J. Hunter Mehaffey

Outcomes of laparoscopic Roux-en-Y gastric bypass in super-super-obese patients

BACKGROUND There is limited outcome data for super-super-obese (SSO) patients, those with Body Mass Index (BMI) ≥ 60 kg/m(2), who seek surgical treatment with Laparoscopic Roux-en-Y Gastric Bypass (LRYGB). A large single center LRYGB experience was reviewed to compare the safety and efficacy of LRYGB in SSO patients to the standard obese population undergoing this procedure. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database and an Institutional Review Board approved prospective database was used to identify all patients undergoing LRYGB by multiple surgeons at a single institution between 1/1/1994 and 11/15/2013. Preoperative co-morbidities, postoperative complications, 30-day outcomes, and weight loss at yearly intervals were analyzed to determine difference between SSO patients and NonSSO patients (BMI < 60 kg/m(2)). RESULTS Of the 2009 patients undergoing LRYGB over the past 20 years; 328 had BMI ≥ 60 kg/m(2). Preoperative co-morbidities, conversion to open, and length of stay were significantly increased among SSO patients; however there was no significant difference in postoperative outcomes or complications. Percent reduction of excess BMI beyond 12 months was significantly improved among NonSSO patients with less than 30% follow-up beyond 2 years. CONCLUSIONS LRYGB appears well tolerated for super-super-obese patients with BMI ≥ 60 kg/m(2) in experienced centers. These patients still have significant reduction in excess BMI despite being less than NonSSO patients undergoing RYGB. The ACS NSQIP database provides excellent tracking of institutional progress with bariatric surgical outcomes to facilitate the improvement of best practice techniques.

Lungs donated after circulatory death and prolonged warm ischemia are transplanted successfully after enhanced ex vivo lung perfusion using adenosine A2B receptor antagonism

Objective: The current supply of acceptable donor lungs is not sufficient for the number of patients awaiting transplantation. We hypothesized that ex vivo lung perfusion (EVLP) with targeted drug therapy would allow successful rehabilitation and transplantation of donation after circulatory death lungs exposed to 2 hours of warm ischemia. Methods: Donor porcine lungs were procured after 2 hours of warm ischemia postcardiac arrest and subjected to 4 hours of cold preservation or EVLP. ATL802, an adenosine A2B receptor antagonist, was administered to select groups. Four groups (n = 4/group) were randomized: cold preservation (Cold), cold preservation with ATL802 during reperfusion (Cold + ATL802), EVLP (EVLP), and EVLP with ATL802 during ex vivo perfusion (EVLP + ATL802). Lungs subsequently were transplanted, reperfused, and assessed by measuring dynamic lung compliance and oxygenation capacity. Results: EVLP + ATL802 significantly improved dynamic lung compliance compared with EVLP (25.0 ± 1.8 vs 17.0 ± 2.4 mL/cmH2O, P = .04), and compared with cold preservation (Cold: 12.2 ± 1.3, P = .004; Cold + ATL802: 10.6 ± 2.0 mL/cmH2O, P = .002). Oxygenation capacity was highest in EVLP (440.4 ± 37.0 vs Cold: 174.0 ± 61.3 mm Hg, P = .037). No differences in oxygenation or pulmonary edema were observed between EVLP and EVLP + ATL802. A significant decrease in interleukin‐12 expression in tissue and bronchoalveolar lavage was identified between groups EVLP and EVLP + ATL802, along with less neutrophil infiltration. Conclusions: Severely injured donation after circulatory death lungs subjected to 2 hours of warm ischemia are transplanted successfully after enhanced EVLP with targeted drug therapy. Increased use of lungs after uncontrolled donor cardiac death and prolonged warm ischemia may be possible and may improve transplant wait list times and mortality.

Airway pressure release ventilation during ex vivo lung perfusion attenuates injury

Objective: Critical organ shortages have resulted in ex vivo lung perfusion gaining clinical acceptance for lung evaluation and rehabilitation to expand the use of donation after circulatory death organs for lung transplantation. We hypothesized that an innovative use of airway pressure release ventilation during ex vivo lung perfusion improves lung function after transplantation. Methods: Two groups (n = 4 animals/group) of porcine donation after circulatory death donor lungs were procured after hypoxic cardiac arrest and a 2‐hour period of warm ischemia, followed by a 4‐hour period of ex vivo lung perfusion rehabilitation with standard conventional volume‐based ventilation or pressure‐based airway pressure release ventilation. Left lungs were subsequently transplanted into recipient animals and reperfused for 4 hours. Blood gases for partial pressure of oxygen/inspired oxygen fraction ratios, airway pressures for calculation of compliance, and percent wet weight gain during ex vivo lung perfusion and reperfusion were measured. Results: Airway pressure release ventilation during ex vivo lung perfusion significantly improved left lung oxygenation at 2 hours (561.5 ± 83.9 mm Hg vs 341.1 ± 136.1 mm Hg) and 4 hours (569.1 ± 18.3 mm Hg vs 463.5 ± 78.4 mm Hg). Likewise, compliance was significantly higher at 2 hours (26.0 ± 5.2 mL/cm H2O vs 15.0 ± 4.6 mL/cm H2O) and 4 hours (30.6 ± 1.3 mL/cm H2O vs 17.7 ± 5.9 mL/cm H2O) after transplantation. Finally, airway pressure release ventilation significantly reduced lung edema development on ex vivo lung perfusion on the basis of percentage of weight gain (36.9% ± 14.6% vs 73.9% ± 4.9%). There was no difference in additional edema accumulation 4 hours after reperfusion. Conclusions: Pressure‐directed airway pressure release ventilation strategy during ex vivo lung perfusion improves the rehabilitation of severely injured donation after circulatory death lungs. After transplant, these lungs demonstrate superior lung‐specific oxygenation and dynamic compliance compared with lungs ventilated with standard conventional ventilation. This strategy, if implemented into clinical ex vivo lung perfusion protocols, could advance the field of donation after circulatory death lung rehabilitation to expand the lung donor pool.

Bariatric surgery insurance requirements independently predict surgery dropout

BACKGROUND Many insurance companies have considerable prebariatric surgery requirements despite a lack of evidence for improved clinical outcomes. The hypothesis of this study is that insurance-specific requirements will be associated with a decreased progression to surgery and increased delay in time to surgery. METHODS Retrospective data collection was performed for patients undergoing bariatric surgery evaluation from 2010-2015. Patients who underwent surgery (SGY; n = 827; mean body mass index [BMI] 49.1) were compared with those who did not (no-SGY; n = 648; mean BMI: 49.4). Univariate and multivariate analysis were performed to identify specific co-morbidity and insurance specific predictors of surgical dropout and time to surgery. RESULTS A total of 1475 patients using 12 major insurance payors were included. Univariate analysis found insurance requirements associated with surgical drop out included longer median diet duration (no-SGY = 6 mo; SGY = 3 mo; P<.001); primary care physician letter of necessity (P<.0001); laboratory testing (P = .019); and evaluation by cardiology (P<.001), pulmonology (P<.0001), or psychiatry (P = .0003). Using logistic regression to control for co-morbidities, longer diet requirement (odds ratio [OR] .88, P<.0001), primary care physician letter (OR .33, P<.0001), cardiology evaluation (OR .22, P = .038), and advanced laboratory testing (OR 5.75, P = .019) independently predicted surgery dropout. Additionally, surgical patients had an average interval between initial visit and surgery of 5.8±4.6 months with significant weight gain (2.1 kg, P<.0001). CONCLUSION Many prebariatric surgery insurance requirements were associated with lack of patient progression to surgery in this study. In addition, delays in surgery were associated with preoperative weight gain. Although prospective and multicenter studies are needed, these findings have major policy implications suggesting insurance requirements may need to be reconsidered to improve medical care.

Risk Associated With Complications and Mortality After Urgent Surgery vs Elective and Emergency Surgery: Implications for Defining “Quality” and Reporting Outcomes for Urgent Surgery

Importance Given the current climate of outcomes-driven quality reporting, it is critical to appropriately risk stratify patients using standardized metrics. Objective To elucidate the risk associated with urgent surgery on complications and mortality after general surgical procedures. Design, Setting, and Participants This retrospective review used the American College of Surgeons National Surgery Quality Improvement Program database to capture all general surgery cases performed at 435 hospitals nationwide between January 1, 2013, and December 31, 2013. Data analysis was performed from November 11, 2015, to February 16, 2017. Exposures Any operations coded as both nonelective and nonemergency were designated into a novel category titled urgent. Main Outcomes and Measures The primary outcome was 30-day mortality; secondary outcomes included 30-day rates of complications, reoperation, and readmission in urgent cases compared with both elective and emergency cases. Results Of 173 643 patients undergoing general surgery (101 632 females and 72 011 males), 130 235 (75.0%) were categorized as elective, 22 592 (13.0%) as emergency, and 20 816 (12.0%) as nonelective and nonemergency. When controlling for standard American College of Surgeons National Surgery Quality Improvement Program preoperative risk factors, with elective surgery as the reference value, the 3 groups had significantly distinct odds ratios (ORs) of experiencing any complication (urgent surgery: OR, 1.38; 95% CI, 1.30-1.45; P < .001; and emergency surgery: OR, 1.65; 95% CI, 1.55-1.76; P < .001) and of mortality (urgent surgery: OR, 2.32; 95% CI, 2.00-2.68; P < .001; and emergency surgery: OR, 2.91; 95% CI, 2.48-3.41; P < .001). Surgical procedures performed urgently had a 12.3% rate of morbidity (n = 2560) and a 2.3% rate of mortality (n = 471). Conclusions and Relevance This study highlights the need for improved risk stratification on the basis of urgency because operations performed urgently have distinct rates of morbidity and mortality compared with procedures performed either electively or emergently. Because we tie quality outcomes to reimbursement, such a category should improve predictive models and more accurately reflect the quality and value of care provided by surgeons who do not have traditional elective practices.

Coronary artery bypass grafting bundled payment proposal will have significant financial impact on hospitals

Objectives The Centers for Medicare and Medicaid Services plans to institute a 5‐year trial of bundled payments for coronary artery bypass grafting through 90 days after discharge. To investigate the impact, we reviewed actual inpatient costs for patients undergoing bypass surgery relative to the target price. Methods A total of 13,276 Medicare patients with estimated cost data underwent isolated coronary artery bypass grafting from 2008 to 2015 in 18 hospitals over 8 Medicare‐defined regions within the Commonwealth of Virginia. Actual 2015 inpatient costs were compared with estimated target prices for each year of the pilot, based on the previous 3 years and stratified by Diagnosis‐Related Group. Results The mean 2015 cost per patient was

Targets to prevent prolonged length of stay after endovascular aortic repair

50,394 with high variation (range,

Increasing circulating sphingosine-1-phosphate attenuates lung injury during ex vivo lung perfusion

27,862‐

Cost of individual complications following coronary artery bypass grafting

74,169). On average, hospitals would receive a refund of

Clinical significance of failure to lose weight 10 years after roux-en-y gastric bypass

17,682 in year 1, but then owe Medicare increasing amounts up to