BACKGROUND:Obesity contributes to chronic inflammation and estrogen dysregulation, mechanisms linked to increased breast cancer (BC) risk and recurrence, particularly in postmenopausal women. Bariatric surgery and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are effective weight-loss interventions, but their comparative impact on BC outcomes remains unclear. This study compared long-term overall survival (OS) and locoregional recurrence (LRR) among postmenopausal BC patients with obesity treated with GLP-1RAs, bariatric surgery, or both. METHODS:Using the TriNetX Network, a real-world federated research database of de-identified electronic records from multiple health care organizations, we identified women aged ≥50 years with BMI ≥30 kg/m² and stage 0-III BC. Study 1 compared patients who initiated GLP-1RA therapy ≥6 months after BC diagnosis with those who underwent bariatric surgery during the same interval. Study 2 compared patients who received both bariatric surgery and GLP-1RA therapy with those who underwent surgery alone. Propensity score matching (1:1) was performed for age, BMI, tumor stage, receptor status, adjuvant therapy, other cancers, and comorbidities. Outcomes included OS and LRR, assessed from 30 days to 10 years after the index event (bariatric surgery or GLP-1RA initiation). Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using Cox proportional hazards models. RESULTS:In Study 1, 22,532 GLP-1RA users and 3468 bariatric surgery patients were identified; 3438 were matched in each cohort. 10-year OS was similar (87% vs. 83%), yet GLP-1RA users experienced significantly lower instantaneous mortality risk (HR 0.57, 95% CI: 0.45-0.73), indicating fewer or delayed deaths over time. LRR occurred in 1.8% vs. 4.7% (HR 0.52, 95% CI: 0.39-0.70), also favoring GLP-1RA therapy.In Study 2, 1220 patients underwent both bariatric surgery and GLP-1RA therapy and 3468 underwent surgery alone; 1129 were matched per group. The combination group showed higher OS (91% vs. 80%; HR 0.44, 95% CI: 0.29-0.67) and lower LRR (2.5% vs. 5.8%; HR 0.52, 95% CI: 0.33-0.81). CONCLUSIONS:Among postmenopausal women with obesity and stage 0-III BC, GLP-1RA therapy was associated with improved OS and lower LRR compared with bariatric surgery alone. Combination therapy achieved the most favorable oncologic outcomes, suggesting a potential synergistic effect. The advantage observed with GLP-1RAs may reflect oncologic effects beyond weight loss, potentially through anti-inflammatory, insulin-modulating, or other metabolic pathways. These findings support further investigation into the underlying biological mechanisms and potential role of GLP-1RAs in oncology.

Stapled and hand-sewn techniques dominate gastrointestinal anastomotic procedures. These techniques are effective but not without flaws. Retained foreign bodies, pathways from mucosa to serosa, and increased scar tissue are some of the drawbacks, and can lead to postoperative complications. The GI Windows Flexagon™ system utilizes self-forming magnets (SFM’s) to create anastomoses by compression, sealing serosa to serosa, leaving no foreign bodies. Combining the Flexagon™ SFM with the OTOLoc™ device (implant with a central lumen which provides radial support to the enterotomies), enables immediate flow through the anastomosis and facilitates creation of enteral bypass procedures unique to this technology. We sought to compare the safety and efficacy of the GI Windows Flexagon™ and OTOLoc™ technologies against conventional stapling. A preclinical study was conducted on 14 Yorkshire swine to compare laparoscopic magnetic and stapled duodenoileostomies and jejunojejunostomies. Study endpoints included: adverse or serious adverse events, anastomotic burst pressure, adhesions, histopathology, and bacterial ingress. A Likert scale was used to assess the usability of the devices. All procedures were successfully completed via laparoscopic approach; no adverse or serious adverse events were observed at the 42-day endpoint. All SFM’s were expelled in less than 20 days. Average anastomotic burst pressure was 129.2 mmHg for SFM compared to 79.4 mmHg in stapled controls. Adhesion scores were similar between groups. Histopathology revealed that magnetic anastomoses have less intestinal wall distortion, fewer signs of chronic inflammation, and no bacterial ingress. The usability of all devices was reported as “Easy” or “Very Easy.” GI Windows magnetic compression anastomoses creation in this porcine model revealed an overall ease of use, all while demonstrating procedural feasibility, safety, and clinical effectiveness. Surprisingly, in nearly all results assessed, SFM anastomoses were found to be comparable to the control stapled anastomoses in regard to structural, physiological, and histological endpoints.

Previous studies have demonstrated Black-vs-White disparities in postoperative outcomes following primary metabolic and bariatric surgery (MBS). With the rising prevalence of MBS, it is important to examine racial disparities using quality indicators in primary and revisional procedures. This study explores Black-vs-White disparities in postoperative outcomes following primary and revisional MBS. We performed an observational cohort study using the 2015–2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database of adults who underwent primary or revisional Roux-en-Y gastric bypass, sleeve gastrectomy, duodenal switch, or one-anastomosis gastric bypass. Black and White patients were 1:1 matched using propensity scores across 19 covariates for primary and revisional MBS groups. McNemar’s tests were used to compare 11 postoperative outcomes from the MBSAQIP semi-annual report and death, between matched cohorts. We identified 112,495 Black and 434,266 White primary MBS and 10,838 Black and 37,075 White revisional MBS patients. A total of 219,114 primary and 21,314 revisional patients were matched. Following primary MBS, Black patients had higher rates of death (0.1

We characterized circulating extracellular vesicles (EVs) in obese and lean humans, identifying transcriptional cargo differentially expressed in obesity (277 unique genes; false discovery rate < 10%). Since circulating EVs may have broad origin, we compared this obesity EV transcriptome with expression from human visceral-adipose-tissue-derived EVs from freshly collected and cultured biopsies from the same obese individuals, observing high concordance. Using a comprehensive set of adipose-specific epigenomic and chromatin conformation assays, we found that the differentially expressed transcripts from the EVs were those regulated in adipose by body mass index-associated SNPs (p < 5 × 10-8) from a large-scale genome-wide association study (GWAS). Using a phenome-wide association study of the regulatory SNPs for the EV-derived transcripts, we identified a substantial enrichment for inflammatory phenotypes, including type 2 diabetes. Collectively, these findings represent the convergence of the GWAS (genetics), epigenomics (transcript regulation), and EV (liquid biopsy) fields, enabling powerful future genomic studies of complex diseases.

Background Laparoscopic sleeve gastrectomy (LSG) is the most common surgical treatment for morbid obesity. While certain specialized ambulatory surgery centers offer LSG on an outpatient basis, patients undergoing LSG at most academic centers are admitted to hospital for initial postoperative convalescence and monitoring. Our institution has begun to offer LSG with same-day discharge (SDD) in select patients. We aimed to compare the perioperative outcomes and costs for patients undergoing LSG with inpatient admission versus SDD. Methods All patients enrolled in the SDD program from December 2020 through July 2022 were identified from a prospectively maintained database. Patients enrolled in this pathway were analyzed on an intention-to-treat basis even if ultimately admitted postoperatively. Propensity scoring was used to match these patients 1:1 to those with planned inpatient recovery based on age, BMI, and ASA classification. Results Seventy-five patients were enrolled in the LSG with SDD program during the study period. Among these, 62 patients (82.7%) had successful immediate postoperative discharge. Reasons for cancelation of planned SDD included anxiety ( n = 5), pain ( n = 3), nausea ( n = 2), and one patient each with hypotension, urinary retention, and bleeding. After matching, there were no differences in age, BMI, or ASA classification in a comparison group of patients with planned inpatient recovery. There were no differences in perioperative complications. There were no readmissions or requirements for outpatient intravenous fluids among patients with SDD, compared to n = 3 (4.0%) and n = 2 (2.7%) in the inpatient cohort, respectively. The total perioperative cost for patients undergoing LSG with planned SDD was 6.8% less than those with inpatient recovery. Conclusion With appropriate protocols, LSG with same-day discharge can safely be performed at large academic surgery centers without increased morbidity or need for additional services in the perioperative period. SDD may be associated with decreased costs and allows for more efficient hospital bed allocation.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m 2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m 2 . Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

BackgroundIt is unclear whether routine upper gastrointestinal swallow study (SS) in the immediate postoperative period is associated with earlier diagnosis of gastrointestinal leak after bariatric surgery.ObjectiveTo investigate the relationship between routine SS and time to diagnosis of postoperative gastrointestinal leak.SettingMBSAQIP-accredited hospitals in the United States and Canada.MethodsWe conducted an observational cohort study of adults who underwent laparoscopic primary Roux-en-Y gastric bypass (RYGB) (n=82,510) and sleeve gastrectomy (SG) (n=283,520) using the MBSAQIP 2015-2019 database. Propensity scores were used to match patient cohorts who underwent routine v. no routine SS. Primary outcome was time to diagnosis of leak. Median days to diagnosis of leak were compared. The Nelson-Aalen estimator was used to determine the cumulative hazards of leak.ResultsIn our study, 36,280 (23%) RYGB and 135,335 (33%) SG patients received routine SS. Routine SS was not associated with earlier diagnosis of leak (RYGB routine SS median 7 [IQR 3-12] days v. no routine SS 6 [2-11] days, p=0.9; SG routine SS 15 [9-22] days v. no routine SS 14 [8-21] days, p=0.06) or lower risk of developing leak (RYGB HR 1.0, 95%-CI 0.8-1.2; SG HR 1.1, 95%-CI 1.0-1.4). More routine SS patients had a length of stay 2 days or greater (RYGB 78.3% v. 61.1%; SG 48.6% v. 40.3%).ConclusionRoutine SS was not associated with earlier diagnosis of leaks compared to the absence of routine SS. Surgeons should consider abandoning the practice of routine SS for the purpose of obtaining earlier diagnosis of postoperative leaks.

BACKGROUND:The Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) assesses safety after metabolic and bariatric surgery and the impact on weight and obesity-related diseases. However, changes in quality of life are likely what matters most to patients, and these are not currently assessed. The best way to measure health-related quality of life (HRQoL) is to use validated patient-reported outcomes measures (PROMs), which capture patients' perspectives of their quality of life both before and after surgery.OBJECTIVES:Identify the outcomes most important to bariatric surgery patients and identify the most appropriate validated PROMs to implement in a national program for the MBSAQIP.SETTING:Five hospitals from a single healthcare system in New England.METHODS:A series of 18 focus groups and/or interviews conducted with patients, patients' family members, and bariatric health providers determined the outcomes most important to bariatric patients and which validated PROMs would accurately measure those outcomes. Immersion crystallization was used to analyze focus group data and identify appropriate PROMs.RESULTS:Focus group participants ranked health as the most important outcome for metabolic and bariatric surgery. Self-confidence, mobility, and everyday activities were the next highest ranked HRQoL domains. The Patient-Reported Outcomes Measurement Information System 10-Item Global Health Survey was selected as the general health measure. The Obesity-Related Problems scale and the Obesity and Weight-Loss Quality of Life Instrument were the disease-specific measures selected for inclusion in the MBSAQIP PROMs program.CONCLUSION:The addition of PROMs to the MBSAQIP provides a unique opportunity to monitor HRQoL at the national level, which can foster improved shared decision-making before surgery.

Aim: The simple six-variable Codman score is a tool designed to reduce the complexity of contemporary risk-adjusted postoperative mortality rate predictions. We sought to externally validate the Codman score in colorectal surgery.Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file and colectomy targeted dataset of 2020 were merged. A Codman score (composed of six variables: age, American Society of Anesthesiologists score, emergency status, degree of sepsis, functional status and preoperative blood transfusion) was assigned to every patient. The primary outcome was in-hospital mortality and secondary outcome was morbidity at 30 days. Logistic regression analyses were performed using the Codman score and the ACS NSQIP mortality and morbidity algorithms as independent variables for the primary and secondary outcomes. The predictive performance of discrimination area under receiver operating curve (AUC) and calibration of the Codman score and these algorithms were compared.Results: A total of 40 589 patients were included and a Codman score was generated for 40 557 (99.02%) patients. The median Codman score was 3 (interquartile range 1-4). To predict mortality, the Codman score had an AUC of 0.92 (95% CI 0.91-0.93) compared to the NSQIP mortality score 0.93 (95% CI 0.92-0.94). To predict morbidity, the Codman score had an AUC of 0.68 (95% CI 0.66-0.68) compared to the NSQIP morbidity score 0.72 (95% CI 0.71-0.73). When body mass index and surgical approach was added to the Codman score, the performance was no different to the NSQIP morbidity score. The calibration of observed versus expected predictions was almost perfect for both the morbidity and mortality NSQIP predictions, and only well fitted for Codman scores of less than 4 and greater than 7.Conclusion: We propose that the six-variable Codman score is an efficient and actionable method for generating validated risk-adjusted outcome predictions and comparative benchmarks to drive quality improvement in colorectal surgery.

Background: Development of patient-reported outcomes (PROs) to include traditionally clinic -reported data has the potential to decrease the data-collection burden for patients and clinicians and increase follow-up rates. However, replacing clinic report by patient report requires that the data reasonably agree.Objective: To assess agreement between PROs and clinical registry data at 1 year after bariatric surgery. Setting: Not-for-profit organization, bariatric surgery data registry, PROs platform.Methods: Patient-and clinic-reported 1-year postoperative weight and co-morbidities were compared for matched PROs and registry records. The co-morbidities evaluated were diabetes, sleep apnea, hypertension, gastroesophageal reflux disease, and hyperlipidemia. Weight differ-ence in pounds and nominal groupings (binary, 4-level) for co-morbidities were assessed for agreement between data sources using descriptive statistics, Bland-Altman plots, multiple regression, and kappa coefficients. Sensitivity analyses and follow-up by response method were examined.Results: Among 1130 patients with both 1-year PROs and registry weights, 95% of patient-reported weights were within 13 lb of the registry-recorded weight, and patients underreported their weight by w2 lb, on average. Percent agreement and kappa coefficients were highest for diabetes (n = 999; bi-nary: 94%, K = .72; 4-level: 86%, K = .71) and lowest for gastroesophageal reflux disease (n = 1032; binary: 75%, K = .40; 4-level: 57%, K = .35). Of patients eligible for both PROs and registry 1-year follow-up, 21% had PROs only.Conclusions: One-year patient-and clinic-reported weights and disease status for patients with dia-betes and hypertension showed high agreement. The degree of bias from patient report was low. Patient report is a viable alternative to clinic report for certain objective measurements and may increase follow-up. (Surg Obes Relat Dis 2023;19:309-317.)(c) 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

One anastomosis gastric bypass (OAGB) has emerged as a potentially safe and effective weight-loss procedure. Worldwide, OAGB is the third most commonly performed primary bariatric procedure, comprising 4% of the annual volume. In the USA, OAGB has yet to be endorsed as a primary bariatric procedure and can only be performed under research protocols or as a revision procedure. We performed an observational cohort study to describe the preoperative, intraoperative, and postoperative characteristics of adult patients who underwent primary or revision OAGB from 2015 to 2019 at MBSAQIP centers. Exclusion criteria included emergent surgery, incomplete 30-day follow-up, and non-laparoscopic- or robotic approach. During the study period, 803,906 bariatric procedures were performed and 645 (0.08%) were OAGB. Among these, 436 (67.6%) were primary and 209 (32.4%) were revision OAGB. The mean operation time was 89 min (SD, 59) and 8% were performed using a robotic approach. The overall complication rate was 7.4% and there was one death (0.2%). The post-operative complication rates were generally higher than the early complication rate (3.4%) reported in the YOMEGA trial, an RCT from France. Revision OAGB had a longer mean operation time of 141 min (SD, 85, p < 0.001). Primary OAGB was a rarely performed bariatric procedure at MBSAQIP-accredited centers comprising only 0.05% compared to 4% worldwide. Future studies should compare safety of OAGB to that of established bariatric procedures like Roux-en-Y gastric bypass and sleeve gastrectomy.

BackgroundMetabolic and bariatric surgery (MBS), despite being the only effective durable treatment for obesity, remains underused as approximately 1% of all patients who qualify undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate treatment.ObjectiveThe objective of this study was to provide the best estimated number of metabolic and bariatric procedures performed in the United States in 2020.SettingUnited States.MethodsWe reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and state databases were used to estimate activity at nonaccredited centers. Data from 2020 were compared mainly with data from the previous 2 years.ResultsCompared with 2019, the total number of MBS performed in 2020 decreased from approximately 256,000 to 199,000. Sleeve gastrectomy continues to be the most common procedure. The gastric bypass procedure trend remained relatively stable, and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Single-anastomosis duodeno-ileostomy was listed for the first time in 2020. Intragastric balloons placement declined from the previous year.ConclusionThere was a 22.5% decrease in MBS volume from 2019 to 2020, which coincided with the COVID-19 pandemic. Sleeve gastrectomy continues to be the dominant procedure, and for the first time, single-anastomosis duodeno-ileostomy is reported in the MBSAQIP database.

Background: One anastomosis gastric bypass (OAGB) is the third most common (4%) primary bariatric procedure worldwide but is seldom performed in the United States and is currently under consideration for endorsement by the American Society for Metabolic and Bariatric Surgery. Evidence from the United States on safety of OAGB compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) is limited. Objective: To compare the short-term safety outcomes of the three primary bariatric procedures. Setting: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSA-QIP)-accredited hospitals in the United States and Canada. Methods: Using the 2015-2019 MBSA-QIP database, we compared the safety outcomes of adult patients who underwent primary laparoscopic OAGB, RYGB, and SG. Exclusion criteria included age over 80 years, emergency operation, conversion, and incomplete follow-up. The primary outcome was 30-day overall complication. Secondary outcomes were 30-day surgical and medical complications and hospitalization length. Results: A total of 341 patients underwent primary OAGB. Using propensity scores, we matched the OAGB cohort 1:1 with two cohorts of similar baseline characteristics who underwent RYGB and SG, respectively. The OAGB cohort had a lower overall complication rate than the RYGB cohort (6.7% versus 12.3%, P = .02) and a similar rate to the SG cohort (5.0%, P = .43). The OAGB cohort had a similar rate of surgical complication to the RYGB cohort (5.0% versus 8.5%, P = .1) and a higher rate than the SG group (1.2%, P = .009). The OAGB cohort had a shorter median hospitalization than the RYGB cohort (1 d [interquartile range (IQR) 1-2 d] versus 2 d [IQR 1-2 d], P < .001) and a similar hospitalization length to the SG cohort ([1-2 d], P = .46). Conclusion: Using the largest and the most current U.S. data, this study demonstrated that the short-term safety profile of primary OAGB is acceptable, but future studies should determine the long-term safety. (C) 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Gastrointestinal leaks after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) occur infrequently but lead to clinical and socioeconomic burden on patients. Surgeons perform intraoperative leak test (IOLT) via gastric tube or endoscopy to help prevent postoperative leaks. However, there is knowledge gap in the literature on effectiveness of IOLT during bariatric surgery. In this observational cohort study using the 2015–2017 MBSAQIP database, we compared the outcomes in patients who received IOLT with those who did not during primary or revision RYGB and SG. The primary outcome was 30-day postoperative leak. Secondary outcomes were procedure duration and the rates of 30-day postoperative bleed, readmission, reoperation and intervention. Propensity score matching was used to assemble cohorts of patients with similar baseline characteristics. Among 363,042 patients, 82% underwent IOLT. Four subgroups of patients who underwent operations with or without IOLT during primary RYGB (n = 13,756), primary SG (n = 110,810), revision RYGB (n = 1140), and revision SG (n = 5576) had similar propensity scores and were matched 1:1. Patients who underwent IOLT had similar postoperative leak rates compared to those who did not (Primary RYGB with IOLT 0.7% v. without IOLT 0.6%; Primary SG 0.4% v. 0.3%; Revision RYGB 2.3% v. 1.0%; Revision SG 1.1% v. 0.7%). In primary SG subgroup, patients who underwent IOLT had lower postoperative bleed rates (0.6% v. 0.8%, p = 0.002). In primary RYGB and SG subgroups, operations with IOLT were slightly longer. Postoperative leak rates after primary and revision bariatric surgery were low and similar irrespective of IOLT. Patients who had IOLT during primary SG had lower postoperative bleed rates. Current judgment as to whether to perform an IOLT leads to excellent outcomes, and thus, current practices should continue. However, one should consider an IOLT during primary SG, not necessarily to reduce leak rates but to help reduce postoperative bleeding occurrences.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Introduction: Surgical treatment for obesity, a major risk factor for diabetes and cardiovascular disease, may lead to important improvements in cardiovascular health. Sleeve gastrectomy (SG) procedures have gained popularity over Roux-en-Y gastric bypass (RYGB), though it is unclear which procedure results in improved cardiovascular outcomes. Our objective was to evaluate the comparative cardiovascular safety of SG vs. RYGB in older patients with type 2 diabetes (T2D). Methods: Using Medicare claims data, we identified a cohort of T2D patients ≥65 years that underwent a SG or RYGB procedure between 2010 and 2018. Patients undergoing a SG were propensity-score (PS) matched 1:1 to RYGB patients on the propensity score of receiving the procedure. The two co-primary outcomes were a major adverse cardiovascular event (MACE, a composite of stroke, myocardial infarction (MI) or all-cause mortality) and hospitalization for heart failure (HHF). Secondary outcomes were the individual components of MACE. Subjects were followed until the occurrence of an outcome, end of patient data or enrollment or death, whichever came first. We estimated the hazard ratios (HR) for each outcome, adjusting for demographics, comorbidities, medication use and healthcare utilization using PS matching. Results: A total of 5,514 patients undergoing SG were PS-matched to 5,514 undergoing RYGB and followed for a median of 2.3 years (IQR: 1.2, 3.9) after the procedures. Compared to RYGB, patients undergoing SG had a similar risk of MACE (rate 2.5 vs. 3.0 per 100 person-years (py); HR: 0.94; 95% CI: 0.82, 1.09) and of HHF (rate 12.2 vs. 10.9 per 100 py; HR: 1.01; 95%CI: 0.94, 1.09). For secondary outcomes, the risk of MI was higher for SG (rate 0.8 vs. 0.7 per 100 py; HR: 1.33, 95%CI: 1.02, 1.75), whereas SG was associated with a lower risk of all-cause mortality (rate 1.5 vs. 2.2 per 100 py; HR: 0.68; 95%CI: 0.57, 0.81). Conclusions: In older patients with T2D, SG was associated with a similar risk of MACE and HHF compared to RYBG. However, when we assessed the individual components of MACE separately, SG was associated with a higher risk of MI and a lower risk of death, compared with RYBG.

Approaches to manage nonalcoholic fatty liver disease (NAFLD) are limited by an incomplete understanding of disease pathogenesis. The aim of this study was to identify hepatic gene‐expression patterns associated with different patterns of liver injury in a high‐risk cohort of adults with obesity. Using the NanoString Technologies (Seattle, WA) nCounter assay, we quantified expression of 795 genes, hypothesized to be involved in hepatic fibrosis, inflammation, and steatosis, in liver tissue from 318 adults with obesity. Liver specimens were categorized into four distinct NAFLD phenotypes: normal liver histology (NLH), steatosis only (steatosis), nonalcoholic steatohepatitis without fibrosis (NASH F0), and NASH with fibrosis stage 1‐4 (NASH F1‐F4). One hundred twenty‐five genes were significantly increasing or decreasing as NAFLD pathology progressed. Compared with NLH, NASH F0 was characterized by increased inflammatory gene expression, such as gamma‐interferon‐inducible lysosomal thiol reductase (IFI30) and chemokine (C‐X‐C motif) ligand 9 (CXCL9), while complement and coagulation related genes, such as C9 and complement component 4 binding protein beta (C4BPB), were reduced. In the presence of NASH F1‐F4, extracellular matrix degrading proteinases and profibrotic/scar deposition genes, such as collagens and transforming growth factor beta 1 (TGFB1), were simultaneously increased, suggesting a dynamic state of tissue remodeling. Conclusion: In adults with obesity, distinct states of NAFLD are associated with intrahepatic perturbations in genes related to inflammation, complement and coagulation pathways, and tissue remodeling. These data provide insights into the dynamic pathogenesis of NAFLD in high‐risk individuals.