IMPORTANCE: Severe obesity and its related diseases, such as type 2 diabetes, hypertension, dyslipidemia, and sleep apnea, are very common in the United States, but currently very few patients with ...these conditions choose to undergo bariatric surgery. Summaries of the expanding evidence for both the benefits and risks of bariatric surgery are needed to better guide shared decision-making conversations. OBSERVATIONS: There are approximately 252 000 bariatric procedures (per 2018 numbers) performed each year in the US, of which an estimated 15% are revisions. The 1991 National Institutes of Health guidelines recommended consideration of bariatric surgery in patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 40 or higher or 35 or higher with serious obesity-related comorbidities. These guidelines are still widely used; however, there is increasing evidence that bariatric procedures should also be considered for patients with type 2 diabetes and a body mass index of 30 to 35 if hyperglycemia is inadequately controlled despite optimal medical treatment for type 2 diabetes. Substantial evidence indicates that surgery results in greater improvements in weight loss and type 2 diabetes outcomes, compared with nonsurgical interventions, regardless of the type of procedures used. The 2 most common procedures used currently, the sleeve gastrectomy and gastric bypass, have similar effects on weight loss and diabetes outcomes and similar safety through at least 5-year follow-up. However, emerging evidence suggests that the sleeve procedure is associated with fewer reoperations, and the bypass procedure may lead to more durable weight loss and glycemic control. Although safety is a concern, current data indicate that the perioperative mortality rates range from 0.03% to 0.2%, which has substantially improved since early 2000s. More long-term randomized studies are needed to assess the effect of bariatric procedures on cardiovascular disease, cancer, and other health outcomes and to evaluate emerging newer procedures. CONCLUSIONS AND RELEVANCE: Modern bariatric procedures have strong evidence of efficacy and safety. All patients with severe obesity—and especially those with type 2 diabetes—should be engaged in a shared decision-making conversation about the risks and benefits of surgery compared with continuing usual medical and lifestyle treatment, and the decision about surgery should be driven primarily by informed patient preferences.
Background
Bariatric surgery is a safe and effective treatment for clinically severe obesity, but inequity in male and female utilization is well recognized. Approximately 20% of patients undergoing ...bariatric surgery are male. This paper aims to describe differences in outcomes by gender and to understand the physiologic and psychological differences that may explain this gender gap.
Methods
We examined 61,708 patients from the Michigan Bariatric Surgery Collaborative (MBSC) undergoing primary bariatric surgery between 2006 and 2016. Clinical data regarding demographics, comorbidities, and outcomes were compared by gender. Preoperative and 1-year postoperative surveys gathered psychological outcomes.
Results
This cohort was consistent with the national population with approximately 22% male patients. There were several significant differences between males and females at the time of surgery. Males tended to be older, have a higher BMI, be married, have lower self-reported depression scores, and have more comorbidities (all
p
< 0.05). Postoperatively, males suffered more serious complications than women (2.67 vs. 2.12, respectively,
p
< 0.05). At 1 year postoperatively, males were significantly more satisfied with their operation despite increased complications, decreased weight loss, and decreased rates of comorbidity resolution as compared to females (all
p
< 0.05).
Conclusions
Despite significantly lower weight loss and increased complication rates, males tend to have markedly higher satisfaction and psychological well-being scores than females. To improve outcomes in males, earlier referral to surgery may help to significantly reduce their risk. Conversely, increased attention to psychological support in the perioperative period for females may lead to improved psychological outcomes (i.e., body image, depression, psychological well-being).
BACKGROUND:BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based ...recommendations for safe cholecystectomy and prevention of BDI.
METHODS:Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.
RESULTS:Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.
CONCLUSIONS:These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
OBJECTIVE:To quantify gender composition of 10 high-impact general surgery journals, delineate how board composition has changed over time, and evaluate qualification metrics by gender.
...BACKGROUND:Underrepresentation of women on editorial boards may contribute to the gender-based achievement gap in surgery.
METHODS:We performed a cross-sectional analysis of the editorial board gender composition among 10 high-impact general surgery journals in 1997, 2007, and 2017. Univariate and multivariate regression analyses were used to assess differences in editors’ H-indices, academic rank, and number of advanced degrees. Differences in editor turnover and multiple board positions were evaluated for each time interval.
RESULTS:Over 20 years, the proportion of women on editorial boards increased from 5% to 19%. After controlling for time since board certification, no differences between men and womenʼs number of advanced degrees, H-indices, or academic rank remained significant. Women and men were equally likely to hold multiple board positions (1997 P = 0.74; 2007 P = 0.42; 2017 P = 0.69), but menʼs editorial board tenure was longer across each time interval (1997–2007 P = 0.003; 2007–2017 P < 0.001; 1997–2017 P = 0.01).
CONCLUSIONS:Women surgeons have a small but growing presence on surgical editorial boards, and gender-based qualification differences are likely attributable to practice length. Menʼs longer tenure on editorial boards may drive some of the observed disparity by limiting new appointment opportunities. Strategies such as imposing term limits or instituting merit-based performance reviews may help editorial boards capture the fieldʼs changing demographics.
Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patient's and family's ...perspective, goals, and expectations. Here, Minneci et al determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children. When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery.
Background
Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the ...rate, management, and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve.
Methods
The New York State (NYS) Planning and Research Cooperative System longitudinal administrative database was used to identify patients. From 2005 to 2010, 156,315 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Patients were then tracked with unique identifiers for common bile duct injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery.
Results
From 2005 to 2010, 156,958 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Of the total patients, 149 patients underwent a biliary duct procedure within a year. Twenty-four of them were diagnosed with gallbladder cancer and excluded, leaving 125 for further analysis. The biliary injuries were identified at a rate of 0.080 %. Thirty-one of those patients (24.8 %) underwent hepatectomy, 40 patients (32.0 %) underwent hepaticoenterostomy, and 54 patients (43.2 %) underwent primary repair of the bile duct. Thirty-two (26 %) patients were repaired on the same day of their initial procedure. Of the remaining 93 patients, 38 (30 %) were repaired within 10 days, seven (6 %) repaired between 11 and 20 days, and 48 (38 %) patients over 21 days from injury.
Conclusion
In NYS, the rate of bile duct injury has now decreased to 0.08 % and mirrors the historical figures quoted for open cholecystectomy. This improvement likely reflects increased experience, improved instrumentation, and movement beyond the “learning curve.”
OBJECTIVE:The aim of this study was to understand relationships among insurance plan type, out-of-pocket cost sharing, and the utilization of bariatric surgery among commercially insured patients.
...BACKGROUND:Only 1% of eligible persons undergo bariatric operations, and this underutilization is often attributed to lack of insurance coverage. But even among the insured, underinsurance is now recognized as a major barrier to accessing medical care. The relationships among commercial insurance design, out-of-pocket cost sharing, and elective surgery utilization, particularly in bariatrics, are not well understood.
METHODS:Retrospective review of 73,002 commercially insured members of the IBM MarketScan commercial claims database who underwent bariatric surgery from 2014 to 2017. The exposure variables were insurance plan type and out-of-pocket cost sharing. The outcome was utilization of bariatric surgery. We also examined seasonal trends in bariatric surgery utilization stratified by average levels of cost sharing.
RESULTS:Utilization of bariatric surgery was higher in plans with lower cost sharing, such as PPOs (20 operations/100,000 enrollees) than in HDHPs (high-deductible health plans, 12.1 operations/100,000 enrollees). Overall, every $1000 increase in cost sharing was associated with 5 fewer bariatric operations per 100,000 insured lives; this association was strongest in plans with high cost sharing (high-deductible and consumer-directed health plans). Members of all plan types had higher surgical utilization in quarter 4 relative to quarter 1 of each year; these seasonal variations were also most pronounced in plans with high cost sharing.
CONCLUSIONS:Insurance plan types with higher cost sharing have lower utilization of bariatric surgery. Underinsurance may represent a newly identified barrier to surgical care that should be addressed by advocates and policymakers.
This Viewpoint discusses developing a more nuanced preoperative optimization strategy for hernia repair that considers patient and disease factors to determine the right operation for the right ...patient at the right time.
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