e13783 Background: Cancer survivors with obesity are at increased risk of cancer recurrence, cancer-related mortality, and secondary cancer development. Evidence-based obesity treatments such as glucagon-like peptide-1 receptor agonists (GLP-1RAs) and bariatric surgery reduce these risks yet remain profoundly underutilized in survivorship care. We surveyed oncology clinicians to characterize barriers to adoption and identify potential implementation solutions. Methods: We conducted a cross-sectional, anonymous web-based survey of oncology clinicians at a single academic institution, purposively sampling across specialties to ensure broad representation, including surgical oncologists, medical oncologists, and advanced practice practitioners. Likert-scale items assessed clinician knowledge, comfort with counseling and referral, and perceived patient awareness, while short-answer items elicited barriers to integrating GLP-1RAs and bariatric surgery in survivorship care. Quantitative responses were summarized using descriptive statistics, and qualitative responses were reviewed to identify common themes. Results: Twenty-eight clinicians completed the survey (76% response rate). Respondents reported low utilization of these therapies, with 84% reporting they never or only sometimes discussed bariatric surgery or GLP-1RAs with patients, and 63% reporting they had never referred a patient for either therapy. Respondents also described substantial knowledge and confidence gaps: 79% reported low understanding of the oncologic benefits of these treatments, 84% reported low confidence discussing them in practice, and 76% perceived that cancer survivors with obesity were not at all or only slightly aware of their benefits. Despite these gaps, 79% of respondents agreed that bariatric surgery and GLP-1RAs should be a standard component of survivorship care. Reported barriers included unclear referral pathways (71%), limited knowledge of eligibility criteria (54%), and lack of support or resources (46%). Across candidate implementation strategies, 40-60% of respondents rated clarified referral pathways, decision support, and enhanced education/training as “highly helpful.” Conclusions: Oncology clinicians endorsed GLP-1RAs and bariatric surgery as an important component of survivorship care, but reported low utilization driven by knowledge gaps and system-level barriers. These findings highlight the need for multi-level, multi-component implementation strategies to support the integration of evidence-based obesity treatment into cancer survivorship care.

Background Although the prevalence of same-day discharge (SDD) after bariatric surgery has more than doubled in recent years, the practice remains controversial. We conducted a survey of practicing bariatric surgeons across Michigan to evaluate surgeon perspectives toward SDD. Objectives To characterize surgeon perceptions and barriers to SDD adoption in Michigan Setting Academic and community bariatric surgery programs participating in the Michigan Bariatric Surgery Collaborative (MBSC), a statewide quality improvement collaborative Methods Surgeon survey was distributed to all surgeons of MBSC. This survey included questions regarding current practice of SDD and potential concerns or barriers to implementation. The questions were multiple-choice items with optional free-text responses, with some allowing selection of more than one response option. Results The overall response rate to the survey was 100% (N = 76). Only 15 (20%) reported performing SDD. Concerns about “Overall risks” (39 [51%]) and “Fear of complications” (26 [34%]) were identified as the leading reasons for not performing. Key institutional barriers included “Safety concerns” (41 [54%]) and “Lack of outpatient resources” (22 [29%]). Perceived advantages were rarely endorsed, and no free-text responses supported SDD. The most frequently cited disadvantages were “Failure to rescue” (69 [91%]) and “Inability to monitor” (64 [84%]). Conclusions SDD after bariatric surgery is not widely adopted in Michigan, primarily due to surgeon safety concerns and limited outpatient resources. These findings indicate that institutional readiness and postoperative support capacity remain key constraints to broader SDD adoption.

This Viewpoint examines the underutilization of glucagon-like peptide-1 receptor agonists and bariatric surgery in survivors of cancer.

BACKGROUND:Nicotine use after bariatric surgery can lead to serious complications. Although smoking cessation prior to surgery is often mandatory, the incidence and risk factors for smoking relapse postsurgery are not well understood. OBJECTIVES:To determine the incidence of smoking relapse 1 year after bariatric surgery and to identify patient, clinical, and smoking-related risk factors for relapse. SETTING:Statewide quality improvement collaborative of academic and community hospitals, Michigan, United States. METHODS:Using a statewide bariatric-specific data registry, we conducted a retrospective review of 15,421 former smokers who underwent bariatric surgery between 2014 and 2023. Smoking status was assessed via 1-year follow-up survey; of 28,720 eligible former smokers, 15,421 (53.7%) responded and comprised the analytic cohort. Multivariable logistic regression identified independent risk factors for smoking relapse. RESULTS:The cohort had a mean age of 46.5 years and was predominantly female (80.4%). Sleeve gastrectomy was the most common procedure (81.0%). At 1 year, 7.4% of patients reported resuming smoking. The strongest predictor of relapse was quitting smoking within 1 year before surgery (adjusted odds ratio [aOR]: 14.55; 95% confidence interval [CI]: 8.28-25.56). Uninsured status/self-pay (aOR: 9.25; 95% CI: 1.34-63.77). Additional tobacco product use (aOR: 2.17; 95% CI: 1.07-4.39) and greater number of pack-years (aOR: 1.02 per pack-year; 95% CI: 1.01-1.04) were also associated with higher risk of relapse. More recent surgery was linked to lower odds of relapse (aOR: .75 per year; 95% CI: .64-.88). Nonresponders were younger and more likely to have recently quit and be uninsured, suggesting 7.4% is a lower bound on the true rate. CONCLUSIONS:Despite smoking cessation prior to bariatric surgery, 7.4% of patients resumed smoking at 1 year. Shorter duration of smoking cessation before surgery, multiple tobacco product use, and uninsured status increased risk. Identifying at-risk patients may guide targeted postoperative support and improve long-term outcomes.

This cross-sectional study examines bariatric surgery utilization among fee-for-service Medicare beneficiaries from 2014 to 2024 to better understand trends across this period of declining utilization.

ObjectiveTo explore the impact of delayed or deferred ventral hernia repair for surgical optimization, including consequences on physical, social, and emotional well-being.Summary Background Data:While previous studies have shown that surgical optimization can reduce complications of ventral hernia repair surgery, many patients face various barriers that preclude them from meeting these requirements, resulting in delayed or deferred surgery. Though these optimization requirements are well intentioned, the unintended consequences on patient well-being of needing to live with untreated hernia repairs remains unknown.Methods:Semistructured qualitative interviews from January to June 2022 were conducted in a preoperative optimization clinic of 20 participants with ventral wall hernias were analyzed using an inductive thematic approach. The discussions aimed to explore challenges that patients living with untreated hernias faced, and what their expectations were during clinic visits. The transcripts were coded and analyzed using the MAXQDA software.Results:Our study demonstrated 3 predominant themes in unintended consequences of delaying ventral hernia repair surgery for surgical optimization, including decreased feelings of emotional and social well-being, feelings of fear and uncertainty about the future, and frustration with lack of patient autonomy and preferences.Conclusion:Untreated hernias have many unintended psychosocial consequences that need to be accounted for when determining surgical candidacy, using a shared decision-making approach.

This cross-sectional study evaluates whether clinician counseling is associated with weight loss attempts among survivors of obesity-associated cancers and whether this differs from the general population with obesity.

BACKGROUND: Robotic surgery may mitigate technical challenges associated with patient obesity. However, prevalence of robotic cholecystectomy and impact on outcomes in patients with obesity are unclear. We evaluated trends in robotic cholecystectomy, factors contributing to robot use, and outcomes based on BMI. STUDY DESIGN: We analyzed data from a statewide, 69-hospital member clinical registry and identified patients who underwent elective robotic or laparoscopic cholecystectomy from 2020 to 2024. Patients were stratified by BMI (lower than 35 kg/m 2 , 35 to 49.9 kg/m 2 , greater than or equal to 50 kg/m 2 ) and outcomes were compared. Multivariable logistic regression was used to evaluate the association between patient characteristics, surgical approach, and outcomes. An interaction term was used to evaluate the impact of BMI category on the risk associated with the surgical approach. RESULTS: A total of 27,006 patients underwent laparoscopic (18,610; 68.9%) or robotic (8,396; 31.1%) cholecystectomy. Robotic approach increased over time, with the greatest increase in patients with BMI greater than or equal to 50 kg/m 2 (23.1% in 2020 vs 55.8% in 2024, p < 0.001). Compared with patients who underwent laparoscopic surgery, those who underwent robotic surgery were more likely to have a higher BMI (BMI 35 to 49.9 kg/m 2 : odds ratio [OR] 1.15, 95% CI 1.08 to 1.23, p < 0.001; BMI greater than equal to 50 kg/m 2 : OR 1.34, 95% CI 1.14 to 1.57, p < 0.001). BMI did not modify the effect of surgical approach on postoperative complication risk (BMI 35 to 49.9 kg/m 2 with robotic approach: OR 0.97, 95% CI 0.60 to 1.56, p = 0.887; BMI greater than or equal to 50 kg/m 2 with robotic approach OR 1.55, 95% CI 0.50 to 4.86, p = 0.451). CONCLUSIONS: Robotic approach is increasingly used in elective minimally invasive cholecystectomy, especially for patients with the highest BMI. Postoperative outcomes did not differ across BMI groups between robotic and laparoscopic cholecystectomy, indicating that BMI did not alter the relationship between surgical approach and outcomes.

Patient-centered clinical trials are vital for ensuring surgical research reflects patient priorities. Using groin hernia as a case study, this exploratory qualitative study explored female patients' perspectives on research priorities and trial participation. Thirty-four interviews revealed strong interest in nonoperative options, willingness to participate in trials, and emphasis on outcomes such as pain, recovery, and quality of life, highlighting the need for inclusive, patient-informed trial design.

BACKGROUND:Although postoperative leak is one of the most feared complications after bariatric surgery, trends in its incidence, risk factors, and contemporary management are unclear. OBJECTIVES:Describe trends in the incidence of postoperative leak after bariatric surgery, identify factors associated with postoperative leak, and describe trends in leak management. SETTING:Hospitals in Michigan. METHODS:This retrospective cohort study used a statewide clinical registry to identify adults who underwent primary laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass in a mature quality improvement-driven US healthcare setting between January 1, 2007 and December 31, 2023. The main outcome was postoperative leak within 30 days of surgery. Multivariable logistic regression was used to identify factors associated with postoperative leak. RESULTS:108,708 patients with a mean age of 45.0 (11.7) years and 86,712 (79.8%) females underwent primary bariatric surgery, of whom 74,268 (68.3%) underwent sleeve gastrectomy and 34,440 (31.7%) underwent gastric bypass. 628 (.58%) leaks occurred. Over the 17-year study period, the incidence of postoperative leak decreased by .06 (95% confidence interval [CI]: .04-.08) percentage points (pp) per year, from 1.06% in 2007 to .45% in 2023. Individually, there was a significant decrease in the incidence of postoperative leak for both procedures (sleeve gastrectomy .06 [95% CI: .03-.10] pp per year; gastric bypass .03 [95% CI: .01-.06] pp per year). Factors associated with higher odds of postoperative leak included prior gastric surgery (adjusted odds ratio [aOR]: 5.92 [95% CI: 2.57-13.65]), gastric bypass (aOR: 2.46 [95% CI: 1.87-3.24]), active or recent smoking (aOR: 1.68 [95% CI: 1.14-2.47]), and diabetes (aOR: 1.35 [95% CI: 1.01-1.80]). Among patients who developed a postoperative leak, 311 (49.5%) were managed operatively, while 317 (50.5%) were managed nonoperatively. CONCLUSIONS:Over the last 2 decades, there was a significant decrease in the incidence of postoperative leak after sleeve gastrectomy and gastric bypass.

INTRODUCTION:Long-term patient-reported outcomes (PROs) after abdominal wall hernia repair (AWHR) are essential for evaluating recovery and informing shared decision-making, yet population-level data and predictors of hernia-related quality of life (QOL) are limited. We measured 1-y postoperative QOL after AWHR and identified preoperative predictors of PROs. METHODS:We performed a cohort study using prospectively collected clinical data and 1-y postoperative surveys from the Michigan Surgical Quality Collaborative Core Optimization in Hernia Registry. Adults ≥18 y undergoing AWHR from January 2020 to December 2023 with completed 1-y PRO surveys were included (n = 2867). QOL was measured using Hernia-Related Quality-of-Life tool (2021-2022) or the abdominal hernia questionnaire (AHQ; 2023-2025); Hernia-Related Quality-of-Life scores were standardized and calibrated to the AHQ scale (0-100). Covariates included preoperative demographic, clinical, and hernia-specific characteristics. Weighted unadjusted and adjusted linear regression models estimated associations between risk factors and AHQ scores. RESULTS:Median (interquartile range) AHQ score was 92.5 (8.1), with a left-skewed distribution (mean [standard deviation], 86.8 [14.4]) and a 10th percentile score of 66.5. In adjusted models, female sex (versus male; -3.4 points), tobacco use (versus none; -3.6 points), and larger hernia size (e.g., ≥6 cm versus <2 cm; -4.9 points) were associated with lower AHQ score. Older age was associated with higher AHQ score. Race/ethnicity, body mass index, mesh use, and surgical approach were not associated with AHQ score. CONCLUSIONS:Most patients reported high 1-y QOL after AWHR, but a meaningful subset experienced low AHQ scores. Preoperative characteristics may inform counseling and shared decision-making beyond short-term surgical risk.

Smoking has long been regarded as a contraindication to elective ventral hernia repair, however some have begun to question whether this practice is unnecessarily restrictive. In order to better understand the implications of more liberal patient selection for commonly encountered hernias, we evaluated outcomes among smokers and nonsmokers undergoing elective ventral hernia repair. We retrospectively reviewed a population-level registry to identify adults who underwent elective ventral hernia repair between 2021 and 2023. The primary explanatory variable was active smoking, which was defined as smoking within the month prior to surgery. Outcomes included 30-day complications, emergency department utilization (including reason for utilization), readmission, and reoperation. Multivariable logistic regression was used to assess the association of smoking with all outcomes while controlling for patient, hernia, and operative characteristics. 12,233 patients underwent elective ventral hernia repair during the study period. Mean age was 54.3 (14.3) years, 5151 (42.1

Importance:Hundreds of thousands of people have mesh placed for ventral hernia repair every year, but the long-term risks of clinically significant mesh infection requiring mesh removal remain unknown. Objective:To examine the risk of clinically significant mesh infection requiring removal after ventral hernia repair. Design, Setting, and Participants:This retrospective cohort study included 100% Medicare fee-for-service administrative claims data from January 1, 2011, to December 31, 2021, for adults aged 18 years or older who underwent elective inpatient open ventral hernia repair with mesh. Data were analyzed from October 21, 2024, to May 2, 2025. Exposure:Mesh placed at the time of ventral hernia repair. Main Outcomes and Measures:The primary outcome was mesh removal up to 10 years after the index operation. Current Procedural Terminology codes were used to identify mesh removal, which was used as a surrogate measure for a clinically significant mesh infection. Secondary outcomes included the association between 30-day wound complications and subsequent mesh removal. Results:Of 59 453 people (35 209 female [59.2%]), 1330 (2.2%) underwent mesh removal with a median time to mesh removal of 8 months (238 days; 25th to 75th percentile = 49 to 757 days = 2 to 25 months). People who underwent mesh removal were more often female than people who did not undergo mesh removal (63.0% [838] vs 59.1% [34 371]; P = .005), more often underwent enterectomy (3.5% [46] vs 2.3% [1342]; P = .008), and more often experienced a wound complication within 30 days (23.6% [314] vs 6.6% [3825]; P < .001). The cumulative hazard percentage of mesh removal for a patient with wound complications at 10-year follow-up was 7.94 (95% CI, 7.03-8.84) compared with 2.48 (95% CI, 2.31-2.64) for patients without. Most mesh removals occurred within the first 5 years after surgery. Conclusions and Relevance:These findings suggest that the risk of mesh removal is low overall, even for people who experience a wound complication. These findings support the broad use of mesh for people undergoing elective open ventral hernia repair.

This Viewpoint discusses guidance recommending standardized labeling practices for hernia mesh products used in various types of hernia repairs.