The aim of this study was to assess risk factors of mortality after unplanned surgery following colorectal resection. All the consecutive patients who underwent colorectal resection between 2011 and 2020 in a French national cohort were retrospectively included. Perioperative data of the index colorectal resection (indication, surgical approach, pathological analysis, postoperative morbidity), and characteristics of unplanned surgery (indication, time to complication, time to surgical redo) were assessed in order to identify predictive factors of mortality. Among 547 included patients, 54 patients died (10

Treatment of common bile duct stones (CBDS) includes laparoscopic cholecystectomy (LC) with either laparoscopic common bile duct exploration (LCBDE) or perioperative endoscopic retrograde cholangiopancreatography (ERCP). The main objective of this study was to identify predictive factors for the failure of upfront and exclusive surgical treatment by LCBDE. This is a single-center, retrospective study on patients with CBDS and operated for LC between 2007 and 2019. The use of intra- or postoperative endoscopy for CBD clearance within 6 months after surgery was considered as failure of LCBDE. Predictors for the failure of LCBDE were investigated and outcomes were compared. Among 222 operated patients, LCBDE was successfully performed in 173 patients (78 ClinicalTrials.gov (ID: NCT04467710).

BACKGROUND:The rates of unscheduled revision surgery (URS) after colorectal surgery and failure to rescue-surgical (FTR-s) are 2.4% and 11-17% respectively. The aim of this study was to evaluate the causes of URS lethality to reduce this rate after colorectal surgery.METHODS:From 2011 to 2021, 337 surgeons collected 547 URS. Type of procedure, time course, diagnostic and detection means, time to decision, time to complication(s), causes of URS, delay of URS, and death were recorded and allowed for multivariate systemic analysis of risk factors for death (FTR-s) after URS. Systemic causes of delay were analyzed as assessment of urgency, communication, skills, organization of the operative program, and transport.RESULTS:The two main causes of URS were infectious (66% of which 50% by fistula or anastomotic release) and vascular (18%). The rate of FTRs was 10%. The systemic causes rate of FTR-s were 35%. The FTRs were related to the patient (ASA score 3-4: RR: 6 [1-40]; age: RR: 1.05 [1-1.1]), to the surgical procedure (laparotomy: RR: 4.5 [1.6-12]) and to the systemic causes responsible for the delay in the realization of URS (RR: 4.1 [1.4-12]).CONCLUSION:By avoiding systemic causes, more than one third of the deaths from FTR-s after colorectal surgery could be avoided.

Resume La Federation de Chirurgie Viscerale et Digestive (FCVD) a enquete sur les consequences personnelles et professionnelles des decisions prises pour faire face a la pandemie COVID 19 chez les chirurgien(ne)s de la specialite. Materiel et methodes : Du 1er mai au 11 mai 2020, 565 Chirurgien(ne)s (105 femmes) ont repondu a un questionnaire explorant 3 domaines : repercussions personnelles, retentissement sur les activites professionnelles au sein de leur(s) etablissement(s), perspectives quant a un impact ulterieur sur leur activite chirurgicale. Les Chirurgien(ne)s temoignant un mal etre severe ont repondu a un deuxieme questionnaire specifique. Resultats : Environ 75% des chirurgien(ne)s etaient impactes moralement et 10% allaient moralement et professionnellement mal. L’impact etait plus fort pour les praticiens liberaux (p=0.008). La moitie (53 %) des Chirurgien(ne)s declaraient avoir eu des cas de COVID parmi les chirurgien(ne)s et/ou anesthesistes de leur etablissement. Une reduction des activites de consultations et d’actes chirurgicaux de 70 a 100% s’est imposee pour 70% des chirurgien(ne)s, tout particulierement pour l’activite chirurgicale liberale (p=0.003). Un chirurgien sur 5 n’avait plus aucune activite chirurgicale et un sur deux a participe a des tâches non chirurgicales, plus souvent dans le secteur public (p=0.003). La majorite des chirurgien(ne)s prevoyait un impact de la pandemie sur les conditions futures de l’activite chirurgicale. Conclusion : Pour les chirurgien(ne)s, cette crise a ete / est douloureuse dans ses consequences immediates et inquietantes quant a ses consequences pour l’avenir.

BACKGROUND:The Federation of Visceral and Digestive Surgery (FCVD) is in charge in France of the continuing medical education of digestive surgeons. Since 2016 and in collaboration with SAGES, it has offered the Fundamental Use of Surgical Energy (FUSE) program as part of the continuing education for surgeons including eLearning and hands-on workshops.METHODS:The aim of this study was to evaluate the impact of the FUSE program on the participants by participating in a knowledge test and completing a survey.RESULTS:485 participants fully completed the knowledge test of 18 questions. Post-test assessment showed an increase in the mean score with respect to pre-test assessment, and the surgeons who have participated to the hands-on workshops had a better score. 304 participants filled the survey of 6 questions. The majority were satisfied by the FUSE program and felt that the objectives were achieved.CONCLUSIONS:The FUSE program developed by SAGES and adopted by the FCVD in France was very much appreciated by the participants and achieved its educational objectives. Our goal is to spread it as widely as possible to all members of the operating room team.

Le défaut de communication orientée sur la tâche à exécuter ou sur la relation inter-individu se définit comme une rupture ou une perte de fluidité dans le processus de soin. Il est responsable d’évènement indésirable associé aux soins ayant des conséquences comme le retard de prise en charge qui peuvent être de significatives à graves et parfois entraîner le décès. La connaissance des types de communication, des zones d’échanges et de ruptures de communications et les situations à risque avant pendant et après l’hospitalisation est indispensable pour la conception de solutions d’amélioration de la communication pour la sécurité du patient. Les objectifs et les outils d’améliorations ont été définis en fonction de chaque parcours de soin du patient.

BACKGROUND:Concerns are rising about the late adverse events following gastric bypass and sleeve gastrectomy. We aimed to assess, over a 7-year period, the late adverse events after gastric bypass and sleeve gastrectomy compared with matched control groups. METHODS:In this nationwide, observational, population-based, cohort study, we used data extracted from the French National Health Insurance (Système National des Données de Santé) database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009, except those who had undergone bariatric surgery in the previous 4 years before inclusion, were matched with control patients with obesity in terms of age, sex, BMI category, baseline antidiabetic therapy, and baseline insulin therapy. Exclusion criteria for the control group included cancer, pregnancy, chronic infectious disease, serious acute or chronic disease in 2008-09, or previous (2005-09) or forthcoming (2010-11) bariatric surgery. The incidence rate was calculated for each type of adverse event leading to inpatient hospital admission over a 7-year period; incidence rate ratios (with 95% CIs) were computed to compare the rate of complications among the bariatric surgery and control groups. Risks of complications during follow-up were compared using Cox proportional-hazards regression analyses. Data were analysed according to the intention-to-treat methodology. FINDINGS:From Jan 1, 2009, to Dec 31, 2009, 8966 patients who underwent bariatric surgery (7359 [82%] women; mean age 40·4 years [SD 11·3]) and 8966 matched controls (7359 [82%] women; mean age 40·9 years [11·4]) were included in analyses 4955 (55%) off 8966 patients in the bariatric surgery group had a primary gastric bypass and 4011 (45%) patients had sleeve gastrectomy. With a mean follow-up of 6·8 years (SD 0·2), mortality was lower in the gastric bypass group than in its control group (hazard ratio 0·64 [95% CI 0·52-0·78]; p<0·0001) and in the sleeve gastrectomy group than in its control group (0·38 [0·29-0·50]; p<0·0001). The gastric bypass and sleeve gastrectomy groups had higher risk than did their control groups for invasive gastrointestinal surgery or endoscopy (incidence rate ratio 2·4 [95% CI 2·1-2·7], p<0·0001, for gastric bypass vs control and 1·5 [1·3-1·7], p<0·0001, for sleeve gastrectomy vs control); for gastrointestinal disorders not leading to invasive procedures (1·9 [1·7-2·1]), p<0·0001, for gastric bypass vs control and 1·2 [1·1-1·4], p<0·0001, for sleeve gastrectomy vs control); and for nutritional disorders (4·9 [3·8-6·4], p<0·0001, for gastric bypass vs control and 1·8 [1·3-2·5], p<0·0001, for sleeve gastrectomy vs control). For psychiatric disorders, there was no significant association (1·1 [0·9-1·4], p=0·190, for gastric bypass vs control and 1·1 [0·8-1·3], p=0·645, for sleeve gastrectomy vs control), except for gastric bypass and alcohol dependence (1·8 [1·1-2·8], p=0·0124). INTERPRETATION:Despite lower 7-year mortality, patients undergoing gastric bypass or sleeve gastrectomy had higher risk of hospital admission at least once for late adverse events, except for psychiatric disorders, than did control patients, with a higher risk observed after gastric bypass than with sleeve gastrectomy. FUNDING:None.

IMPORTANCE Few large-scale long-term prospective cohort studies have assessed changes in antidiabetes treatment after bariatric surgery. OBJECTIVE To describe the association between bariatric surgery and rates of continuation, discontinuation, or initiation of antidiabetes treatment 6 years after bariatric surgery compared with a matched control obese group. DESIGN, SETTING, AND PARTICIPANTS This nationwide observational population-based cohort study extracted health care reimbursement data from the French national health insurance database from January 1, 2008, to December 31, 2015. All patients undergoing primary bariatric surgery in France between January 1 and December 31, 2009, were matched on age, sex, body mass index category, and antidiabetes treatment with control patients hospitalized for obesity in 2009 with no bariatric surgery between 2005 and 2015. EXPOSURES Bariatric surgery, including adjustable gastric banding (AGB), gastric bypass (GBP), and sleeve gastrectomy (SG). MAIN OUTCOME AND MEASURE Reimbursement for antidiabetes drugs. Mixed-effects logistic regression models estimated factors of discontinuation or initiation of antidiabetes treatment over a period of 6 years. RESULTS In 2009, a total of 15 650 patients (mean [SD] age, 38.9 [11.2] years; 84.6% female; 1633 receiving antidiabetes treatment) underwent primary bariatric surgery, with 48.5% undergoing AGB, 27.7% undergoing GBP, and 22.0% undergoing SG. Among patients receiving antidiabetes treatment at baseline, the antidiabetes treatment discontinuation rate was higher 6 years after bariatric surgery than in controls (-49.9% vs -9.0%, P <.001). In multivariable analysis, the main predictive factors for discontinuation were the following: GBP (odds ratio [OR], 16.7; 95% CI, 13.0-21.4), SG (OR, 7.30; 95% CI, 5.50-9.50), and AGB (OR, 4.30; 95% CI, 3.30-5.60) compared with no bariatric surgery, as well as insulin use (OR, 0.17; 95% CI, 0.13-0.22), dual therapy without insulin (OR, 0.38; 95% CI, 0.32-0.45) vs monotherapy, lipid-lowering treatment (OR, 0.76; 95% CI, 0.63-0.91), antidepressant treatment (OR, 0.67; 95% CI, 0.55-0.81), and age (OR, 0.96; 95% CI, 0.95-0.97) per year. For patients without antidiabetes treatment at baseline, the 6-year antidiabetes treatment initiation rate was much lower after bariatric surgery than in controls (1.4% vs 12.0%, P <.001). In multivariable analysis, protective factors were GBP (OR, 0.06; 95% CI, 0.04-0.09), SG (OR, 0.08; 95% CI, 0.06-0.11), and AGB (OR, 0.16; 95% CI, 0.14-0.20) vs controls, and risk factors were as follows: body mass index category (OR, 2.04; 95% CI, 1.68-2.47 for >= 50.0 vs 30.0-39.9 and OR, 1.68; 95% CI, 1.49-1.90 for 40.0-49.9 vs 30.0-39.9), antihypertensive treatment (OR, 1.49; 95% CI, 1.33-1.67), low income (OR, 1.43; 95% CI, 1.26-1.62), and age (OR, 1.04; 95% CI, 1.03-1.05) per year. CONCLUSIONS AND RELEVANCE Bariatric surgery was associated with a significantly higher 6-year postoperative antidiabetes treatment discontinuation rate compared with baseline and with an obese control group without bariatric surgery.

Les complications liées aux différentes sources d’énergie au bloc opératoire sont très mal connues et peu publiées malgré parfois des conséquences dramatiques pour le patient et le chirurgien responsable. L’objectif de cette étude était d’évaluer les risques liés à l’utilisation des sources d’énergie au bloc opératoire et leurs conséquences.

Thirty-day readmission after surgery has been proposed as a quality-of-care indicator. We explored the effect of postoperative rehabilitation on readmission risk after groin hernia repair. We used the French National Discharge Database to identify all index hospitalizations for groin hernia repair in 2011. Readmissions within 30 days of discharge were clinically classified in terms of their relationship to the index stay. We used logistic regression to adjust the risk of readmission for patient, procedure and hospital factors. Among 122,952 index hospitalizations for inguinal hernia repair, 3,357 (2.7%) related 30-day readmissions were recorded. Reiterated analyses indicated that readmission risk was consistently associated with patient complexity: age (per year after 60 years, OR 1.03, 95% CI 1.02–1.03, P < 0.001), hospitalization within the previous year (OR 1.56, 95% CI 1.44–1.69, P < 0.001), and increasing severity and combination of co-morbidities. Postoperative rehabilitation was identified as a protective factor (OR 0.56, 95% CI 0.46–0.69, P < 0.001). Older patients and those with greater comorbidity are at elevated risk of readmission after inguinal hernia repair. Postoperative rehabilitation may reduce this risk. Further studies are warranted to confirm the protective effect of postoperative rehabilitation.

BACKGROUND:Few studies have assessed changes in antihypertensive and lipid-lowering therapy after bariatric surgery. The aim of this study was to assess the 6-year rates of continuation, discontinuation or initiation of antihypertensive and lipid-lowering therapy after bariatric surgery compared with those in a matched control group of obese patients.METHODS:This nationwide observational population-based cohort study used data extracted from the French national health insurance database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009 were matched with control patients. Mixed-effect logistic regression models were used to analyse factors that influenced discontinuation or initiation of treatment over a 6-year interval.RESULTS:In 2009, 8199 patients underwent primary gastric bypass (55·2 per cent) or sleeve gastrectomy (44·8 per cent). After 6 years, the proportion of patients receiving antihypertensive and lipid-lowering therapy had decreased more in the bariatric group than in the control group (antihypertensives: -40·7 versus -11·7 per cent respectively; lipid-lowering therapy: -53·6 versus -20·2 per cent; both P < 0·001). Gastric bypass was the main predictive factor for discontinuation of therapy for hypertension (odds ratio (OR) 9·07, 95 per cent c.i. 7·72 to 10·65) and hyperlipidaemia (OR 11·91, 9·65 to 14·71). The proportion of patients not receiving treatment at baseline who were subsequently started on medication was lower after bariatric surgery than in controls for hypertension (5·6 versus 15·8 per cent respectively; P < 0·001) and hyperlipidaemia (2·2 versus 9·1 per cent; P < 0·001). Gastric bypass was the main protective factor for antihypertensives (OR 0·22, 0·18 to 0·26) and lipid-lowering medication (OR 0·12, 0·09 to 0·15).CONCLUSION:Bariatric surgery is associated with a good discontinuation of antihypertensive and lipid-lowering therapy, with gastric bypass being more effective than sleeve gastrectomy.

Complications related to energy sources in the operating room are not well-recognized or published, despite occasionally dramatic consequences for the patient and the responsible surgeon. The goal of this study was to evaluate the risks and consequences related to use of energy sources in the operating room. Patients and methods: Between 2009 and 2015, 876 adverse events related to health care (AERHC) linked to energy sources in the operating room were declared in the French experience feedback data base "REX". We performed a descriptive analysis of these AERHC and analyzed the root causes of these events and of the indications for non-elective repeat operations, for each energy source. Results: Five different energy sources were used, producing 876 declared AERHC: monopolar electrocoagulation: 614 (70%) AERHC, advanced bipolar coagulation (thermofusion): 137 (16%) AERHC, ultrasonic devices: 69 (8%) AERHC, traditional bipolar electrocoagulation: 32 AERHC, and cold light: 24 AERHC. The adverse events reported were skin bums (27.5% of AERHC), insulation defects (16% of AERHC), visceral burns or perforation (30% of AERHC), fires (11% of AERHC), bleeding (7.5% of AERHC) and misuse or miscellaneous causes (8% of AERHC). For the five energy sources, the root causes were essentially misuse, imperfect training and/or cost-related reasons regarding equipment purchase or maintenance. One hundred and forty-six non-elective procedures (17% of AERHC) were performed for complications related to the use of energy sources in the operating room. Conclusion: This study illustrates the risks related to the use of energy sources on the OR and their consequences. Most cases were related to persistent misunderstanding of appropriate usage within the medical and paramedical teams, but complications are also related to administrative decisions concerning the purchase and maintenance of these devices. (C) 2017 Elsevier Masson SAS. All rights reserved.

Few large long-term prospective cohorts have assessed the evolution of antidiabetic treatment after bariatric surgery (BS). The aim of our study was to study, under real life conditions and at a national level, remission and occurrence of antidiabetic treatment over 6 post-operative years after BS, compared to a matched control group, using the French national health insurance database. Each patient undergoing primary BS in France in 2009 was matched on age, sex, BMI categories and antidiabetic treatment with one control patient hospitalised for obesity in 2009 who had no BS between 2005-2015. Reimbursements of antidiabetic treatment were extracted from the French National Health Insurance database (SNIIRAM) between 2008-2015. Mixed-effects logistic regression models analysed factors of remission or occurrence of antidiabetic treatment over 6 years. In 2009, 15,650 patients (85% female; 1,633 with antidiabetic treatment) had undergone primary BS: gastric banding (AGB) 48%, gastric bypass (GBP) 28%, sleeve gastrectomy (SG) 24%. For patients with antidiabetic treatment at baseline, discontinuation of treatment at 6 years was more frequent after BS than in controls (50% vs. 9%; P<0.001). In multivariate analysis, the main predictive factors of discontinuation were overall (OR; 95%CI): GBP=16.7 (13.0-21.4); SG= 7.3 (5.5-9.5), AGB=4.3 (3.3-5.6), no baseline insulin (5.9 (4.5-7.7)) and no hypolipidemic treatment (1.5 (1.1-1.6)). For patients without antidiabetic treatment at baseline, occurrence of treatment at 6 years was much less frequent after BS than in controls (1% vs. 12%; P<0.001). All types of procedures were protective factors: GBP=0.06 (0.04-0.09), SG=0.08 (0.06-0.1), AGA=0.16 (0.14-0.19). Our large study confirms that BS leads to a significant discontinuation rate of antidiabetic treatment compared to baseline and to non-surgical obese controls over 6 post-operative years, as well as to a lower occurrence rate of antidiabetic treatment, with GBP being the most effective procedure.

Cette cohorte nationale étudie l’évolution à 6 ans de la consommation de médicaments antidiabétiques après une chirurgie bariatrique (CB) réalisée en 2009 comparée à un groupe témoin. Les 15 650 patients opérés de CB en 2009, en France, ont été suivis jusqu’en 2015 et appariés à un groupe de patients obèses morbides hospitalisés en 2009 et non opérés entre 2005–2015. Les données de remboursements ont été extraites du SNIIRAM pour 2008–2015. L’arrêt complet du traitement à 6 ans était plus fréquent après CB (50 % vs 9 % ; p < 0,001). En multivariée, les principaux facteurs associés à l’arrêt du traitement à 6 ans étaient (OR ; IC95 %) un GBP = 16,7 (13,0–21,4) et l’absence initiale d’insulinothérapie (5,8 [4,6–7,4]). Le taux d’apparition d’un traitement à 6 ans était moins fréquent chez les opérés que chez les témoins (1 % vs 12 % ; p > 0,001). En multivariée, le GBP était le meilleur facteur protecteur d’apparition de traitement antidiabétique (0,06 [0,04–0,09]). À 6 ans, la CB conduit plus souvent à l’arrêt du traitement antidiabétique et à l’absence de nouveau traitement en comparaison à un groupe témoin d’obèses non opérés. Cet impact semble plus marqué pour le GBP.

Objective: The aim of the present study was to assess the incidence, risk factors, and the impact of posthospital discharge (PHD) chemoprophylaxis on venous thromboembolism (VTE) in patients undergoing bariatric surgery (BS). Background: VTE is a major concern after BS, especially during the PHD period. No large-scale study has previously focused on the clinical value of PHD chemoprophylaxis. Methods: In this nationwide observational population-based cohort study, all data from patients undergoing BS were extracted from the French National Health Insurance database (SNIIRAM) from 1st January 2012 to 31st September 2014. Logistic regression models were used to compute odds ratios for potential risk factors for VTE occurring within 90 postoperative days (PODs). The association between use of PHD chemoprophylaxis (heparin) and VTE was also assessed. Results: The majority (56%) of the 110,824 patients had sleeve gastrectomy. VTE rates during the first 30 and 90 PODs were 0.34% and 0.51%, respectively. On multivariate analyses, the major risk factors for VTE during the first 90 PODs were history of VTE [odds ratio = 6.33 95% confidence interval (4.44–9.00)], postoperative complications [9.23 (7.30–11.70)], heart failure [2.45 (1.48–4.06)], and open surgery [2.38 (1.59–3.45)]. PHD chemoprophylaxis was delivered to 75% of patients. No use of PHD chemoprophylaxis [1.27 (1.01–1.61)] was an independent predictive factor of VTE during the first 90 PODs [in the gastric bypass group: 1.51 (1.01–2.29)). Conclusions: In the modern era of BS, this nationwide study shows a non-negligible rate of VTE especially after sleeve gastrectomy, depending on the individual risk level. Use of PHD chemoprophylaxis may decrease the risk of PHD VTE.

Context The rate of thyroid cancer is increasing in France, as well as concerns about overdiagnosis and treatment. Objectives To examine the care pathway of patients who undergo thyroid surgery in France and detect potential pitfalls. Design A large observational study based on medical reimbursements, 2009–2011. Setting Data from the Sniiram (National Health Insurance Information System). Patients Patients with thyroid surgery in 2010, classified into 4 groups: thyroid cancer, benign nodule, goitre or multiple nodules, other (hyperthyroidism, head–neck cancer). Main outcome measures Medical investigations during, prior and after thyroidectomy. Results A total of 35 367 patients underwent surgery (mean age 51 years, 80% women): 17% had a reported diagnosis of thyroid cancer, 20% benign nodule, 38% goitre or multiple nodules and 25% another diagnosis. The ratio of thyroidectomies with cancer over thyroidectomies with benign nodule was 0.8 and varied across regions. In the year preceding surgery, 82% of patients had an investigation by thyroid ultrasonography, 21% thyroid scintigraphy, 34% fine-needle aspiration cytology, 40% serum calcitonin assay and 54% serum calcium assay. In the following year, all patients with total thyroidectomy and 44% of patients with partial thyroidectomy and a diagnosis of benign nodule were taking thyroid hormone therapy. 100 patients had been reoperated for a compressive haematoma and 63 died during the first month, half of whom had been operated for cancer. Mean rates of recurrent laryngeal nerve injury and hypocalcaemia (requiring blood tests plus treatments within 4–12 months) were estimated at 1.5% and 3.4%, respectively, and were higher in the cancer group (2.3% and 5.7%). Conclusions This almost nationwide study demonstrates the suboptimal management of patients prior to thyroidectomy in France. It suggests overdiagnosis and potential harms to patients, and calls for a review of the relevance of thyroidectomy, particularly with regard to microcancers.

Lifelong medical follow-up is mandatory after bariatric surgery. The aim of this study was to assess the 5-year follow-up after bariatric surgery in a nationwide cohort of patients.All adult obese patients who had undergone primary bariatric surgery in 2009 in France were included. Data were extracted from the French national health insurance database. Medical follow-up (medical visits, micronutrient supplementation and blood tests) during the first 5 years after bariatric surgery was assessed, and compared with national and international guidelines.Some 16 620 patients were included in the study. The percentage of patients with at least one reimbursement for micronutrient supplements decreased between the first and fifth years for iron (from 27.7 to 24.5 per cent; P < 0.001) and calcium (from 14·4 to 7·7 per cent; P < 0·001), but increased for vitamin D (from 33·1 to 34·7 per cent; P < 0·001). The percentage of patients with one or more visits to a surgeon decreased between the first and fifth years, from 87·1 to 29·6 per cent (P < 0·001); similar decreases were observed for visits to a nutritionist/endocrinologist (from 22·8 to 12·4 per cent; P < 0·001) or general practitioner (from 92·6 to 83·4 per cent; P < 0·001). The mean number of visits to a general practitioner was 7·0 and 6·1 in the first and the fifth years respectively. In multivariable analyses, male sex, younger age, absence of type 2 diabetes and poor 1-year follow-up were predictors of poor 5-year follow-up.Despite clear national and international guidelines, long-term follow-up after bariatric surgery is poor, especially for young men with poor early follow-up.

Bariatric surgery is a well-accepted procedure for severe and massive obesity management. We aimed to determine trends, geographical variations, and factors influencing bariatric surgery and the choice of procedure in France in a large observational study.The Health Insurance Fund for Salaried Workers (Caisse National Assurance Maladie Travailleurs Salariés) covers about 86% of the French population. The Système National d'Information Inter-régimes de l'Assurance Maladie database contains individualized and anonymized patient data on all reimbursements for healthcare expenditure. All types of primary bariatric procedures (Roux-en-Y gastric bypass [RYGB] or omega loop, adjustable gastric banding [AGB], or longitudinal sleeve gastrectomy [LSG]) performed during 2011 to 2013 were systematically recorded. Surgical techniques performed by region of residence and age-range relative risks with 95% confidence intervals of undergoing LSG or RYGB versus AGB were computed.In 2013, LSG was performed more frequently than RYGB and AGB (57% vs 31% and 13%, respectively). A total of 41,648 patients underwent a bariatric procedure; they were predominantly female (82%) with a mean (±standard deviation) age of 40 (±12) years and a body mass index ≥40 kg/m for 68% of them. A total of 114 procedures were performed in patients younger than 18 years and 2381 procedures were performed in patients aged 60 years and older. Beneficiaries of the French universal health insurance coverage for low-income patients were more likely to undergo surgery than the general population. Large nationwide variations were observed in the type choice of bariatric surgical procedures. Significant positive predictors for undergoing RYGB compared to those for undergoing AGB were as follows: referral to a center performing a large number of surgeries or to a public hospital, older age, female gender, body mass index ≥50 kg/m, and treatment for obstructive sleep apnea syndrome, diabetes, or depression. Universal health insurance coverage for low-income patients was inversely correlated with the probability of RYGB.Differences in access to surgery have been observed in terms of the patient's profile, geographical variations, and predictors of types of procedures. Several challenges must be met when organizing the medical care of this growing number of patients, when delivering surgery through qualified centers while assuring the quality of long-term follow-up for all patients.