on mortality. Inverse-probability of treatment weights were used to account for potential confounding by year of diagnosis, sex, age, race/ethnicity, tumor grade, and derived AJCC TNM value. 

Results: A total of 10,755 patients were included. The median follow-up time was 15 months (interquartile range 7 – 33). During the study period, the percentage of esophagectomy alone significantly decreased from 14.6% to 4.8% (p<0.0001), the percentage of chemoradiation alone significantly decreased from 25.45% to 28.5% (p=0.08), and the percentage of chemoradiation plus esophagectomy significantly increased from 13.7% to 19.8% (p<0.0001). The 60-month survival rate was 13.0% for chemoradiation only, 33.0% for esophagectomy only, and 36.3% for chemoradiation plus esophagectomy (figure). After accounting for patient and cancer characteristics, both esophagectomy (hazard ratio [HR] 0.62, 95% CI 0.55, 0.70, p<0.0001) and chemoradiation plus esophagectomy (HR 0.45, 95% CI 0.41, 0.48, p<0.0001) had significantly lower rates of mortality compared to chemoradiation only.

Conclusion: The use of esophagectomy alone has decreased, and both the use of chemoradiation plus esophagectomy and chemoradiation alone have increased for patients with esophageal adenocarcinoma. Considering the better survival outcomes achieved with surgical resection, the use of chemoradiation alone should be discouraged in surgically fit patients.    

 

61.09 Referral to surgery:What Factors Are Associated with Completion of Adolescent Weight Loss Surgery?

Posted on January 31, 2019

N. V. Mulpuri2, E. C. Victor1,3, G. P. Wools1, M. Lott1,3, F. G. Qureshi1,2  1Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Department Of Psychiatry,Dallas, TX, USA

Introduction: Bariatric surgery has been used to treat severe obesity in adolescents. However, only a limited number of adolescents referred to surgery successfully complete the surgical program. Better identification of pre-surgical factors associated with completing bariatric surgery may determine successful referrals to surgical programs versus alternative behavioral health interventions.

Methods: A retrospective chart review of all patients referred from 2015 to 2018 to an adolescent surgical weight loss program was performed. Pre-operative factors, weight loss, and resolution of premorbid conditions among surgery completers (n=47) was compared to surgery non-completers (n=149) using backward stepwise logistic regression. Choice of procedure was laparoscopic sleeve gastrectomy.  IRB approval was obtained.

Results:196 adolescents were identified (17.1±1.61 yrs, body mass index (BMI) 50.2±8.8kg/m2, 66% female). 47 (24%) underwent sleeve gastrectomy (age (17.6±1.16 yrs, BMI 50.71±7.50kg/m2, 78% female) and 149  (16.2±1.51 yrs, body mass index (BMI) 49.98±9.19kg/m2, 62% female)) did not complete the surgical program. There was no difference between completers and non-completers in terms of age, race, ethnicity, BMI, premorbid medical conditions (hypertension, fatty liver disease, type 2 diabetes, hyperlipidemia), current or past mental health diagnosis, insurance type, referral source, or family history of weight loss surgery at surgical referral.  Regression analyses revealed that boys (p=.045), patients with sleep apnea (OSA p=.009), and those that spent shorter time in the preoperative phase of the bariatric program (p<.001) were significantly more likely to have surgery.  Surgery completers lost weight successfully (figure 1) p<0.05

Conclusion:The conversion rate from adolescent referral to weight loss surgery is 24%.  Male patients, and patients with OSA are more likely to undergo weight loss surgery.  Patients who make significant changes upon surgical referral spend less time in the preoperative phase and are more likely to complete surgery.  Laparoscopic sleeve gastrectomy is successful in helping completers lose significant weight. These factors may help streamline referrals to adolescent surgical weight loss programs. 

 

61.08 Defective Homologous Recombination in Platinum-based Chemotherapy for Gastric Cancer

Posted on January 31, 2019

T. Katada1, H. Ichikawa1, Y. Hirose1, M. Nagahashi1, Y. Shimada1, T. Hanyu1, T. Ishikawa1, Y. Kano1, Y. Muneoka1, 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

Introduction: Defective homologous recombination (HR) due to genetic alteration of HR genes contributes to a high response of platinum therapy in ovarian and breast cancers. The aim of this study is to clarify the clinical significance of defective HR in platinum-based chemotherapy for gastric cancer (GC).

Methods: A total of 26 patients (19 men and 7 women, with a median age of 66 years) who underwent platinum-based chemotherapy for unresectable metastatic GC were enrolled. Metastatic sites after gastrectomy were lymph node in 10 (38%), liver in 8 (31%), peritoneum in 8 (31%), others in 2 (8%) patients. Genetic alterations of HR genes (BRCA1, BRCA2, RAD50, RAD51C, RAD51D, BLM, PALB2 and FANCD2) in the primary tumor were assessed by cancer gene-panel. We evaluated the association between defective HR and treatment response (RECIST ver. 1.1), progression free survival (PFS) and overall survival (OS).

Results: BRCA1, BRCA2, RAD50, BLM, and FANCD2 mutations were shown in 3 (12%), 2 (8%), 2 (8%), 1 (4%) and 1 patient (4%), respectively. Overall, 6 patients (23%) had genetic alterations of HR genes (defective HR group). Objective response rate (complete or partial response) was 60% in the defective HR group and 27% in the proficient HR group (P = 0.29). Disease control rate (complete or partial response or stable disease) was 100% in the defective HR group and 47% in the proficient HR group (P = 0.06). PFS was significantly longer in the defective HR group than in the proficient HR group (median 6 months vs. 3 months; P = 0.035). OS was also significantly longer in the defective HR group than in the proficient HR group (median 18 months vs. 8 months; P = 0.025).

Conclusions: Genetic alteration of HR genes was significantly associated with a high response of platinum-based chemotherapy and favorable patient outcome in unresectable metastatic GC. Clinical utility of the assessment of defective HR in GC is worth considering further large-scale validation studies.

61.06 Weight Loss for Patients with Severe Obesity: An Analysis of Long Term Electronic Health Record Data

Posted on January 31, 2019

N. Liu1, J. Birstler3, M. Venkatesh1, L. P. Hanrahan2, G. Chen3, L. M. Funk1,4,5  4University Of Wisconsin,Department Of Surgery / Division Of Minimally Invasive, Foregut, And Bariatric Surgery,Madison, WI, USA 5William S. Middleton VA Hospital,Madison, WI, USA 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Wisconsin,Department Of Family Medicine And Community Health,Madison, WI, USA 3University Of Wisconsin,Biostatistics And Medical Informatics,Madison, WI, USA

Introduction:  Obesity is a significant health problem in the US, affecting one-third of all adults. Numerous studies have reported that losing as little as 5% of total body weight (TBW) can improve comorbidities, specifically cardiovascular health. However, for adults with severe obesity, 5% TBW loss rarely results in resolution of comorbidities. The objective of this study was to quantify clinically significant weight loss during a 5-year window for severely obese patients who had not undergone bariatric surgery. We defined clinically significant weight loss as a final BMI of < 30 kg/m2. We hypothesized that less than 10% of our patients would achieve clinically significant weight loss.

Methods:  All 18-75 year old patients at a single institution academic health center who had at least 2 height and weight measurements 5 years apart between 1/1/2011 and 12/31/2016 were retrospectively identified from the electronic health record (EHR). We excluded all underweight patients with BMI ≤ 18.5 kg/m2, pregnant and cancer patients using ICD-9 and -10 codes, and bariatric surgery patients using the bariatric surgery registry. We categorized patients by their initial BMI measurement: normal (18.5-24.9 kg/m2), overweight (25.0-29.9), class 1 (30.0-34.9), class 2 (35.0-39.9), and class 3 (≥ 40.0) obesity. BMI changes from initial to end date were plotted. Within each BMI group, we identified patients who lost ≥ 5% TBW.

Results: 23,769 patients met our study inclusion criteria. 19.8% were severely obese (class 2 or 3) at baseline. 25.6% of class 2 obesity patients and 29.6% of class 3 patients lost ≥ 5% TBW; 17.8% and 21.7% of overweight and class 1 patients, respectively, lost ≥ 5% TBW. The majority of patients with severe obesity (51.5% for class 2 and 81.3% for class 3) remained in the same BMI category (Figure 1). 22.4% of class 2 and 14.4% of class 3 patients lost enough weight to drop down 1 obesity class. Only 3.1% of class 2 patients and 0.5% of class 3 patients achieved clinically significant weight loss, or BMI of < 30 kg/m2.

Conclusion: Patients with severe obesity were more likely to lose at least 5% of their total weight compared to overweight and class 1 obesity patients. However, weight loss into a non-obese weight class was very uncommon over a 5-year period for patients with severe obesity. The vast majority either remained in the same obesity class or increased classes. This pattern of ongoing weight gain for the most obese patients is concerning and requires solutions at societal and health systems levels.

 

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