BACKGROUND:The incidence of bariatric surgery in younger adults, and subsequently conversional surgery, is increasing. OBJECTIVES:We aim to describe patients ≤40 requiring conversion, operative details, and complications associated with different procedures. SETTING:MBSAQIP centers (United States and Canada). METHODS:We included patients ≤40 years from 2020 to 2022 undergoing a conversion procedure to sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileal bypass (SADI-S), or biliopancreatic diversion-duodenal switch (BPD/DS). Baseline characteristics and bivariate complication rates were compared. Multivariate models were generated for 30-day complication for all patients undergoing conversion surgery from index adjustable gastric banding (AGB) or SG. RESULTS:Of 13,486 patients, 842 were converted to SG, 9812 to RYGB, 549 to SADI-S, and 2283 to BPD/DS. The most common reason for conversion to RYGB was gastroesophageal reflux disease (GERD) (48.7%) and to SADI-S and BPD/DS was insufficient weight loss/regain (89.6% and 88.1%, respectively). On multivariate analysis, conversion to RYGB (adjusted odds ratio [aOR] 2.14) and BPD/DS (aOR 2.30) were associated with increased risk compared to SG. After controlling for initial operation, conversion of AGB to RYGB had a higher likelihood of having 30-day serious complication compared to SG (aOR 2.18). For patients with an index SG, conversion to BPD/DS carried similar likelihood of 30-day complication to RYGB (aOR .78, P = .302), while conversion to SADI-S carried lower likelihood (aOR .47, P = .031). CONCLUSION:Each conversion surgery is associated with differing rates of complications, and conversion from index AGB to SG versus RYGB and from index SG to SADI-S versus RYGB or BPD/DS may be associated with fewer complications.

Barrett’s esophagus (BE) is a metaplastic, premalignant condition that can develop following sleeve gastrectomy (SG). While various treatment modalities exist for management of post-SG BE, conversion to Roux-en-Y gastric bypass (RYGB) can be an effective option which can also improve gastroesophageal reflux disease (GERD). However, the effectiveness of RYGB for resolving BE has not been rigorously studied. This systematic review evaluates the outcomes of BE in patients converted from SG to RYGB. A comprehensive literature search was conducted in Ovid MEDLINE, Ovid Embase, PubMed, and Cochrane Library. Studies reporting BE onset following SG and subsequent RYGB conversion were included. Data extracted included patient demographics, Prague classification, dysplasia status, time from SG to BE diagnosis and time to RYGB conversion, and resolution of BE post-RYGB. The validated MINORS tool was used to assess the quality and risk of bias of reviewed studies. A total of 4 studies were included, comprising 21 patients who underwent conversion from SG to RYGB with BE. The weighted mean age at RYGB was 46.7 ± 13.8 years, with an initial BMI of 44.7 ± 2.7 kg/m2 and post-SG BMI of 32.5 ± 6.9 kg/m2. The time for conversion between SG and RYGB occurred at an average of 58 ± 19.31 months. BE resolution was observed in 81

Prophylactic drain use during primary bariatric surgeries continues despite previous literature cautioning against their routine use. Modern drain utilization and associated outcomes remain largely poorly studied which limits selective utilization and perhaps may lead to excess morbidity and healthcare resource utilization. This study aimed to reassess current trends of drain use in primary bariatric procedures, factors driving surgeons to place drains, and patient outcomes associated with drain placement. Patients undergoing the most common primary bariatric surgery operations from 2020 to 2022 were included using the Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database. Two cohorts were created, a drain placed (DP) cohort and no drain (ND) cohort, which were then compared in terms of baseline characteristics, rates of complications, and length of stay. Multivariate modeling was performed to assess the effect of drains on various complications and factors associated with drain placement. Of 526,723 included patients, drain utilization decreased across operative years (8.7

Background: Drains are often placed during bariatric procedures; however, their use in conversional or revisional bariatric surgery (CRBS) has not been thoroughly explored. Our study sought to identify the frequency of drain placement in CRBS, and characterize factors associated with drain placement and their influence on 30-day serious complications. Methods: Patients undergoing CRBS between 2020 and 2022 were included from the MBSAQIP database. Patients were placed into drain placed (DP) versus no drain (ND) cohorts and baseline characteristics and complication rate were compared. Multivariable logistic regression models were used to identify independent predictors of drain placement and complications. Results: of 64,495 included patients, drains were placed in 19.1% in 2020; this was down to 14.4% in 2022. Drain placement was associated with increased risk of multiple complications such as hemorrhage, readmission, surgical site infection, and gastrointestinal bleeding. On multivariate analysis, drain placement was an independent predictor of serious complications (aOR 1.45, p < 0.001), anastomotic leak (aOR 2.25, p < 0.001), organ space infection (aOR 2.12, p < 0.001), and reoperation (aOR 1.37, p < 0.001), as well as excess LOS (aOR 2.06, p < 0.001). Predictors of drain placement include older age, higher BMI, smoking status, history of venous thromboembolism, and procedural factors, such as undergoing non-sleeve revisional surgery or having an intraoperative leak test. Conclusions: Drain placement during CRBS surgical procedures is common and more likely in higher risk patients and anastomotic revisional procedures. Though the reasons for drain placement were not available, these data suggest that surgeons should be judicious in selecting patients for drain placement due to its association with increased LOS and postoperative morbidity in CRBS.

Biliopancreatic diversion-duodenal switch (BPD-DS) procedures are being performed more often for patients with higher metabolic burden. These patients routinely get a concomitant sleeve gastrectomy. However, the effect on postoperative GERD has not been clearly elucidated. We performed a systematic review and meta-analysis assessing the course of postoperative GERD in patients undergoing BPD-DS using a random effects model with restricted maximum likelihood. A comprehensive search of Ovid MEDLINE, Ovid Embase, Scopus, Web of Science Core Collection, and Cochrane Library (via Wiley) was performed. Included studies discussed BPD-DS, postoperative GERD or related outcomes and had a sample size > 5. Of 618 unique results, 14 studies were included, containing 1832 patients. Mean age and initial BMI were 44.6 and 51.2. Most patients were female (71

INTRODUCTION:Bariatric surgery is primarily performed using minimally invasive techniques. Intraoperative conversion to open is associated with increased complications. This study aimed to provide a contemporary overview of frequency of conversion to open, compare complication rates and determine factors associated with conversion. METHODS:The MBSAQIP database from 2020 to 2022 was analyzed to identify two cohorts; those who underwent a minimally invasive approach and those who required conversion to open. Patients undergoing primary sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS) and single anastomosis duodenal-ileal bypass (SADI) were included. Univariate analysis was performed to characterize differences and assess for rate of complications between cohorts. Multivariate logistic regression was performed to determine factors associated with conversion and 30-day serious complications. RESULTS:A total of 524 224 patients were identified of which 181 (0.03%) required conversion to open. Factors associated with increased risk of conversion to open included age, BMI, lower albumin, sleep apnea, undergoing RYBG or BPD-DS (vs. SG) and previous foregut surgery. Patients converted were more likely to have 30-day reoperation, reintervention, or readmission on bivariate analysis. Conversion to open was also an independent predictor of serious complications on multivariate analysis. CONCLUSION:Conversion to open in bariatric surgery is rare but associated with significant increased risk of postoperative complications. Patients at increased risk may benefit from preoperative risk mitigation, such as those undergoing BPD-DS or RYGB, with sleep apnea, or with a history of previous foregut surgery.

Background: The adoption of robotic bariatric surgery has increased dramatically over the last decade. While outcomes comparing bariatric and laparoscopic approaches are debated, little is known about patient factors responsible for the growing delivery of robotic surgery. A better understanding of these factors will help guide the planning of bariatric delivery and resource allocation. Methods: Data were extracted from the MBSAQIP registry from 2020 to 2021. The patient population was organized into primary robot-assisted sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) versus those who underwent laparoscopic procedures. Bivariate analysis and multivariable logistic regression modeling were conducted to characterize cohort differences and identify independent patient predictors of robotic selection. Results: Of 318,151, 65,951 (20.7%) underwent robot-assisted surgery. Patients undergoing robotic procedures were older (43.4 ± 11.8 vs. 43.1 ± 11.8; p < 0.001) and had higher body mass index (BMI; 45.4 ± 7.9 vs. 45.0 ± 7.6; p < 0.001). Robotic cases had higher rates of medical comorbidities, including sleep apnea, hyperlipidemia, gastroesophageal reflux disease (GERD), and diabetes mellitus. Robotic cases were more likely to undergo RYGB (27.4% vs. 26.4%; p < 0.001). Robotic patients had higher rates of numerous complications, including bleed, reoperation, and reintervention, resulting in higher serious complication rates on multivariate analysis. Independent predictors of robotic selection included increased BMI (aOR 1.02), female sex (aOR 1.04), GERD (aOR 1.12), metabolic dysfunction, RYGB (aOR 1.08), black racial status (aOR 1.11), and lower albumin (aOR 0.84). Conclusions: After adjusting for comorbidities, patients with greater metabolic comorbidities, black racial status, and those undergoing RYGB were more likely to receive robotic surgery. A more comprehensive understanding of patient factors fueling the adoption of robotic delivery, as well as those expected to benefit most, is needed to better guide healthcare resources as the landscape of bariatric surgery continues to evolve.

Small bowel obstruction (SBO) after bariatric surgery is an uncommon but important complication. We sought to characterize bariatric surgery patients who developed SBO, to compare 30-day complications, and to determine the influence of patient and procedure factors on the development of SBO. All data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database using the 2020 operative year. Multivariable logistic regression modelling was used to determine the influence of patient and operative factors on the development of SBO. Of a total of 142 111 patients, 408 (0.3

Background: The use of a single anastomosis duodeno-ileal bypass (SADI) as a revisional procedure in patients with pre-operative GERD is not well understood. Thirty-day outcomes in patients with pre-existing GERD undergoing revision with an SADI have not been previously reported. Methods: The Metabolic and Bariatric Accreditation and Quality Improvement Program registry was consulted to identify patients undergoing revisional bariatric surgery with an SADI between 2020 and 2021. Our analysis sought to determine if preoperative GERD had significant impact on thirty-day outcomes. Bivariate and multivariable logistic regression analyses were used to identify independent predictors of 30-day morbidity. Results: Preoperative GERD was seen in 342 patients (36.7%). Preoperative GERD was not associated with anastomotic leak (2.5% non-GERD cohort vs. 1.2% GERD cohort; p = 0.2) nor bleeding (1% non-GERD cohort vs. 1.8% GERD cohort; p = 0.33). There was no difference in thirty-day readmission (5.6% vs. 5.9%, p = 0.9), reintervention (2.4% vs. 1.2%, p = 0.2), or reoperation (3.6% vs. 2.05%; p = 0.19) rates. The multivariable regression analysis revealed that a history of myocardial infarction was associated with a significantly elevated risk of serious complication (OR 12.2; 95% CI 2.79-53.23; p = 0.001), as was dyslipidemia (OR 2.2; 95% CI 1.04-4.56; p = 0.04). Conclusions: Pre-operative GERD does not have any association with anastomotic leak, bleeding, thirty-day readmission, reintervention, or reoperation in patients undergoing revisional bariatric surgery to SADI. A history of myocardial infarction and dyslipidemia are independent predictors of post-operative thirty-day morbidity, irrespective of the presence of preoperative GERD.

Microbial-based therapeutics in clinical practice are of considerable interest, and a recent study demonstrated fecal microbial transplantation (FMT) followed by dietary fiber supplements improved glucose homeostasis. Previous evidence suggests that donor and recipient compatibility and FMT protocol are key determinants, but little is known about the involvement of specific recipient factors. Using data from our recent randomized placebo-control phase 2 clinical trial in adults with obesity and metabolic syndrome, we grouped participants that received FMT from one of 4 donors with either fiber supplement into HOMA-IR responders (n = 21) and HOMA-IR non-responders (n = 8). We further assessed plasma bile acids using targeted metabolomics and performed subgroup analyzes to evaluate the effects of recipient parameters and gastrointestinal factors on microbiota engraftment and homeostatic model assessment of insulin resistance (HOMA2-IR) response. The baseline fecal microbiota composition at genus level of recipients could predict the improvements in HOMA2-IR at week 6 (ROC-AUC = 0.70). Prevotella was identified as an important predictor, with responders having significantly lower relative abundance than non-responders (p = .02). In addition, recipients displayed a highly individualized degree of microbial engraftment from donors. Compared to the non-responders, the responders had significantly increased bacterial richness (Chao1) after FMT and a more consistent engraftment of donor-specific bacteria ASVs (amplicon sequence variants) such as Faecalibacillus intestinalis (ASV44), Roseburia spp. (ASV103), and Christensenellaceae spp. (ASV140) (p < .05). Microbiota engraftment was strongly associated with recipients' factors at baseline including initial gut microbial diversity, fiber and nutrient intakes, inflammatory markers, and bile acid derivative levels. This study identified that responders to FMT therapy had a higher engraftment rate in the transplantation of specific donor-specific microbes, which were strongly correlated with insulin sensitivity improvements. Further, the recipient baseline gut microbiota and related factors were identified as the determinants for responsiveness to FMT and fiber supplementation. The findings provide a basis for the development of precision microbial therapeutics for the treatment of metabolic syndrome.

Background: The need for surgical management of severe obesity in the context of inflammatory bowel disease (IBD) is becoming an increasingly common clinical scenario, yet has been met with significant reservation due to the paucity of current data from which to inform evidence-based clinical decision making. The aim of our study was to perform a systematic review to characterize and evaluate the safety and efficacy of bariatric surgery in IBD patients. Methods: A medical librarian developed and executed comprehensive searches on November 2, 2021. The population of interest was adult subjects (>18 years) diagnosed with inflammatory bowel disease (IBD) undergoing any type of bariatric surgery. Meta-analysis was used to evaluate outcomes using RevMan 5.4.1. Results: A total of 330 687 patients were identified within the 11 studies included. Within all included studies there were 1595 patients with IBD. Patients had a mean weighted age of 46.0, with a female predominance (n = 1287, 80.7%). The mean duration of follow up was 39.7 months. Metabolic and anthropometric outcomes were only reported in noncomparative studies evaluating only patients with IBD, limiting the ability to complete meta-analysis. Meta-analysis revealed that IBD was associated with increased rates of postoperative complications (RR 2.14; 95% CI 1.87-2.44; P < .00001) in comparison to controls without IBD. Conclusion: While bariatric surgery presents an effective weight loss option for patients with IBD, these patients are associated with higher rates of postoperative complications. This work highlights the need to better delineate the effect of bariatric procedures for patients with IBD with respect to both metabolic and IBD-related outcomes.

Patients undergoing bariatric surgery experience substantial risk of pre- and postoperative substance use. Identifying patients at risk for substance use using validated screening tools remains crucial to risk mitigation and operative planning. We aimed to evaluate proportion of bariatric surgery patients undergoing specific substance abuse screening, factors associated with screening and the relationship between screening and postoperative complications. The 2021 MBSAQIP database was analyzed. Bivariate analysis was performed to compare factors between groups who were screened for substance abuse versus non-screened, and to compare frequency of outcomes. Multivariate logistic regression analysis was performed to assess the independent effect of substance screening on serious complications and mortality, and to assess factors associated with substance abuse screening. A total of 210, 804 patients were included, with 133,313 (63.2

Endoscopic plication offers an alternative to surgical fundoplication for treatment of gastroesophageal reflux disease (GERD). This systematic review and meta-analysis evaluate outcomes following endoscopic plication compared to laparoscopic fundoplication. Systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted in September 2022. Study followed PRISMA guidelines. Studies comparing endoscopic plication to laparoscopic fundoplication with n > 5 were included. Primary outcome was PPI cessation, with secondary outcomes including complications, procedure duration, length of stay, change in lower esophageal sphincter (LES) tone, and DeMeester score. We reviewed 1544 studies, with five included comparing 105 (46.1

We sought to characterize the prevalence and subsequent impact of pre- and post-operative COVID-19 diagnosis on bariatric surgery outcomes. COVID-19 has transformed surgical delivery, yet little is known regarding its implications for bariatric surgery. The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was evaluated with three cohorts described: those diagnosed with COVID-19 pre-operatively (PRE), post-operatively (POST), and those without a peri-operative COVID-19 (NO) diagnosis. Pre-operative COVID-19 was defined as COVID-19 within 14 days prior to the primary procedure while post-operative COVID-19 infection was defined as COVID-19 within 30 days after the primary procedure. A total of 176,738 patients were identified, of which 174,122 (98.5

With expansion of bariatric surgery indications to include Asian patients with diabetes and body mass index (BMI) ≥ 27.5, or BMI ≥ 32.5, it is important to characterize Asian patient population undergoing bariatric surgery and assess their postoperative outcomes. This retrospective study analyzed the 2015–2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All patients undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) who self-reported as Asian or White race were included. The primary outcomes were to characterize the Asian race population in North American and to identify if Asian race was associated with serious complications or mortality at 30 days. Overall, 594,837 patients met inclusion, with 4229 self-reporting Asian racial status. Patients of Asian race were younger (41.8 vs 45.5 years, p < 0.001) and had a lower BMI (42.8 vs 44.7 kg/m2 p < 0.001) than White patients. They were also more likely to have insulin dependent diabetes (10.9

Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes. Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity. 4412 patients required revisional surgery for GERD, encompassing 24

COVID-19 resulted in dramatic changes to the delivery of bariatric surgery; however, the lasting effect on current and future delivery remains uncharacterized. We sought to characterize differences and trends in bariatric surgery care and outcomes between 2020 and 2021. The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 902 centers in North America. The MBSAQIP database was evaluated, including patients undergoing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) with two cohorts described: those receiving surgery in 2020 and those in 2021. Patient selection, operative techniques, and outcomes were compared using bivariate analysis. Multivariable modelling evaluated factors including operative year, independently associated with serious complications and mortality. We evaluated 349,209 patients, with 154,960 (44.4% undergoing bariatric surgery during 2020 compared to 194,249 (55.6%) in 2021. This represents a 20.2% year-to-year increase in total cases, and a 20.7% increase in cases per center (178.5 cases/center in 2020 vs. 215.4 cases/center in 2021). Patients receiving bariatric surgery during 2021 were statistically younger with fewer comorbidities compared to 2020; however, differences were small and groups appeared clinically similar. Length of stay continued to decrease (1.4 ± 1.1 days 2020 vs. 1.3 ± 1.2 days 2021, p < 0.001), yet post-operative outcomes remained similar. Bariatric surgical volumes have increased but may still remain inadequate to meet demand, while trends towards selecting younger, healthier patients for bariatric surgery continue. Efforts to recover from the effects of COVID-19 are ongoing, and long-term evaluation of outcomes following these changes will remain important.

BACKGROUND:The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) Bariatric Surgical Risk/Benefit Calculator was developed to provide patient-specific information to assist surgical decision-making. To date, no study has characterized which patients are being evaluated with this tool. OBJECTIVE:We sought to characterize the use and impact of the MBSAQIP calculator. SETTING:MBSAQIP collects data from 955 centers in North America. METHODS:The 2021 MBSAQIP database was evaluated for the use of the calculator on preoperative counseling for patients undergoing bariatric surgery. Patient characteristics, operative techniques, and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including use of the calculator independently associated with serious complications and mortality. RESULTS:Our study included 210,710 patients, 35,158 (16.7%) of whom were evaluated using the calculator. Patients with whom the calculator was used preoperatively were older (43.8 ± 11.6 yr versus 43.6 ± 11.7 yr; P < .001) and were more likely to have insulin-dependent diabetes, hypertension, gastroesophageal reflux disease, renal insufficiency, and sleep apnea. More patients underwent Roux-en-Y gastric bypass in the calculator cohort compared with the cohort that did not use the calculator (29.6% versus 28.6%; P < .003). The rate of serious complication was significantly less in the calculator cohort (3.1% versus 3.4%; P < .030). Multivariable modeling evaluating serious complications showed that use of the calculator was independently associated with reduced risk of serious complications (odds ratio .87, CI .82-.93, P < .001) but was not associated with mortality. CONCLUSION:The use of the risk calculator may help to reduce the incidence of complications by opening a dialogue between healthcare professionals and patients, setting realistic expectations, and identifying modifiable risk factors.

It is important to appropriately risk stratify bariatric surgery patients, as these patients often have obesity-related comorbidities which can increase postoperative complication risk but also benefit the most from bariatric surgery. We aimed to evaluate the utility of risk stratification using ASA class for bariatric surgery patients and assessed predictive factors of postoperative complications. The 2020 MBSAQIP database was analyzed, and an ASA-deemed high-risk cohort (class IV) and normal-risk (ASA class II and III) cohort were compared. Univariate analysis was performed to characterize differences between cohorts and to compare complication rates. Multivariate logistic regression analysis was performed to determine factors associated with increased odds of postoperative complications. We evaluated 138 612 patients with 5380 (3.9

Revisional bariatric surgery in an option for patients who experience weight regain or inadequate weight loss after primary elective bariatric procedures. However, there is conflicting data on safety outcomes of revisional procedures. We aim to characterize patient demographics, procedure type, and safety outcomes for those undergoing revisional compared to initial bariatric interventions to guide management of these patients. The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) registry was analyzed, comparing primary elective to revisional bariatric procedures for inadequate weight loss. Bivariate analysis was performed to determine between group differences. Multivariable logistic regression determined factors associated with serious complications or mortality. We evaluated 158,424 patients, including 10,589 (6.7