Background The SARS CoV-2 (COVID-19) pandemic catalyzed a dramatic shift in healthcare delivery, with telemedicine emerging as a common mode of care provision. While pre-pandemic telemedicine services were more commonly used for preventive visits and had better adherence among younger and more affluent demographics, the landscape of telehealth in the post-pandemic period has shifted significantly to include surgical visits and publicly-insured patient populations. Without specific insights from patients and clinicians to guide this transition, telehealth delivery risks exacerbating disparities in access, experience and outcomes for medically underserved populations. Methods We utilized a human-centered design (HCD) approach to gain insights into patient and clinician perspectives on telehealth delivery at a surgical outpatient clinic in an urban safety-net hospital and level 1 trauma center. During the Inspiration phase of HCD, we conducted 19 in-depth interviews with patients and surgical clinicians, and applied a combined thematic analysis and design synthesis approach to identify key insight statements representing actionable tensions across cohorts. During the Ideation phase of HCD, we held a structured brainstorming session to identify solutions and facilitated a discussion with surgical faculty to co-design and refine a prototype. Results Interview analysis revealed 12 main themes, which were then reorganized into 5 core insights across both groups: “In-person appointments can be resource intensive for patients, making their attendance costly in more ways than one”; “When sacrificing connection for convenience, telehealth exacerbates discrimination felt by historically marginalized patients”; “Personal interactions are crucial for establishing new relationships and repairing mistrust between patients and clinicians”; “Visual cues and non-verbal communication are essential for personalized and effective surgical care”; “Patients and clinicians value the human infrastructure built into the in-person visit experience.” Brainstorming participants generated ideas from the first insight statement. Subsequent prototyping and co-design sessions led to the development of a screening prototype allowing both clinic staff and patients to book telehealth appropriate appointments. Conclusions This study offers a HCD approach to developing insights and tailoring health service interventions to the local contexts for safety-net providers. By understanding the unique needs and preferences of underserved populations, we can develop telehealth interventions that increase adoption and ensure equitable access to care.

Introduction:Laparoscopic surgery requires significant training, and prior studies have shown that surgical residents lack key laparoscopic skills. Many educators have implemented simulation curricula to improve laparoscopic training. Given limited time for dedicated, in-person simulation center practice, at-home training has emerged as a possible mechanism by which to expand training and promote practice. There remains a gap in published at-home laparoscopic curricula employing embedded feedback mechanisms. Methods:We developed a nine-task at-home laparoscopic curriculum and an end-of-curriculum assessment following Kern's six-step approach. We implemented the curriculum over 4 months with first- to third-year residents. Results:Of 47 invited residents from general surgery, obstetrics/gynecology, and urology, 37 (79%) participated in the at-home curriculum, and 25 (53%) participated in the end-of-curriculum assessment. Residents who participated in the at-home curriculum completed a median of six of nine tasks (interquartile range: 3-8). Twenty-two residents (47%) responded to a postcurriculum survey. Of these, 19 (86%) reported that their laparoscopic skills improved through completion of the curriculum, and the same 19 (86%) felt that the curriculum should be continued for future residents. Residents who completed more at-home curriculum tasks scored higher on the end-of-curriculum assessment (p = .009 with adjusted R 2 of .28) and performed assessment tasks in less time (p = .004 with adjusted R 2 of .28). Discussion:This learner-centered laparoscopic curriculum provides guiding examples, spaced practice, feedback, and graduated skill development to enable junior residents to improve their laparoscopic skills in a low-stakes, at-home environment.

BACKGROUND This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery. METHODS A prospective observational study (2021–2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment. CONCLUSION When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.

OBJECTIVE:To identify well-being threats for surgeons and anesthesiologists and develop interventions using the quality of life improvement (QOLI) approach. BACKGROUND:Developing feasible perioperative well-being interventions requires identifying shared and specialty-specific well-being needs. The QOLI framework integrates human-centered design, implementation science, and quality improvement to address well-being needs. METHODS:Anesthesia and surgery faculty in 8 perioperative departments at an academic medical center completed cross-sectional surveys containing validated measures of well-being and workplace satisfaction, and open-ended questions about professional motivations, pain points, strategies for improvement, and well-being priorities. Using template analysis, we analyzed open-ended survey data and presented resulting themes at a joint-specialty town hall for live voting to identify well-being priorities. RESULTS:One hundred four perioperative faculty completed the survey. Across specialties, higher Mental Health Continuum-Short Form scores (representative of individual global well-being) were associated with higher satisfaction with workplace control, values, decision latitude, and social support. Anesthesiologists reported lower satisfaction and control than surgeons across multiple domains. Template analysis yielded 5 areas for intervention: (1) work culture, (2) work environment/resources, (3) sources of fulfillment, (4) work/life harmony, and (5) financial compensation. Surgeons and anesthesiologists both prioritized high-quality patient care but differed in their other top priorities. The most frequently cited well-being threats for surgeons were operating room inefficiencies/delays and excessive workload, whereas anesthesiologists cited understaffing and unpredictable work hours. CONCLUSIONS:Surgeons and anesthesiologists share many needs and priorities, with pain points that are often negatively synergistic. Applying the QOLI approach across specialties allows for well-being interventions that honor complexity and promote the development of feasible solutions.

Objective:To identify well-being threats for surgeons and anesthesiologists and develop interventions using the quality of life improvement (QOLI) approach.Background:Developing feasible perioperative well-being interventions requires identifying shared and specialty-specific well-being needs. The QOLI framework integrates human-centered design, implementation science, and quality improvement to address well-being needs.Methods:Anesthesia and surgery faculty in 8 perioperative departments at an academic medical center completed cross-sectional surveys containing validated measures of well-being and workplace satisfaction, and open-ended questions about professional motivations, pain points, strategies for improvement, and well-being priorities. Using template analysis, we analyzed open-ended survey data and presented resulting themes at a joint-specialty town hall for live voting to identify well-being priorities.Results:One hundred four perioperative faculty completed the survey. Across specialties, higher Mental Health Continuum-Short Form scores (representative of individual global well-being) were associated with higher satisfaction with workplace control, values, decision latitude, and social support. Anesthesiologists reported lower satisfaction and control than surgeons across multiple domains. Template analysis yielded 5 areas for intervention: (1) work culture, (2) work environment/resources, (3) sources of fulfillment, (4) work/life harmony, and (5) financial compensation. Surgeons and anesthesiologists both prioritized high-quality patient care but differed in their other top priorities. The most frequently cited well-being threats for surgeons were operating room inefficiencies/delays and excessive workload, whereas anesthesiologists cited understaffing and unpredictable work hours.Conclusions:Surgeons and anesthesiologists share many needs and priorities, with pain points that are often negatively synergistic. Applying the QOLI approach across specialties allows for well-being interventions that honor complexity and promote the development of feasible solutions.

Kim, Woon Cho MD, MPH; Abel, Mary Kathryn AB; Schwartz, Hope AB; Boeck, Marissa MD, MPH; Bongiovanni, Tasce MD; Stein, Deborah M. MD, FACS; Kumar, Sandhya B. MD Author Information

BackgroundThe onset of the COVID-19 pandemic led to the postponement of low-acuity surgical procedures in an effort to conserve resources and ensure patient safety. This study aimed to characterize patient-reported concerns about undergoing surgical procedures during the pandemic.MethodsWe administered a cross-sectional survey to patients who had their general and plastic surgical procedures postponed at the onset of the pandemic, asking about barriers to accessing surgical care. Questions addressed dependent care, transportation, employment and insurance status, as well as perceptions of and concerns about COVID-19. Mixed methods and inductive thematic analyses were conducted.ResultsOne hundred thirty-five patients were interviewed. We identified the following patient concerns: contracting COVID-19 in the hospital (46%), being alone during hospitalization (40%), facing financial stressors (29%), organizing transportation (28%), experiencing changes to health insurance coverage (25%), and arranging care for dependents (18%). Nonwhite participants were 5 and 2.5 times more likely to have concerns about childcare and transportation, respectively. Perceptions of decreased hospital safety and the consequences of possible COVID-19 infection led to delay in rescheduling. Education about safety measures and communication about scheduling partially mitigated concerns about COVID-19. However, uncertainty about timeline for rescheduling and resolution of the pandemic contributed to ongoing concerns.ConclusionsProviding effective surgical care during this unprecedented time requires both awareness of societal shifts impacting surgical patients and system-level change to address new barriers to care. Eliciting patients' perspectives, adapting processes to address potential barriers, and effectively educating patients about institutional measures to minimize in-hospital transmission of COVID-19 should be integrated into surgical care.

Lee, Carmen M. BA; Rogine, Camille BA; Kim, Woon Cho MD, MPH; Chehab, Lara MPH; Sammann, Amanda MD, MPH, FACS; Kumar, Sandhya MD Author Information

Background: Gallstone disease occurs more commonly in the obese population and is often diagnosed during the preoperative evaluation for bariatric surgery. Objectives: This study analyzed outcomes of laparoscopic gastric bypass (LGB) and laparoscopic sleeve gastrectomy (SG), with and without cholecystectomy (LC), using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Setting: Patients reported to Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participating centers in the United States and Canada in 2015. Methods: All cases of LGB and SG, with and without LC, were analyzed. A 1:1 propensity-matched cohort was created for both SG and LGB, with and without concomitant LC. Multivariate logistic regression stratified by procedure was used to identify predictors of major complications after SG and LGB, using concomitant LC as a predictor. We also constructed a model for surgical site infections (SSIs) for SG group. Results: Of 98,292 sleeve operations, 2046 (2%) had concomitant LC. Of 44,427 bypass operations, 1426 (3%) had concomitant LC. For the sleeve group, concomitant LC increased operative time by an average of 27 minutes but did not affect length of stay, mortality, or major complications. Concomitant LC was associated with increased SSI (1% versus .4%) and need for reoperation (1.6% versus .7%) in univariate models. After adjusting for other predictors, concomitant LC was associated with increased risk for SSI (odds ratio 2.5, confidence interval 1.0-5.9, P = .04). For the bypass group, concomitant LC increased operative time by an average of 28 minutes to the operation, and postoperative length of stay averaged similar to 5 hours longer (2.4 versus 2.2 d, P = .03). Thirty-day complications were similar between the groups. On multivariate analysis, concomitant LC was not a significant risk factor for major complications. Only operative time was an independent factor for major complications. Conclusions: Concomitant LC with laparoscopic sleeve gastrectomy or gastric bypass did not affect mortality or risk of major complication. For sleeve patients, concomitant LC was associated with a .6% increased risk (.4% to 1.0%) of SSI. Concomitant LC with laparoscopic sleeve gastrectomy or gastric bypass is safe when indicated for gallstone disease. (C) 2019 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.

Kumar, Sandhya B. MD; YC. Lin, Matthew MD, FACS; Carter, Jonathan T. MD, FACS Author Information

Previous risk calculators for complications after bariatric surgery have been developed using single-center data or large datasets that were not specific to bariatric surgery, and were developed before the widespread adoption of laparoscopic sleeve gastrectomy (LSG). The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (MBSAQIP) data registry captures detailed bariatric-surgery specific information and reflects the recent increase in the number LSG cases. Machine learning techniques such as random forest algorithms are uniquely suited for use with such large datasets. We used these techniques to develop a novel risk score calculator for LSG and laparoscopic gastric bypass (LGB) based on pre-operative patient characteristics.

Before laparoscopic techniques to perform gastric bypass were developed, most surgeons routinely performed cholecystectomy during open gastric bypass in order to avoid future complications of gallstone disease. Nowadays, laparoscopic cholecystectomy (LC) is only performed selectively during laparoscopic gastric bypass (LGB). We hypothesized that concomitant laparoscopic cholecystectomy adds little additional morbidity to laparoscopic gastric bypass.

ed data and patient interviews was completed across 39 hospitals participating in a statewide quality improvement collaborative. Trained nurses collected data on the circumstances surrounding patient’s 30-day post-operative ED visits utilizing a previously validated interview tool. Patients were interviewed if their ED visit was bariatric related, they had not contacted their surgical team prior to their visit, and they were not readmitted. Over a 10-month period, 141 patients out of 432 total ED visits met the inclusion criterion, with 100% of those patients being interviewed. Results: The most common patient chief complaints were abdominal pain, nausea/vomiting, and chest pain with rates of 35%, 26%, and 12%, respectively. 60% of patients were treated with IV fluids, 38% with pain control medicine, and 35% with antiemetics. 61% of patients visited the ED during a weekday, and 77% reported their visit occurring outside of traditional office hours. Patients reported high compliance (>90%) with provider driven perioperative measures aimed at reducing readmissions and ED visits. 70% of patients said they did not seek any alternatives prior to their ED visit. Most patients reported no knowledge of or guidance in the use of alternative care settings such as urgent care clinics or infusion centers. Conclusions: Most patients experienced non-life threatening symptoms, but believed their concerns required immediate medical attention in an ED. Patients who self-referred to the ED did not seek care alternatives despite the increasing availability of these options. Urgent care centers are a practical alternative to the ED for patients who elect not to contact their surgical team, but require prompt medical attention. Providing focused, patientcentered education on appropriate alternative care options available to patients experiencing non-life threatening symptoms may decrease inappropriate ED utilization among post-operative bariatric patients. A107 Do Patients With Higher Baseline BMI Have Improved Weight Loss With Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy? Deepali Jain Baltimore MD, Andrew Averbach Baltimore MD, Anne Sill Baltimore MD Saint Agnes Hospital Introduction: Laparoscopic sleeve gastrectomy (LSG) has become the most frequently performed bariatric surgery in recent years. It remains unclear for which patients laparoscopic Roux-en-Y gastric bypass (LRYGB) may be advantageous. Some contend that patients with higher initial body mass index (BMI) achieve better weight loss with LRYGB. This study evaluates percentage of weight loss in LSG versus LRYGB patients based on preoperative BMI. Methods: A convenience cohort of 4451 individuals, that underwent bariatric surgery at a community teaching hospital in Baltimore, Maryland between 2001 and 2016, was studied to examine 3-year postsurgical trends in weight loss and maintenance stratified by baseline BMI groups and by primary LSG (n = 1341) versus LRYGB (n = 3110). Student T-tests were used to compare mean weight loss of baseline BMI groups (< 45 vs. > 45; < 50 vs. > 50 and < 55 vs. > 55) and line graphs and plotted 95% confidence intervals of mean weight loss by year were examined to discern differences in % weight loss by procedure type. Results: All patients were more likely to be female (79%) and Caucasian (62.5%); Nearly twice as many patients underwent bypass surgery (N=3104) compared to sleeve surgery (N=1307). Patients receiving bypass surgery had significantly higher BMI at baseline (49.2 + 8.9) than did those receiving sleeve surgeries (46.9 + 10.4, P < .001); no differences were found in mean age of patients in the two groups (44.1 and 43.7, respectively). Threeyear follow-up was analyzed for each group. As baseline BMI increases (> 45, > 50 and > 55), the mean % baseline weight loss increases accordingly for both LSG and LRYGB. Additionally, for each baseline BMI grouping % excess weight loss was greater in the higher BMI group for each procedure. Line graphs of % weight loss over time by LSG vs. LRYGB reveal a marginal superiority of the LRYGB over LSG across all BMI groups, although low N’s at the 3-year follow-up preclude interpretation as to the durability of weight loss. Conclusions: Preoperative BMI did not significantly impact weight loss in patients undergoing LSG versus LRYGB. However, across all BMI groups, patients undergoing LRYGB did have significantly higher weight loss. Procedure selection should be an individualized decision based on several patient factors, but based on these results we cannot recommend using preoperative BMI as a definitive parameter. A108 EFFECTS OF BARIATRIC SURGERY ON CHANGE OF BROWN ADIPOCYTE TISSUE AND ENERGY METABOLISM IN OBESE MICE Yan Gu Shanghai Shanghai shanghai Jiao Tong University Background: Bariatric surgery is an effective treatment for obesity causing changes in energy expenditure. Brown adipose tissue (BAT) is an energy-related organ, and the potential effects of bariatric surgery are yet to be investigated. Objective: To study the effects of different bariatric surgeries on GH/IGF-1 axis, brown adipocyte differentiation, and energy metabolism in obese mice and explore the underlying mechanisms. Methods: Mice were fed a high-fat diet for 12 weeks and subjected to different bariatric procedures. 8week surviving mice were divided into 4 groups: adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and shamoperation (SO). Preand postoperative weight, a metabolic index, content, and metabolic activity of BAT was recorded by micro-PET/CT. Altered energy metabolism was estimated by metabolic cage technology. Serum GH/IGF-1 level and the brown adipose cell differentiation-related gene expression: PRDM16 and UCP-1 by qRT-PCR were estimated. Results: By postoperative week 4, body weight, serum blood sugar, and serum cholesterol of the obese mice improved in the surgery groups. Serum GH and IGF-1 levels, and the content and metabolic activity of BAT increased postoperatively. The differentiation factors of the brown adipose cell were significantly stronger, energy consumption increased, and respiratory exchange frequency decreased post-operative. The effect was predominant in RYGB; SG demonstrated superior result to ABG. With weight regain 8-week postoperation, these parameters deteriorated in the operation groups, significantly in the GB group; the RYGB group seemed superior to the SG group. Conclusions: The GH/IGF-1 axis was significantly suppressed, the brown adipose cell differentiation factors down-regulated and the BAT content greatly reduced with a sharp decrease in energy metabolism in obese mice. Bariatric surgery elevated the GH/IGF1 levels, contributing to the differentiation of a brown adipose cell, promoting BAT regeneration, and decreasing the respiratory exchange frequency. This improves the body energy consumption resulting in weight loss; mostly evident in the RYGB group. A109 Rate of revisions or conversion following bariatric surgery over ten years in the state of New York Maria Altieri Rocky Point NY, Jie Yang STONY BROOK New York, Lizhou Nie stony brook New York, Robin Blackstone Phoenix AZ, Konstantinos Spaniolas Stony Brook NY, Mark Talamini Stony Brook NY, Aurora Pryor Stony Brook NY Stony Brook University Medical Center Stony Brook Hospital University Medical Center of Phoenix Introduction: Bariatric surgery proves to be the only efficacious treatment of obesity and obesity related comorbidities. A primary measure of the success of a procedure is whether or not additional surgery may be necessary. Multi-institutional studies regarding the need for re-operation following bariatric surgery is scarce. The purpose of this study is to evaluate the rate of revisions/conversions (RC) following three common bariatric procedures over ten years in the state of New York. Methods: The SPARCS database was used to identify all patients undergoing Laparoscopic Adjustable Gastric Banding (LAGB), Sleeve Gastrectomy (SG), and Roux-en-Y Gastric Bypass (RYGB) between 20042010. Patients with age<18 years, duplicate records, and lost to follow up (n=7,197) were excluded from analysis. Patients were followed for RC to other bariatric procedures for at least five years (up to 2015). Internal hernias (n=129) following RYGB were excluded from analysis. Univariate and multivariable logistic regression analysis was performed to identify risk factors for additional surgery. Results: There were 40,994 bariatric procedures with 16,444 LAGB, 22,769 RYGB, and 1,781 SG. Rate of RC was 26.03% for LAGB, 9.77% for SG, and 4.86% for RYGB. Multiple RC (=/>2) were more common for LAGB (5.7% for LAGB, 0.5% for RYGB, and 0.22% for LSG). Band revision/replacements required further procedures compared to patients who underwent conversion to RYGB/SG (939 compared to 48 procedures). Figure 1 shows the different procedures in each group. Time to subsequent procedure was 3.8 +/-2.3 years for LAGB, 3.6 +/-2.9 years for RYGB and 3+/2.2 years for SG. Majority of RC were not performed at initial institution (68.2% of LAGB patients, 75.9% for RYGB, 63.8% of SG). Risk factors for multiple procedures included surgery type, as LAGB was more likely to have multiple RC. In addition, patients having younger age, being female, having inpatient initial procedures, without liver disease, having experienced anastomotic complications, with COPD, or with psychoses were more likely to undergo multiple revisions (p-values<0.05). Conclusions: Reoperation was common for LAGB, but less common for RYGB (4.9%) and SG (9.77%). This may be partly due to perceived efficacy of conversion. RC are almost twice as likely following SG, raising concerns about long-term efficacy compared to RYGB. In addition, LAGB had the highest rate (5.7%) of multiple reoperations. However, very few reoperations were required for these patients after conversion to either sleeve or bypass, suggesting that conversion is a procedure of choic

Concomitant prophylactic cholecystectomy during bariatric surgery was once routinely performed in order to minimize the future risks of gallstone disease. Now, concomitant laparoscopic cholecystectomy is only selectively performed. This study analyzed outcomes of laparoscopic sleeve gastrectomy (LSG) with and without cholecystectomy (LC) using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry.