Introduction Sepsis after aortic root replacement (ARR) is a severe complication that results in significant postoperative mortality. To date, risk factors associated with development of sepsis after ARR have not been thoroughly studied. The objective of this study was to identify risk factors of sepsis following elective ARR using the National Inpatient Sample (NIS) database. Methods The NIS core files of the Health care Cost and Utilization Project database from 2017 to 2022 were used to identify adults (≥18 y) who underwent elective ARR. Demographic, comorbidity, and other health factors selected from the NIS dataset were analyzed to construct a multivariable logistic regression model. Results A total of 66,530 patients who underwent elective ARR between 2017 and 2022 were identified, and the incidence of sepsis was 2.1% (n = 1380). Weight loss/cachexia (odds ratio (OR) and [95% confidence interval]: 5.98 [4.27, 8.38], P < 0.001), neurologic disorders (OR: 3.08 [2.26, 4.19], P < 0.001), renal failure (OR: 2.16 [1.56, 2.99], P < 0.001), heart failure (OR: 2.11 [1.59, 2.79], P < 0.001), liver disease (OR: 2.03 [1.23, 3.36], P = 0.006), chronic lung disease (OR: 1.73 [1.26, 2.38], P = 0.001), cerebrovascular disease (OR: 1.67 [1.18, 2.35], P = 0.004), aortic dissection (OR: 1.62 [1.02, 2.57], P = 0.042), and coagulopathy (OR: 1.52 [1.16, 1.99], P = 0.003) were comorbidities associated with increased odds of sepsis development following ARR. Presence of thoracic aortic aneurysm (OR: 0.48 [0.34, 0.68], P < 0.001), hypertension (OR: 0.53 [0.39, 0.72], P < 0.001), hyperlipidemia (OR: 0.65 [0.49, 0.87], P = 0.003), and tobacco use (OR: 0.36 [0.26, 0.50], P < 0.001) were associated with decreased odds of sepsis development. Conclusions Health care professionals should be aware of the risk factors associated with the development of sepsis after ARR, as well as patient characteristics that are protective against sepsis. High risk patients should undergo preoperative optimization of modifiable risk factors to minimize postoperative sepsis risk.

BACKGROUND:Endoscopic sleeve gastroplasty (ESG) offers a less invasive alternative to sleeve gastrectomy (SG) while preserving gastric anatomy; however, comparative effectiveness data from large real-world cohorts remain limited. Using the 2023 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) follow-up file, we compared short-term weight-loss and clinical outcomes after ESG and SG. STUDY DESIGN:ESG and SG cases were identified from the 2023 MBSAQIP follow-up file. Using target trial emulation methodology, patients underwent 1:8 nearest-neighbor matching on age, sex, race, diabetes, hypertension, cardiovascular comorbidity, and highest preoperative body mass index. The primary outcome was percent weight change (%WC) from highest preoperative weight to 6 months. The primary analysis used inverse probability of censoring weighting regression to account for missing 6-month weights. Secondary outcomes included 30-day adverse events and 6-month comorbidity and laboratory outcomes. RESULTS:The matched cohort included 3,753 patients (ESG, 417; SG, 3,336). At 6 months, SG achieved greater weight loss than ESG (-18.51% ± 7.98 vs -12.33% ± 6.96; p<0.001). In inverse probability of censoring weighting regression, SG remained associated with greater %WC (ESG coefficient +7.40; 95% CI, 6.59-8.21). Absolute adverse-event rates were low in both groups. SG demonstrated more favorable comorbidity outcomes, whereas ESG was associated with higher 30-day and 6-month readmission (3.8% vs 1.6%) and reoperation (1.0% vs 0.3%) rates. CONCLUSIONS:In this target trial emulation of a national bariatric registry, SG was associated with greater 6-month weight loss and more favorable short-term comorbidity outcomes than ESG. Although ESG produced clinically meaningful weight reduction with low absolute adverse-event rates, its higher readmission and reoperation rates should be considered during procedure selection and patient counseling.

Patients undergoing ERCP with chronic kidney disease (CKD), congestive heart failure (CHF), or liver cirrhosis (LC) often experience worse outcomes. It is unclear whether these are driven by procedure-related events or underlying comorbidity. We analyzed the National Inpatient Sample to identify adult ERCP cases. High-risk comorbidities were defined as CKD, CHF, or LC. Primary outcomes were inpatient mortality and morbidity. Among 1,171,973 ERCP admissions, 267,739 (22.8

BackgroundDeep vein thrombosis and pulmonary embolism (collectively, venous thromboembolism [VTE]) cause significant morbidity after bariatric surgery. The aim of this study was to compare predictors of VTE after bariatric surgery in two national databases.MethodsThe core National Inpatient Sample (NIS) database and Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use data Files from 2016-2021 were concatenated, and elective vertical sleeve gastrectomy and Roux-en-Y gastric bypass procedures were included. Trends in VTE were derived for inpatient hospital stays (NIS and MBSAQIP) and compared and 30-day rates only available in the MBSAQIP were also derived. Preoperative and perioperative factors were identified to construct a multivariable logistic regression model to identify predictors of VTE for each dataset.Results204,866 and 986,210 patients were identified in the NIS and MBSAQIP, and postoperative inpatient VTE rates were 0.11% and 0.10% (P > 0.05), respectively. History of pulmonary embolism (NIS odds ratio [OR] and 95% confidence interval: 3.21 [1.86, 5.53], P < 0.05, MBSAQIP OR: 1.83 [1.45, 2.32], P < 0.05) and increased age (NIS OR: 1.22 [1.02,1.45], P < 0.05, MBSAQIP OR: 1.06 [1.0, 1.11], P < 0.05) were the only factors associated with higher risk of VTE in both databases. There was no difference in in-hospital rates between databases aside from 2021. The MBSAQIP 30-day VTE rate was 0.30%; hence, most (67%) incidences of 30-day VTE occurred after discharge.ConclusionsOur analysis identifies critical risk factors for VTE after bariatric surgery. Most incidences of VTE occurred after the initial hospitalization, and the MBSAQIP underestimates 2021 VTE rates.

INTRODUCTION:The National Inpatient Sample (NIS) is a comprehensive representative database for inpatient hospitalizations; the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database aggregates surgical outcomes from nationally accredited bariatric surgical programs. There has been no comparison of postoperative hemorrhage rates nor a comparison of predictors of hemorrhage between the two databases. The aim of this study was to compare trends and predictors of significant hemorrhage after bariatric surgery using two national databases. METHODS:The core NIS files of the Healthcare Cost and Utilization Project and the MBSAQIP Participant Use Data Files from 2016 to 2021 were concatenated, and vertical sleeve gastrectomy and Roux-en-Y gastric bypass procedures were included. Trends in a 3-d postoperative hemorrhage requiring blood transfusion were derived from both datasets. Demographic, comorbidity, and other health factors were analyzed to construct multivariable logistic regression models. RESULTS:Briefly, 204,866 and 1,029,979 patients were identified in the NIS and MBSAQIP, respectively, and 3-d inpatient blood transfusion rates were 0.48% and 0.64%. Anticoagulants, Black race, diabetes, and increased age were associated with higher risk of a blood transfusion in both datasets. Vertical sleeve gastrectomy had a lower transfusion risk than Roux-en-Y gastric bypass (NIS: odds ratio: 0.62; 95% confidence interval [0.53, 0.71], P < 0.05; MBSAQIP: odds ratio: 0.52 [0.49, 0.55], P < 0.05). The NIS reported consistently lower annual 3-d transfusion rates relative to the MBSAQIP. CONCLUSIONS:Health care professionals should be aware of the associated risk factors for blood transfusion after bariatric surgery. Most blood transfusions occurred during the initial hospitalization.

BACKGROUND:Obesity is increasingly linked to chronic kidney disease, and most patients with end-stage renal disease would benefit from kidney transplantation. Bariatric surgery is the most effective treatment for obesity and possibly improves postrenal transplant outcomes in patients with obesity. OBJECTIVE:To determine if a history of bariatric surgery is predictive of length of stay (LOS) after kidney transplantation. SETTING:National inpatient stays in the United States. METHODS:The National Inpatient Sample (NIS) from 2016 to 2021 was combined, and patients undergoing kidney transplantation were identified with relevant health factors recorded. Cohorts stratified by prior bariatric surgery were identified. Characteristics and outcomes were compared with Welsh t-tests and chi-squared tests. A multivariable linear regression model was created against LOS. Five groups by LOS time were formed and rates of mortality, organ rejection or failure, sepsis, adverse reaction to immunosuppressant therapy, and urinary tract infection (UTI) compared. RESULTS:Twenty-four thousand seven hundred eighty-seven patients were identified with admission for kidney transplantation and 654 (2.6%) had undergone previous bariatric surgery. Patients with a history of bariatric surgery were more frequently female, had obesity, and had diabetes, anticoagulant therapy, sleep apnea, and anxiety or depression. The linear regression modeling showed that patients with history of bariatric surgery had decreased LOS (5.6 versus 6.4 days, P < .001). Patients with increased LOS were associated with greater morbidity (P < .05). CONCLUSION:Previous bariatric surgery is associated with decreased LOS in patients undergoing kidney transplantation. Care teams should be aware of predictors of LOS, as longer LOS is associated with increased postoperative complications and hospital costs.

BACKGROUND & AIMS:Pancreatic cancer continues to have low five-year survival with late-stage diagnosis limiting surgical resection. Class III obesity is a well-established risk factor for pancreatic cancer, while bariatric surgery has been associated with reduced overall cancer incidence. However, the impact of bariatric surgery on pancreatic cancer presentation, treatment options, and outcomes remains poorly understood. We retrospectively evaluated national trends in pancreatic cancer among patients having class III obesity with and without prior bariatric surgery, focusing on metastasis, curative surgical management, and inpatient mortality. METHODS:We used the National Inpatient Sample (2016-2022), to identify adult patients hospitalized with a primary diagnosis of pancreatic cancer and a history of either bariatric surgery or class III obesity. Patients were stratified by tumor location (head vs. tail of pancreas) and matched 2:1 by age, sex, and race. Outcomes included rates of pancreatic resection (pancreaticoduodenectomy [PD] or distal pancreatectomy), metastatic disease, and inpatient mortality. Multivariable logistic regression was used to adjust for comorbidities, socioeconomic factors, and hospital characteristics. RESULTS:Among 3853 matched patients with head-of-pancreas tumors and 1408 with tail tumors, those with prior bariatric surgery had lower odds of undergoing PD (26.4 % vs. 31.1 %; adjusted odds ratio [aOR] 0.81; 95 % CI: 0.71-0.93), higher likelihood of presenting with metastatic disease (aOR 1.70; 95 % CI: 1.33-2.18), reduced inpatient mortality (1.5 % vs. 3.1 %; aOR 0.36; 95 % CI: 0.20-0.63), fewer metabolic comorbidities, and shorter lengths of stay. In patients with tail tumors, similar trends were observed, though distal pancreatectomy rates were not significantly different after adjustment. CONCLUSION:Patients with prior bariatric surgery often present with more advanced pancreatic head tumors which may reflect diagnostic challenges from altered anatomy, likely leading to higher metastatic rates. Despite this, they have lower inpatient mortality and better metabolic profiles. Early referral and specialized diagnostic techniques can improve staging and outcomes. As bariatric surgery is more often encountered, standardized clinical guidelines are needed.

OBJECTIVE:We assessed the impact of medical weight management (MWM; lifestyle modification ± obesity medications) on major adverse cardiovascular events (MACE) compared to metabolic and bariatric surgery (MBS) and usual care (UC). METHODS:We retrospectively analyzed electronic health records of adults with body mass index (BMI) ≥35 kg/m² and type 2 diabetes mellitus (T2D) at an academic health center from 2010 to 2021. The MWM group was propensity score matched on common confounders 1:1 (versus MBS) and 1:5 (versus UC). The primary outcome was a six-component MACE (all-cause mortality, coronary artery events, cerebrovascular events, heart failure, atrial fibrillation, and nephropathy).  Results: Among 2,100 patients (300 MWM, 300 MBS, and 1,500 UC), baseline characteristics were similar among groups. During a median 3.2-year follow-up (range 0-11), the adjusted hazard ratio (aHR) for MACE for MWM versus MBS was 1.61 (0.98-2.65, p=0.06); for MBS versus UC, aHR 0.66 (0.43-1.02, p=0.06); and there was no difference in MWM versus UC, aHR 1.07 (0.77-1.49, p=0.68). CONCLUSIONS:No statistically significant differences in MACE risk were found between those receiving MWM versus UC; there was a trend towards fewer MACE events in those receiving MBS. These findings must be validated in future studies, given that more effective weight loss medications (e.g., semaglutide, tirzepatide) were not available.

BACKGROUND:The development of cholelithiasis and its subsequent complications are a known risk after vertical sleeve gastrectomy (VSG) due to rapid weight loss. Although controversial, concomitant cholecystectomy (CCY) at the time of bariatric surgery has been proposed, with multiple studies investigating simultaneous CCY with Roux-en-Y gastric bypass. Despite VSG being the most commonly performed bariatric surgery in the United States (US) and globally, few studies have investigated the simultaneous VSG and CCY. Therefore, this study aimed to explore the trends of concomitant VSG and CCCY and investigate the outcomes in the US and Canada using a large database. METHODS:This was a retrospective study that used data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. The database from 2015 to 2023 was queried using appropriate Current Procedural Terminology codes to identify patients who underwent VSG. This was further stratified according to patients who underwent simultaneous CCY. The demographics and characteristics of the VSG + CCY group and the VSG alone group were obtained. Logistic regression analysis was performed for the primary outcomes of 30-day morbidity, 30-day readmission, and 30-day reoperation with CCY as an independent variable. The secondary outcomes included length of stay (LOS), mortality, and need for transfusion within 72 h postoperatively. RESULTS:A total of 1,140,484 patients underwent VSG between 2015 and 2023, of whom 40,780 (3.6%) had concurrent CCY. The average ages were 44.5 years in the concurrent VSG + CCY group and 43.2 years in the VSG alone group. Simultaneous surgery was more common in female patients than in those who underwent VSG alone (83.1% vs 80.5%, respectively; P <.001). In patients who underwent VSG, concomitant CCY was not an independent risk factor for increased odds of 30-day morbidity (1.2 [95% CI, 0.99-1.46]; P =.07). However, it was an independent risk factor for increased odds of 30-day readmission (1.39 [95% CI, 1.31-1.47]; P <.05) and increased odds of undergoing reoperation within 30 days (1.63 [95% CI, 1.48-1.79]; P <.05). Patients who underwent concomitant VSG + CCY had a significantly increased rate of mortality, LOS, and transfusion need within 72 h of surgery compared with those who underwent VSG alone. CONCLUSION:Concomitant VSG + CCY was associated with increased odds of 30-day readmission and 30-day reoperation compared with VSG alone. In addition, concomitant surgery was associated with a longer LOS, an increased rate of transfusion postoperatively, and increased mortality compared with VSG alone.

Background Venous waveform analysis is an emerging technique to estimate intravascular fluid status by fast Fourier transform deconvolution. Fluid status has been shown proportional to f0, the amplitude of the fundamental frequency of the waveform’s cardiac wave upon deconvolution. Using a porcine model of distributive shock and fluid resuscitation, we sought to determine the influence of norepinephrine on f0 of the central venous waveform.Methods Eight pigs were anesthetized, catheterized and treated with norepinephrine after precipitation of endotoxemic hypotension, and subsequent fluid resuscitation to mimic sepsis physiology. Hemodynamic parameters and central venous waveforms were continually transduced throughout the protocol for post-hoc analysis. Central venous waveform f0 before, during and after norepinephrine administration were determined using Fourier analysis.Results Heart rate increased, while central venous pressure, pulmonary capillary wedge pressure and stroke volume decreased throughout norepinephrine administration (p < 0.05). Mean f0 at pre-norepinephrine, and doses 0.05, 0.10, 0.15, 0.20 and 0.25 mcg/kg/min, were 2.5, 1.4, 1.7, 1.7, 1.6 and 1.4 mmHg2, respectively (repeated measures ANOVA; p < 0.001). On post-hoc comparison to pre-norepinephrine, f0 at 0.05 mcg/kg/min was decreased (p = 0.04).Conclusions As the performance of f0 was previously characterized during fluid administration, these data offer novel insight into the performance of f0 during vasopressor delivery. Central venous waveform f0 is a decreased with norepinephrine, in concordance with pulmonary capillary wedge pressure. This allows contextualization of the novel, venous-derived signal f0 during vasopressor administration, a finding that must be understood prior to clinical translation.

Background: The vertical banded gastroplasty (VBG) is a historic restrictive bariatric operation often requiring further surgery. In this investigation utilizing the 2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national dataset, we aim to better define the outcomes of VBG conversions.Methods: We queried the 2021 MBSAQIP dataset for patients who underwent a conversion from a VBG to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Demographics, comorbidities, laboratory values, and additional patient factors were examined. Rates of key consequential outcome measures 30-day readmission, reoperation, reintervention, mortality, and a composite endpoint (at least 1 of the 4) were further calculated.Results: We identified 231 patients who underwent conversion from VBG to SG (n = 23), RYGB (n = 208), or other anatomy (n = 6), of which 93% of patients were female, and 22% of non-white race. The median age was 56 years and body-mass index (BMI) was 43 kg/m2. The most common surgical indications included weight considerations (48%), reflux (25%), anatomic causes (eg, stricture, fistula, and ulcer; 10%), and dysphagia (6.5%). Thirty-day morbidity rates included reoperation (7.8%), readmission (9.1%), reintervention (4.3%), mortality (.4%), and the composite endpoint (15%). Upon bivariate analysis, we did not identify any specific risk factor for the 30-day composite endpoint.Discussion: One-stage VBG conversions to traditional bariatric anatomy are beset with higher 30-day morbidity relative to primary procedures. Additional MBSAQIP data will be required for aggregation, to better characterize the risk factors inherent in these operations.

BACKGROUND:Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass is indicated primarily for unsatisfactory weight loss or gastroesophageal reflux disease (GERD). This study aimed to use a comprehensive database to define predictors of 30-day reoperation, readmission, reintervention, or mortality. An artificial neural network (ANN) was employed to optimize prediction of the composite endpoint (occurrence of 1+ morbid event).METHODS:Areview of 8895 patients who underwent conversion for weight-related or GERD-related indications was performed using the 2021 MBSAQIP national dataset. Demographics, comorbidities, laboratory values, and other factors were assessed for bivariate and subsequent multivariable associations with the composite endpoint (P ≤ .05). Factors considered in the multivariable model were imputed into a three-node ANN with 20% randomly withheld for internal validation, to optimize predictive accuracy. Models were compared using receiver operating characteristic (ROC) curve analysis.RESULTS:39% underwent conversion for weight considerations and 61% for GERD. Rates of 30-day reoperation, readmission, reintervention, mortality, and the composite endpoint were 3.0%, 7.1%, 2.1%, .1%, and 9.1%, respectively. Of the nine factors associated with the composite endpoint on bivariate analysis, only non-white race (P < .001; odds ratio 1.4), lower body-mass index (P < .001; odds ratio .22), and therapeutic anticoagulation (P = .001; odds ratio 2.0) remained significant upon multivariable analysis. Areas under ROC curves for the multivariable regression, ANN training, and validation sets were .587, .601, and .604, respectively.DISCUSSION:Identification of risk factors for morbidity after conversion offers critical information to improve patient selection and manage postoperative expectations. ANN models, with appropriate clinical integration, may optimize prediction of morbidity.

Background: Patients taking beta-blockers (BBs) commonly experience weight gain. There is limited research exploring how BBs impact weight loss after bariatric surgery. Objectives: We examined how BBs impact 12 -month weight loss in patients undergoing sleeve gastrectomy (SG) or Roux -en -Y gastric bypass (RYGB). Setting: Large midwest health system. Methods: We reviewed health records of SG and RYGB patients (2011-2022) and categorized them by BB usage (none, pre-, post-, or pre- and postoperative). Multivariable linear regression models examined the relation between BB use, percent total body weight loss (%TBWL), and percent excess body mass index lost (%EBMIL). Results: A total of 889 individuals (SG, n = 485; RYGB, n = 404) had complete data. RYGB led to greater %TBWL compared to SG (31% versus 26%, P < .01) and greater %EBMIL (79% versus 64%, P < .01). BB status did not significantly affect 12 -month %TBWL or %EBMIL. Conclusions: BB use may not significantly affect weight loss 12 months after bariatric surgery. This finding could enable physicians to prescribe BBs for improved blood pressure control in bariatric surgery patients with less concern of blunting weight loss. Longer term follow-up with a larger sample size would be an important next step to better characterize the relationship between BB usage and bariatric surgery. (Surg Obes Relat Dis 2023;19:1415-1420.) (c) 2023 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.

Understanding factors that increase risk of both mortality and specific measures of morbidity after duodenal switch (DS) is important in deciding to offer this weight loss operation. Artificial neural networks (ANN) are computational deep learning approaches that model complex interactions among input factors to optimally predict an outcome. Here, a comprehensive national database is examined for patient factors associated with poor outcomes, while comparing the performance of multivariate logistic regression and ANN models in predicting these outcomes. 2907 DS patients from the 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were assessed for patient factors associated with the previously validated composite endpoint of 30-day postoperative reintervention, reoperation, readmission, or mortality using bivariate analysis. Variables associated (P ≤ 0.05) with the endpoint were imputed in a multivariate logistic regression model and a three-node ANN with 20