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A101 is no consensus for the optimum limb Does the RYGB Common Limb lengths to obtain the best results. Length influence Hypertension Remission, Weight Loss and Cardio- Objective: To evaluate if there is any Metabolic Parameters? Data from correlation between the common limb the GATEWAY TRIAL. (CL) length with hypertension Carlos Schiavon Sao Paulo 1, Dimas remission rate, WL and other cardio- Ikeoka Sao Paulo 2, Renato Santos São metabolic parameters in the Paulo 1, Eliana Santucci São Paulo 3, GATEWAY TRIAL surgical patients. Tamiris Miranda São Paulo 1, Lucas Damiani São Paulo 1, Juliana Methods: GATEWAY is a randomized Oliveira Sao Paulo 1, Camila trial designed to evaluate the efficacy Torreglosa São Paulo 1, Priscila of RYGB on hypertension Bueno São Paulo 1, Angela Bersch- improvement and other cardio- Ferreira SÃO PAULO 4, Patrcia metabolic parameters in patients with Noujaim Sao Paulo 5, Ricardo grade 1 and 2 obesity compared to Cohen Sao Paulo 6, Helio Halpern sao medical therapy. We randomized (1:1) paulo 5, Frederico Monteiro São a hundred patients and we analyzed 45 Paulo 5, Marcio Sousa Sao Paulo 7, patients submitted to RYGB with 1 Celso Amodeo São Paulo 7, Luiz year of follow-up. We measured the Bortolloto São Paulo 8, Otávio entire bowel in all patients and used a Berwanger Sao Paulo 9, Alexandre 150cm alimentary limb (AL) and a Cavalcanti São Paulo SC1, Luciano 100cm biliopancreatic limb (BPL). Drager São Paulo 8 Univariate logistic regression was used Research Institute - Heart to analyze associations of CL length Hospital1 Intensive Care Unit - Heart with hypertension remission. Pearson Hospital2 Reserch Institute - Heart and Spearman correlation were used to Hospital3 Research Institute Heart evaluate the correlation between the CL Hospital4 Surgical Center - Heart length and the variance of weight loss, Hospital5 Oswaldo Cruz German glycemic/A1c, HDL and LDL Hospital6 Dante Pazzanese Institute of cholesterol and triglycerides levels. Cardiology7 Heart Institute, Hypertension Unit8 ARO - Albert Results: 51% of the patients from the Einstein Hospital9 RYGB group showed hypertension remission (controlled blood pressure Background: Although Roux-en-Y without medication). CL length was not Gastric Bypass (RYGB) results for significantly associated with weight loss (WL) and cardio-metabolic hypertension remission (Figure)(odds improvement are well established, there ratio [95% CI] for 50 units increase in

30 www.obesityweek.com the CL: 0.97[0.68; 1.38], p =0.88). the last 16 years. Kidney function Pearson and Spearman Correlation measured as glomerular filtration rate showed no significant correlation for (GFR) and proteinuria were assessed WL and the others cardio-metabolic using the Chronic Kidney Disease parameters (Table). Epidemiology Collaboration Study (CKD-EPI) equation/classification and Conclusions: CL length does not have Urinary albumin/creatinine ratio influence over hypertension remission, (uACRmg/g) classification of the WL and cardio-metabolic parameters National Kidney Foundation after a standard RYGB. guidelines. All measurements assessed pre-operatively up to 3months and at 12 months. A102 RESULTS Effects of bariatric surgery on the Among the 2924 patients reviewed, glomerular integrity of morbidly 2.35%(n=69) presented all the variables obese patients with chronic kidney for (CKD-EPI) GFR-calculation and disease (CKD). uACR measurement at 12 months. Our David Romero Funes Weston FL1, population was predominantly David Gutierrez Blanco Weston FL1, Caucasian women 65.21%(n=45) and Mauricio Sarmiento-Cobos Weston 1, 73.91%(n=51) respectively, with a Rama Rao Ganga Columbia MO1, mean age of 60±13.42. The most Emanuele Menzo Weston FL1, Samuel prevalent procedure was LSG Szomstein North Miami Beach FL1, 60.86%(n=42). The most significant Raul Rosenthal miami FL2 improvements were in patients with Cleveland Clinic Florida1 Cleveland CKD stage 3 showing a Clinic of FL2 48.67ml/min/1.73m2 difference at 12 months (P=0.0001) (Table 1.). The INTRODUCTION uACR showed improvement in all Obesity induces glomerular injury stages of CKD and a most significant through hyperfiltration. Albuminuria improvement in the patients with can gauge glomerular integrity and severely increased albuminuria, with an reflects the increased glomerular improvement of -739mg/g at 12 months permeability. The objective of our (p=0.0252). study is to assess the beneficial extent of bariatric surgery in patients with CONCLUSIONS CKD. Bariatric surgery has a clear positive impact on the improvement of kidney METHODS function. Furthermore, our findings We conducted a retrospective chart suggest that bariatric surgery has a review of all patients who underwent positive effect on the glomerular Bariatric surgery at our institution for permeability and the regression of

31 glomerular injury. These findings (LSG) or Roux-en-Y gastric bypass suggest a relationship between the (RYGB) who were compared to n=505 physiologic mechanisms of bariatric CMS<65. surgery and the kidney function. Results (Table): CMS65 had a higher percentage of white race, more metabolic comorbidities (hypertension, A103 hyperlipidemia), renal disease and a Bariatric Surgery is Safe and higher Charlson co-morbidity index. Effective in ALL Medicare Patients However, there were no differences in Regardless of Age peri-operative outcomes between the Jai Prasad Danville PA1, Jacob groups. After adjusting for gender, Petrosky Danvillle PA1, Jason race, BMI, presence of metabolic Kuhn Danville PA1, Robert disease (diabetes, hypertension, Cunningham Danville PA1, James hyperlipidemia), and surgery type, the Dove Danville PA1, Marcus %TBWL was higher in CMS<65 Fluck Danville PA1, Christopher (31.8%) as compared to CMS65 Still Danville PA1, G. Craig (29.3%, p<0.0001). After adjusting for Wood Danville PA1, David DiaRem score and surgery type, the Parker Danville PA1, Jon rate of complete remission was higher Gabrielsen Danville PA1, Anthony in the CMS<65 group (HR=2.10, Petrick Danville PA1 p=0.011). Geisinger1 Conclusions: The safety of bariatric surgery in CMS65 patients is similar Introduction: Studies have shown to CMS<65 patients. CMS<65 patients Bariatric surgery in older patients is had greater total body weight loss (2.5 safe and effective. However, it is points more) and a greater chance of unclear how the outcomes of bariatric compete diabetes remission. However, surgery differ within the Medicare bariatric surgery was safe and effective population. The purpose of this study in both groups. was to evaluate the safety and efficacy of bariatric surgery in older (CMS65) and younger (CMS<65) Medicare A104 patients. Bariatric Surgery Reduces The Incidence of Atrial Fibrillation: A Methods & Procedures: A Propensity Score Matched Analysis prospectively maintained database of Kevin Lynch Charlottsville VA1, James 3300 patients who underwent bariatric Mehaffey Charlottesville VA, Robert surgery between January 2007 and Hawkins Charlottesville Virginia, December 2017 was utilized. There Taryn Hassinger Charlottesville VA, were n=139 CMS 65 who underwent Bruce Schirmer Charlottesville , Peter Laparoscopic sleeve gastrectomy

32 www.obesityweek.com Hallowell Charlottesville VA, Jennifer development of AF did not differ Kirby Charlottesville VA between groups. Finally, patients University of Virginia1 undergoing surgery who developed AF had significantly greater reduction in Introduction: Obesity is associated with excess BMI then those managed an increased risk of atrial fibrillation medically who developed atrial (AF). Bariatric surgery results in a high fibrillation (55.8% vs -8.3%, p<0.001). rate of long-term weight loss and is associated with amelioration of several Conclusion: The prevalence of AF was chronic comorbidities. We hypothesize lower among patients who underwent weight reduction with bariatric surgery bariatric surgery than their medically will reduce the long-term incidence of managed counterparts. Weight AF. reduction with bariatric surgery may reduce the long-term incidence of atrial Methods: All patients who underwent fibrillation. bariatric surgery at a single institution (n=3,572) from 1985-2015 were A105 propensity score matched 1:1 to a Bariatric Surgery Decreases control population (n=42,987) of Mortality of Congestive Heart morbidly obese patients with outpatient Failure: A Nationwide Study appointments in our clinical data Essa Aleassa Winnipeg MB1, Zhamak repository. Patients with prior AF were Khorgami Tulsa OK1, Chao excluded. Relevant comorbidities, Tu Cleveland OH1, Philip demographics and insurance status Schauer Cleveland OH1, Stacy were collected and a chart review was Brethauer Cleveland OH1, Ali performed for all patients with AF. Aminian Pepper Pike OH1 Paired univariate analyses were used to Cleveland Clinic1 compare the two groups. Background: The impact of bariatric Results: After propensity score surgery on hard cardiovascular events matching, a total of 5,034 patients has been less characterized. were included (2517 surgery vs 2517 medical). There was no difference in Methods: 2,810 patients with a preoperative body mass index (BMI) principal diagnosis of congestive heart (47.9 vs 47.80, p=0.36) or medical failure (CHF) who also had history of comorbidities (Table) with an average prior bariatric surgery were identified follow-up of 7.9 years. The incidence in the National Inpatient Sample of AF was lower in the bariatric database (2007-2014). These patients surgery population than the medical were matched 1:5 with patients who population (0.8% vs 2.9%, p=0.0001) had similar principal diagnoses but no while time from enrollment to history of bariatric surgery (controls).

33 Propensity scores, balanced on 30 baseline characteristics, were used to significantly lower in patients with assemble two control groups. Control history of bariatric surgery compared group-1 included patients with obesity with control group-1 (0.96% versus (BMI 35kg/m2) only and control 1.86%, OR 0.52, 95%CI 0.35-0.77, group-2 were matched according to p=0.0013) and control group-2 (0.96% post-surgery BMI with the bariatric versus 1.86%, OR 0.52, 95%CI 0.35- surgery group. Multivariate regression 0.77, p=0.0011). Furthermore, LOS models were utilized to calculate the was significantly shorter in bariatric odds ratio (OR) and 95% confidence surgery group compared with control interval (CI) of mortality (primary group-1 (4.8±4.4 versus 5.7±5.7 days, endpoint) and length of stay (LOS, p<0.001) and control group-2 (4.8±4.4 secondary endpoint) in CHF patients versus 5.4±6.3 days, p<0.001). with and without history of bariatric surgery. Conclusion: Findings of this study, for the first time, suggest that prior Results: A total of 33,720 (weighted) bariatric surgery is associated with patients were included in the analysis. almost 50% reduction in in-hospital The distribution of covariates was well- mortality and shorter LOS in patients balanced after propensity matching. with CHF. Mortality rates after CHF were

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A106 Sharaiha NYC NY11, Steven Aspiration Therapy for the Edmundowicz Aurora CO12, J. Treatment of Obesity: 2-4 Year Matthew Bohning Langhorne PA5, Results of the PATHWAY Michael Jensen Rochester MN2, Alpana Multicenter Randomized Controlled Shukla New York NY6, Caroline Trial Apovian Boston MA13, DONG WOOK Christopher Thompson Boston MA1, KIM Boston MA13, Daniel Barham Abu Dayyeh Rochester MN2, Tran Washington DC14, Amir Vladimir Kushnir st louis MO3, Robert Zarrinpar La Jolla CA15, Michele Kushner Chicago IL4, Alan Ryan Boston MA1, Meredith Schorr Langhorne PA5, Louis Young Doral FL, Abigail Lowe Denver Aronne New York NY6, Anastassia CO, Miki Haas Philadelphia PA, Heidi Amaro Philadelphia PA7, David Goldsmith , Jennifer McCrea King of Jaffe Philadelphia PA7, Allison Prussia PA, Shelby Sullivan Aurora Schulman Ann Arbor MI8, Dayna CO Early St. Louis MO9, Adam Brigham and Women's Hospital1 Mayo Stein Chicago IL10, Reem Clinic, Rochester, MN

34 www.obesityweek.com USA2 Washington University St Louis, year. Mean baseline BMI of these 55 St. Loui3 Northwestern University participants was 42.1+5.0 kg/m2. Feinberg School4 St. Mary Medical Center, Langhorne, PA5 Weill Cornell Results Medical College6 University of Pennsylvania, Philadelphia7 Michigan Compared to baseline, weight loss, Medicine Internal quality of life scores, and improvement Medicine8 Washington University in St. in select cardiometabolic parameters at Louis9 Northwestern University10 Weill year 1 were maintained at Years 2, 3 Cornell Medicine11 University of and 4. There were no clinically Colorado Denver12 Boston Medical siginifcant metabolic or electrolytes Center13 Howard disorders observed, nor any evidence of University14University of California, a development of an eating disorder. San Diego15 Primary reasons for discontinuation of therapy included fatigue with the Background therapy or study and achievement of weight loss goal. There was no loss to The AspireAssist is the first FDA- follow-up. approved endoluminal device indicated for treatment of Class II and III obesity. Conclusions We earlier reported one-year results of the PATHWAY study: a 10-center This randomized controlled trial has randomized controlled trial involving shown that Aspiration Therapy is an 171 participants with the treatment arm effective, durable and safe weight loss receiving Aspiration Therapy (AT) plus therapy for people with Class II and III Lifestyle Therapy and the control arm obesity. receiving Lifestyle Therapy (2:1 randomization). Here, we report 2-4 year outcomes. A107 MANOMETRIC CHANGES Methods AFTER SLEEVE GASTRECTOMY, ARE THERE Per protocol, AT participants were ANY PREOPERATIVE allowed to continue in the study after MANOMETRIC FINDINGS THAT the first year for an additional 4 years COULD PREDICT REFLUX? providing they achieved at least 10% Luciano Poggi Lima 1, Gerardo total weight loss from baseline at one Arredondo Lima 1, Felix year. Of the 82 AT participants who Camacho Lima 1, Omar Ibarra 1, Diego completed one-year, 57 met this Romani Lima 2, Luis Poggi Lima 27 1 criterion at one-year; 55 participants elected to continue the study beyond 1-

35 CLINICA ANGLO 11mmhg to 20 mmhg and the AMERICANA1 CLINICA intragastric pressure after 100cc of ANGLOAMERICANA2 water swallow went from 24 mmhg to 142 mmhg. Preoperative esophageal Introduction: Sleeve gastrectomy is dismotility was associated with reflux currently the most common bariatric after surgery procedure performed. One of its most (OR=1.62).Conclusion: Sleeve concerning secondary effect is gastrectomy and reflux are associated alteration of the antireflux mechanism. with esophageal dismotility and a Several theories have been described to marked increase in the intragastric explain the etiology of “de Novo” pressure,which proves that the Sleeve reflux. Methods: A retrospective Gastrectomy is a high-pressure system. search of our prospectively collected database between 2006-2016 was conducted to identify patients with A108 preoperative and postoperative Efficiency and safety of One esophageal manometry studies. We Anastomosis Gastric Bypass versus also included the intragastric pressure, Roux-en-Y Gastric Bypass: baseline and after 100 ml water preliminary data of the YOMEGA swallow. Patients also answered a randomized controlled trial . survey during follow up regarding Maud Robert LYON 1, Philippe reflux symptoms. Our goal was to Espalieu Saint Etienne 2, Elise evaluate the physiological PELASCINI Lyon 3, robert consequences on esophageal and Caiazzo Lille Hauts de France4, Adrien gastric manometry perioperatively and STERKERS 5, Litavan its relationship with reflux. A total of KHAMPHOMMALA Saint gregoire 56 patients were included in our GU5, Tigran POGHOSYAN Paris 6, analysis. Results:The lower esophageal Adriana Torcivia Bondy 7, JEAN portion was found to have a decrease in MARC CHEVALLIER PARIS 6, pressure from 99 mmhg to 88 mmhg Vincent MALHERBE GUILHERAND before and after surgery respectively. GRANGES 8, Elie The lower esophageal sphincter (LES) CHOUILLARD POISSY 9, Fabian mean pressure decreased from 12.5 to RECHE Grenoble 10, Delphine 8.7mmhg (p<0.001). 18 of 56 patient MAUCORT-BOULCH Lyon FL3, had a baseline incompetent LES and Sylvie BIN LYON 3, Francois after surgery 35 patients were classified Pattou Lille 4, Emmanuel DISSE Pierre as an incompetent LES (p<0.001). 10 Benite 11 patients prior to surgery had esophageal Edouard Herriot University Hospital, dismotility and after surgery this Department of bariatric number increased to 18 (p=0.013). surgery1 Hôpital Privé de la Intragastric pressure increased from Loire2 Edouard Herriot University

36 www.obesityweek.com Hospital3 Centre Hospitalier mean EBL% was not different between Universitaire Lille4 Clinique Saint RYGB and OAGB (84.7 vs 88.9; p= Grégoire5 Hôpital Européen Georges 0.18). Mean HbA1c and serum albumin Pompidou6Hôpital Pitié at 1 year were lower in 0AGB (-0.6%, Salpétrière7 Hôpital Privé Drôme p<0.01; -0.8g/L, p=0.03, respectively). Ardèche8 POISSY-SAINT-GERMAIN- At the time of this analysis, 65 SAE EN-LAYE MEDICAL CEN9 Centre related to surgery have been reported Hospitalo-Universitaire (23 in RYGB vs 42 in OAGB group). Grenoble10 Centre Hospitalier Lyon The mean number of SAE (0/1/2/3/4) Sud11 experienced by each patient was higher after OAGB (101/18/7/2/1) than after BACKGROUND RYGB (106/13/5/0/0) (P=0.03, One anastomosis gastric bypass Poisson Regression). (OAGB) is increasingly used in the CONCLUSION treatment of morbid obesity. The Preliminary results of the YOMEGA efficiency and safety outcomes of this Study show no significant difference of procedure remains however debated. weight loss after 1 year between OAGB We report here the preliminary data of and RYGB, slightly lower levels of YOMEGA, a randomized controlled HbA1c and serum albumin after trial comparing the outcomes of OAGB OAGB and a higher risk of SAE after vs standard Roux-en-Y gastric bypass OAGB (RYGB). METHOD YOMEGA is a prospective multicenter, A109 open label, randomized clinical trial Employing New Enhanced Recovery comparing OAGB vs RYGB Goals for Bariatric Surgery (NCT02139813). Study primary (ENERGY): A Metabolic and outcome was excess body mass index Bariatric Surgery Accreditation and loss (EBL%) at 2 years. Here, we Quality Improvement (MBSAQIP) analyzed EBL%, glucose control National Quality Improvement (HbA1c) and nutritional status (serum Project albumin) at 1 year, and serious adverse Stacy Brethauer Cleveland OH1, events (SAE). Variables were Anthony Petrick Danville PA2, Arielle compared using adequately t-test, Man- Grieco Chicago IL3, Teresa Whitney test, Chi2 and Poisson Fraker Chicago IL3, Kimberly Evans- regression. Labok Chicago IL3, April RESULTS Smith Omaha NE4, Matthew From May 2014 to March 2016, 9 high McEvoy Nashville TN5, John volume institutions enrolled 253 Morton Stanford CA6 patients with morbid obesity (129 Cleveland Clinic1 Geisinger Health OAGB vs 124 RYGB). After one year, System2 American College of

37 Surgeons3 Creighton of ttheir patients did not receive University4 Vanderbilt postoperative opioids. University5 Stanford University6 Conclusion: Implementation of a large-scale enhanced recovery project Introduction: To date, there have been in bariatric surgery is feasible. The no large-scale enhanced recovery first 6 months of the ENERGY project projects in bariatric surgery. The aim has seen a decrease in ALOS and of this project was to implement a ELOS without increasing adverse multi-center enhanced recovery events or readmissions. Better protocol for selected MBSAQIP adherence to the ENERGY protocol centers. was associated with decreased Methods: Participating sites were ELOS. Opioid-free recovery was identified based on historical extended achieved in 27% of patients. length of stay (ELOS, 4 days). A six- month run-up period was used to allow implementation of the protocol. Primary procedures were A110 included in the analysis which Metabolic surgery versus best compared historical data (2016) to the medical management for type 2 first six months of the diabetes: Interim analysis of the project. Relationships between REMISSION prospective controlled adherence to 28 process measures and trial ELOS were analyzed. Laurent Biertho Quebec Quebec, Results: 36 centers participated with a Mélanie Nadeau Quebec City , Melissa total of 4692 eligible cases in the first 6 Pelletier Québec , Simon months of the study period compared to Marceau Quebec City , Stefane 8696 in 2016. Adherence to the Lebel Sainte Foy AB, Frederic-Simon process measures increased from 59% Hould Quebec AB, Francois during the run-up period to 78% during Julien Quebec QC, Francois the study period. Comparing 2016 Dube Québec , Denis Richard , Andre cases to the first 6 months of Tchernof Quebec City 1 ENERGY, average LOS decreased Laval University Medical Center1 from 2.24 to 1.76 days (p<0.001) and ELOS decreased from 8.2% to 4.4% Background: The effects of sleeve (p<0.001) without increased bleeding, gastrectomy (SG), Roux-en-Y gastric reoperation, or readmission bypass (RYGB) and biliopancreatic rates. There was a significant diversion with duodenal switch (BPD- association between increased DS) have never been directly compared adherence to the protocol and in a well-controlled, prospective decreased odds of ELOS (p<0.001). study. Methods: Interim analysis of a Participating centers reported that 27% prospective non-randomized controlled

38 www.obesityweek.com trial comparing SG, RYGB or BPD-DS Complete T2DM remission rates were to best medical treatment in obese 79%, 37% and 39% in patients patients with Type 2 Diabetes (T2DM). receiving BPD-DS, RYGB and SG Evolution of T2DM was based on respectively (p=0.06). International Diabetes Federation Improvement/partial remission was criteria. Differences in weight loss respectively observed in 21%, 62% and trajectories were tested in patients with 53%. Outcomes for all surgical arms complete 12-month data with were significantly superior to medical adjustment for baseline treatment which induced a - BMI. Results: 177 patients were 0.8±2.9%EWL, 27% T2DM recruited. Baseline BMI was improvement with no complete or significantly different in the BPD-DS, partial remission. Conclusion: At one RYGB, SG and Control group year, the three current bariatric (48.8±5.0, 41.0±2.5, 44.5±4.9 and operations are superior to medical 42.5±6.7kg/m2 respectively, p<0.0001). treatment for weight loss and T2DM At 12 months, BPD-DS induced remission. BPD-DS induces significantly greater weight loss significantly more weight loss and compared to RYGB and SG, at higher diabetes remission rates 90.7±2.7 (n=29), 63.2±3.6 (n=15) and compared to the other surgical 58.3±2.0% (n=42) Excess Weight Loss approaches. RYGB and SG have a (EWL), respectively (p<0.0001). comparable impact on weight loss and Weight loss trajectories of RYGB and diabetes remission. SG patients did not differ significantly.
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A268 bariatric surgeries. PONV impedes The Effects of a Dexamethasone- recovery and may lengthen the duration based Prophylaxis Protocol on and, thereby, the cost of the hospital Postoperative Nausea and Vomiting stay. In this study, we have (PONV) and the Duration and determined the effects of a prophylaxis Associated Cost of the Hospital Stay protocol involving high dose Sharon Krzyzanowski Harmony FL1, dexamethasone on the incidence and Keith Kim Celebration FL1, Dennis severity of PONV and the length of the Smith Celebration FL1, Michele hospital stay (LOS). Young Celebration FL1, cynthia Methods. The antiemetic protocol buffington Celebration FL1 consisted of 10 mg Dexamethasone (IV Florida Hospital Celebration Health1 early intraoperatively and 8 hours postoperatively), 4 mg ondansetron Introduction. Postoperative nausea (intraoperatively), and early (4 hour) and vomiting (PONV) is common with introduction to fluids. PONV severity

39 was assessed by the need for antiemetic Maher El Chaar Allentown PA1, Jill rescue medication (RM). Protocol Stoltzfus Bethlehem PA2, Keith effectiveness was determined pre- and Gersin Charlotte NC3, Kyle post-protocol by examining PONV Thompson Charlotte NC3 severity, LOS and costs for 104 (52/52) St Luke's University Hospital1 St luke's Roux-en-Y gastric bypass and 104 University and Health (52/52) sleeve gastrectomy (SG) Network2 Carolinas Medical Center3 patients similar in age, weight and gender. Introduction: The objective of this Results. The dexamethasone-based study is to evaluate the outcome and protocol significantly improved both safety of sleeve (SG) and gastric the incidence and severity of bypass (GB) based on patient PONV. After initiation of the characteristics and develop a risk protocol, the percentage of patients prediction model for the occurrence of with severe PONV (5 RM) declined Serious Adverse Events (SAE) and from 33% to 10% and the percentage of readmission within the first 30-days patients without PONV (0 RM) following surgery using for the first increased from 27% to time the MBSAQIP data registry. 62%. Reduction in PONV severity Methods: Using the 2015 MBSAQIP was associated with a significant PUF we selected all SG and GB and (p<0.01) decrease in LOS. Duration of then we created two separate direct hospitalization post-protocol fell from multivariate logistic regression models 2.36 to 1.63 days (p<0.0001) for all using SAS 9.4 (Cary, NC) for the patients, i.e. RYGB=2.44 to 1.76 days, following outcomes: 1) Serious SG=2.27 to 1.49 days. The reduction Adverse Events (SAE) and 2) in LOS resulted in an average cost readmissions. We included 12 savings of $428.35 per person. covariates in our models. We report c- Conclusions. A protocol involving statistic as measures of the models’ high dose dexamethasone improves the predictive capability. Models goodness incidence and severity of PONV and of fit was assessed using Pearson's chi significantly reduces the duration and square. External validation was costs of hospitalization. performed using 2016 MBSAQIP PUF. Results: For the SAE and readmission models , the following covariates significantly and independently A269 predicted complications: preoperative A Novel Risk Prediction Model for BMI (AOR 1.07 and 1.05) GB surgery Complications and Readmissions (AOR 2.08 and 1.81), cardiovascular Following Bariatric Surgery Based disease (AOR 1.43 and 1.61); smoking on the MBSAQIP database (AOR 1.12 and 1.14); diabetes (AOR 1.15 and 1.08); hypertension (AOR

40 www.obesityweek.com 1.17 and 1.11); limited ambulation surgery is relatively unknown. (AOR 1.48 and 1.55); sleep apnea Objective: To evaluate the association (AOR 1.12 and 1.11) and history of of postoperative complications on the pulmonary embolism (AOR 2.81and subsequent risk of VTE following 2.35). sleeve gastrectomy and gastric SAE and readmission models had a c- bypass. statistic of 0.64 and 0.61 respectively Methods: Utilizing a statewide clinical and a significant Pearson’s chi square. registry, all patients undergoing sleeve Conclusion: Using the MBSAQIP gastrectomy (34,460) and gastric database and for the first time we have bypass (28,568) from June 2006 thru developed a clinical risk prediction September 2017 were assessed for model for SAE and readmission in the postoperative complications and first 30-days following bariatric subsequent VTE within 30 days surgery. following surgery. Multivariate analyses were adjusted for patient specific risk factors for VTE. A270 Results: The rate of VTE in these Postoperative complications increase 63,028 patients was 0.475%. The mean the risk of venous thromboembolism age and BMI were 46 years and 48 following sleeve gastrectomy and kg/m2 with 79% female and 76% gastric bypass white. A surgical or medical Arthur Carlin Detroit MI1, Oliver complication was associated with VTE Varban Ann Arbor MI2, Jonathan in 51% of those having a VTE. All Finks Ann Arbor MI2, Matthew complications were significant Weiner West Bloomfield MI, Aaron predictors of VTE (p<0.0001). The Bonham Ann Arbor MI2, Amir most common associated complications Ghaferi Ann Arbor MI2 were respiratory (17%) and hemorrhage Henry Ford Health System - Wayne (15%). Of the surgical complications State University1 University of leak/perforation (OR 21; 95% CI 12.3- Michigan2 36.7) was most strongly associated with VTE, followed by hemorrhage (OR 9; Background: Patient specific risk 6.2-13), obstruction (OR 5; 2.6-7.8) factors associated with venous and infection (OR 4; 2.4-7.4). Overall thromboembolism (VTE) following medical complications were strongly bariatric surgery are currently used to associated with VTE (OR 21; 12.7- direct routine 35.2). chemoprophylaxis. Additional Conclusions: Postoperative innovative strategies are required to complications increase the risk of VTE further reduce VTE. The impact of following bariatric surgery. Strategies postoperative complications on to extend the duration and intensity of subsequent risk of VTE after bariatric chemoprophylaxis should be

41 considered in patients that develop Results: The RA approach postoperative complications to mitigate significantly lengthened operation time the risk of VTE. by 26 and 34 minutes, respectively, for SG and RYGB, without affecting the time from operation to discharge (see A271 Table for details). The RA approach MBSAQIP National Registry Study did not affect the 30 day mortality rate of Robotic-assisted Outcomes in for either surgery. However, healthcare Patients Undergoing Sleeve service utilization was differentially Gastrectomy or Roux-en-Y Gastric affected. Within SG, RA slightly but Bypass significantly increased the rates of Pavlos Papasavas Hartford CT1, intervention and ED visits. In contrast, Richard Seip Glastonbury CT2, Andrea within RYGB, ED visit rate was Stone Glastonbury CT1, Tara unaffected, but rates of intervention, re- McLaughlin Hartford CT3, Darren admission, and re-operation were Tishler Glastonbury CT1 increased. RA RYGB was associated Hartford Hospital - Metabolic and with less blood transfusions. Bariat1 Hartford Hospital Metabolic Conclusion: The RA approach and Bariatric Surgery Center2 Hartford lengthens surgical time but is as safe as Hospital3 the conventional laparoscopic approach. For RYGB, the conventional Introduction: Robotic-assisted (RA) laparoscopic approach favors small bariatric surgery is increasing. We reductions in re-admit, re-op and investigated the safety of the RA intervention while robotic assist results surgical approach in the context of in lesser need for blood sleeve gastrectomy (SG) and Roux-en- transfusion. Some of these differences Y gastric bypass (RYGB) as principle may not be clinically relevant and may bariatric procedures. be the result of preoperative differences Methods: The MBSAQIP 2015-16 in patient characteristics. registry included patients who
underwent conventional laparoscopic A111 SG (N=84,651), RA SG surgery Current role of staple line (N=6,945), conventional laparoscopic reinforcement in 30-day Outcomes of RYGB (N=33,682), and RA RYGB Primary Laparoscopic Sleeve (N=2,270). Cases that were converted Gastrectomy: An analysis of from laparoscopic to open were MBSAQIP data, 2015-2016 PUF included. Excluded were patients who Andrew Demeusy Baltimore MD1, underwent previous foregut surgery; Anne Sill Baltimore MD1, Andrew whose surgery represented revision or Averbach Baltimore MD1 conversion; emergent cases, and cases St. Agnes Hospital1 with other or concurrent CPT codes.

42 www.obesityweek.com Background: Laparoscopic Sleeve mortality. Staple line reinforcement is Gastrectomy (LSG) has become a associated with decreased rates of dominant bariatric procedure. In the bleeding and reoperations, but does not past, significant leak rates prompted the affect leak rates. The selection of search for staple line reinforcement staple line reinforcement technique techniques. Previous analysis of should be left to surgeon’s discretion MBSAQIP database for all LSG with an understanding of the risks, suggested a detrimental influence of benefits and costs of the various staple line reinforcement on leak rates techniques. and overall morbidity. Objective: Investigate the relationship between various staple line A112 reinforcement techniques and bougie The impact of chronic kidney disease size with 30-day outcomes. on peri-operative outcomes following Setting: MBSAQIP-accredited bariatric surgery: An analysis of the bariatric surgery hospitals. MBSAQIP Participant Use Data File Methods: Using the MBSAQIP 2015- Michael Mazzei Philadelphia PA1, 2016 Participant Use File (PUF) data, Michael Edwards Philadelphia PA1 primary LSG cases were divided in Temple University Hospital1 study groups based on staple line reinforcement techniques. All variables Introduction: Morbid obesity is were reported in PUF except leak rate considered a strong independent risk and overall morbidity which had to be factor for chronic kidney disease derived. Multiple bivariate analyses (CKD), and bariatric surgery remains were used to analyze the 30-day the most effective treatment for outcomes. obesity-related comorbidities. Previous Results: A total of 198,339 primary large database analyses have suggested LSG operations were included and that CKD does not independently grouped into No reinforcement (No increase the risk of adverse outcomes SLR, 23%), Staple Line Reinforcement following bariatric surgery. The safety (SLR, 54%), Over-sewn Staple Line of elective bariatric surgery in this (OSL, 9%), and a combination of patient population remains unclear. We SLR+OSL (13%). There were no compared 30-day outcomes in this statistical differences between study patient population after laparoscopic groups in mortality, overall morbidity, sleeve gastrectomy (LSG) or gastric or leak rate. Bleeding and reoperation bypass (LGB). rates were statistically higher in the No Methods: Using the Metabolic and SLR group. Bougie size was not Bariatric Surgery Accreditation Quality associated with change in leak rates. Improvement Program (MBSAQIP) Conclusion: Primary LSG is a safe database, we identified patients with procedure with a low morbidity and CKD who underwent LSG or LGB in

43 2015 or 2016. An un-matched cohort Schauer Cleveland OH1, Ali analysis as well as a propensity- Aminian Pepper Pike OH1 matched cohort analysis was performed Cleveland Clinic1 McGill University2 of patients with and without CKD. Results: Of the 302,092 patients who Background: Safety profile of bariatric underwent a LSG or LGB in 2015- surgery in patients with class I obesity 2016, 2,362 (0.7%) had CKD, of which (BMI 30-35 kg/m2) has been a matter 837 (35.4%) required dialysis. CKD of concern among patients and patients were older with significantly physicians. higher rates of comorbid conditions. HLOS, unplanned ICU Methods: The Metabolic and Bariatric admission, reoperation, readmission, Surgery Accreditation and Quality bleeding, cardiopulmonary, infectious Improvement Program (MBSAQIP) complications and mortality were dataset was queried for patients with a significantly higher in CKD patients. In BMI30 and <35kg/m2 who underwent a matched analysis of 3,592 patients, primary bariatric procedures in 2015-6. poorer outcomes in CKD patients were The 30-day postoperative safety preserved, including 30-day profile, predictors of adverse events, readmission, reoperation and and comparison between Roux-en-Y intervention (Table 1). gastric bypass (RYGB) versus sleeve Conclusions: In contrast to previously gastrectomy (SG) were studied. reported large database analysis, chronic kidney disease and dependence Results: A total of 8,628 cases with a on dialysis independently increases the mean preoperative BMI of 33.7±1.1 risk of some 30-day adverse outcomes kg/m2 were analyzed: 1,838 (21.3%) following primary bariatric surgery. RYGB, 6,243 (72.4%) SG, 532 (6.1%) The benefits conferred by bariatric gastric banding, and 17 (0.2%) surgery should be carefully weighed duodenal switch procedures were against the increased risk of performed. 33.9% had diabetes and complications in this challenging 75% had hypertension. Incidence of all surgical population. individual major complications was <0.3% in this cohort except for postoperative bleeding (0.9%). The composite morbidity rate (defined as A113 presence of any of 24 postoperative How Safe is Bariatric Surgery in adverse events) for the entire cohort Patients with Class I obesity (BMI was 3.8%, and the serious morbidity 30-35 kg/m2)? rate (presence of any of 9 serious Xiaoxi Feng Cleveland OH1, Amin complications) was 0.7%. The 30-day Andalib Westmount QC2, Stacy mortality rate was 0.05% (4 cases). Brethauer Cleveland OH1, Philip Presence of diabetes (OR: 2.4, 95%CI:

44 www.obesityweek.com 1.4-3.9), cardiac disease (OR: 4.2, Methods: Using the 2015 and 2016 95%CI: 2.1-8.6), and chronic kidney database of accredited centers, data was disease (OR: 11.1, 95%CI: 3.3-37.0) analyzed for primary sleeve were predictors of serious morbidity. gastrectomy (SG), Roux-en-Y gastric Patients who underwent SG had bypass (RYGB) and biliopancreatic significantly better short-term safety diversion with duodenal switch outcomes than patients who underwent (BPDDS) to determine the outcomes of RYGB (Table 1). anastomotic/staple line leak (A/SL). Multivariable logistic regression was Conclusion: Findings of this study, the used to evaluate the effect of IOLT on largest series to date, indicate that the outcomes of interest. bariatric surgery, which is a two-hour Results: A total of 266,665 patients surgery requiring less than two-day who underwent SG (69.9%), RYGB hospital stay, is safe in patients with (29.3%) or BPDDS (0.8%) were BMI<35 kg/m2. analyzed. IOLT was performed in 81.9% of all cases. Overall A/SL and mortality rate in patients with leak were A114 0.5% and 0.012%, respectively. There The Effect of Intraoperative Leak was no significant difference between Testing on Postoperative Leak- the IOLT and non-IOLT groups after related outcomes after Bariatric and SG or RYGB in terms of A/SL Metabolic Surgery: An Analysis of (0.5%vs0.5% in SG, 0.5%vs0.4% in the MBSAQIP Database RYGB), leak-related readmission Kamthorn Yolsuriyanwong Hat Yai 1, (0.3%vs0.3% in SG, 0.2%vs0.1% in Bipan Chand Maywood IL2, Eric RYGB), leak-related reoperation Marcotte Maywood IL2 (0.2%vs0.2% in SG, 0.3%vs0.3% in 1. Loyola University Chicago Stritch RYGB), leak-related intervention School of Medicine, IL, USA. ... 2. (0.3%vs0.3% in SG, 0.2%vs0.2% in Songklanagarind Hospital, Prince of RYGB) or organ/space surgical site Songkla University, Thailand1 Loyola infection (0.3%vs0.3% in SG, University Chicago Stritch School of 0.6%vs0.8% in RYGB). However, Medicine, Maywood, IL, USA2 patients who underwent BPDDS with IOLT had significantly fewer A/SL Background: Intraoperative leak (2.7%vs7.2%, adjusted odds ratio: 0.36, testing (IOLT) is commonly performed 95% confidence interval: 0.20- to evaluate the integrity of an 0.65, p<0.001) compared with non- anastomosis or staple line during IOLT group. bariatric surgery. We aimed to evaluate Conclusion: The overall rate of A/SL the impact of IOLT on postoperative and leak-related morbidity was low. leak-related outcomes after bariatric This study provided no evidence of surgery. benefit or harm from IOLT in patients

45 who underwent SG or RYGB. in BPDDS patients. However, IOLT should be considered
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A115 regression analysis Cardiac Complications after Bariatric Surgery: Does the Type of Results: 108,432 patients (SG: 54.6% Procedure Matter? and RYGB: 45.4%) were analyzed. 116 Zhamak Khorgami Tulsa OK1, Ali patients (0.1%) were diagnosed with Aminian Pepper Pike OH2, Theresa CAEs and 3,670 patients (3.4%) Jackson Tulsa OK1, James Sahawneh 1, experienced dysrhythmia. Median Guido Sclabas Tulsa OK1, Geoffrey (interquartile range) of LOS was 4.5(4) Chow Tulsa OK1 days in patients with CAEs compared University of Oklahoma - to 2(1) days in patients without CAEs Tulsa1 Cleveland Clinic, Ohio2 (P<0.001). There were 43 deaths in the entire cohort, and 31 (0.8%) was in Introduction: Cardiac complications patients with CAEs or dysrhythmias after surgery are among the major (p<0.001). In patients with CAEs, postoperative events that may need mortality was similar in RYGB and several diagnostic studies, advanced SG. On multivariate analysis, six interventions, and may increase length independent predictors of CAEs were of stay (LOS) and mortality. identified (Table). RYGB vs. SG was not an independent predictor for CAEs Method: Data of adult patients with (odds ratio: 1.41, 95%confidence morbid obesity who underwent primary interval: 0.77-2.55). sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were retrieved Conclusion: While CAEs are rare from the Nationwide Inpatient Sample after bariatric surgery, their occurrence database (2011-2015). Cardiac adverse can increase LOS and mortality. Older events (CAEs) were identified as a age, male gender, and cardiopulmonary composite variable including comorbidities predict CAEs. RYGB myocardial infarction (MI), acute does not add the overall risk of CAEs ischemic heart disease without MI, and comparing to SG. acute heart failure. Dysrhythmias (except premature beats) were also identified as a separate outcome. A116 Association of demographic factors, Cardiovascular Biomarkers after BMI, comorbidities, and type of Metabolic Surgery versus Medical surgery (SG vs. RYGB) with CAEs Therapy for Diabetes: Insights from was assessed using multivariate the STAMPEDE Trial

46 www.obesityweek.com Deepak Bhatt Boston MA1, Sangeeta cardiovascular risk including Kashyap Cleveland OH2, Philip apolipoprotein A1, high-sensitivity C- Schauer Cleveland OH2, Ali reactive protein, and plasminogen Aminian Pepper Pike OH2, John activator inhibitor-1 were significantly Kirwan Cleveland Ohio2, Kathy improved in both surgical groups at 5 Wolski Cleveland OH2, Stacy years compared with the medical Brethauer Cleveland OH2, Steven group. Furthermore, myeloperoxidase, Nissen Cleveland OH2 interleukin-6, leptin, and uric acid were Harvard Medical School1 Cleveland significantly reduced after RYGB Clinic2 compared with IMT. Leptin was reduced after RYGB compared with Background: Longitudinal studies SG. Changes in apolipoprotein B, have shown that bariatric and metabolic lipoprotein (a), homocysteine, and pro surgery is associated with significant B-type natriuretic peptide were not reduction in cardiovascular events and statistically significant among the study mortality. The Surgical Treatment And groups. Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) Conclusion: In patients with T2DM, trial showed that 5-years after bariatric surgery is associated with randomization, Roux-en-Y gastric long-term favorable changes in key bypass (RYGB) and sleeve gastrectomy cardiovascular biomarkers compared (SG) were superior to intensive medical with IMT. These findings can provide therapy (IMT) alone in achieving direction for studies on the possible glycemic control in patients with type 2 mechanisms of cardio-protection after diabetes mellitus (T2DM). The aim of metabolic surgery. this study was to assess long-term changes in cardiovascular biomarkers after surgical versus medical treatment A117 of T2DM. Sleeve Gastrectomy in obese, Wistar rats improves diastolic function Methods: Blood samples for independent of weight loss. measurement of 11 cardiovascular Jennifer Strande Milwaukee WI1, John biomarkers were available in 100 Corbett MILWAUKEE WI1, Gwen patients (IMT n=25, RYGB n=39, SG Lomberk Milwaukee WI1, Tammy n=36) at baseline and 5-years after Kindel Milwaukee WI1 randomization. Percent changes from Medical College of Wisconsin1 baseline were compared between the study groups. Introduction. Heart failure with preserved ejection fraction (HFpEF) is Results: Table 1 summarizes the the most common cause of heart failure findings. Biomarkers associated with and characterized by impaired diastolic

47 relaxation. Bariatric surgery stress-induced signaling and changes in significantly improves diastolic glucose transporters independent of relaxation due to unknown weight loss. SG may improve diastolic mechanisms. In this study, we tested dysfunction due to changes in cardiac the hypothesis that a sleeve metabolism initiated by the entero- gastrectomy (SG) will improve cardiac axis and translate to extending diastolic dysfunction independent of metabolic surgery to patients with weight loss. HFpEF independent of obesity status.

Methods. Male, Wistar rats were fed a high-fat (HF) or low-fat (LF) diet for A118 10 weeks followed by SG-HF, pair-fed Development of a Bariatric Surgery sham (PF-HF), ad-lib sham (AL-HF), Specific Scoring Syestem for or ad-lib LF sham surgery (n=10-14 per Screening Patients at Risk for group). Echocardiograms were Perioperative Myocardial Infarction. performed pre- and at 8 weeks post- Amlish Gondal Tucson AZ1, Chiu- operatively. At 10 weeks, blood was Hsieh Hsu Tucson AZ1, Rostam collected 15 minutes after a liquid Khoubyari Tucson AZ2, Matthew meal. Left ventricular tissue was Mobily Tucson AZ1, Iman Ghaderi 3 analyzed for mRNA and protein The University of Arizona1 CareMore expression. Health2 University of Arizona3

Results. PF-HF rats weighed the same Background: as SG-HF rats throughout the study Perioperative myocardial infarction period. Only SG induced a significant (MI) is a dangerous cardiac improvement in diastolic relaxation complication after non-cardiac surgery. (IVRT pre: 14.7 ± 2.3 msec, post: 11.2 Bariatric surgery, due to its ± 1.8 msec, p<0.001). SG intraabdominal nature, has traditionally significantly increased glucagon-like been considered an intermediate risk peptide-1 (GLP-1) compared to PF-HF procedure; however, there is limited rats (p=0.03) without a change in total large scale data on MI rates and its bile acids, glucose or insulin predictors in patients undergoing concentrations. Surprisingly, there was bariatric surgery. a significant decrease in cardiac FXR Methods: gene expression (p=0.04) and in down- Patients undergoing primary bariatric stream effectors of the GLP-1 receptor surgery were identified from the including p38-MAPK (p=0.01) and Metabolic and Bariatric Surgery GLUT-1 (p=0.003). Accreditation and Quality Improvement Program (MBSAQIP®) Discussion. SG improved diastolic participant use file(PUF) 2016. function with a significant reduction in Preoperative characteristics that

48 www.obesityweek.com correlated with perioperative MI were Can surgical weight loss reduce the identified by multiple regression risk of developing Coronary Heart analysis. PUF 2015 was used to Disease? validate the scoring system developed David Gutierrez Blanco Weston FL1, from initial analysis. David Romero Funes Weston FL1, Results: Cristian Milla Matute Davie FL1, Rama A total of 172017 patients were studied Rao Ganga Columbia MO1, Emanuele from PUF 2016. Event rate for MI Menzo Weston FL1, Samuel within 30 days of the operation was Szomstein North Miami Beach FL1, 3/10000 procedures; with a mortality Raul Rosenthal miami FL2 rate of 17.3% in patients who had an Cleveland Clinic Florida1 Cleveland MI. Four variables correlated with Clinic of FL2 perioperative MI on regression analysis, including history of a previous INTRODUCTION MI (OR= 8.57, CI=3.4-21.0), Coronary Heart Disease(CHD) is the preoperative renal insufficiency leading cause of death in the United (OR=3.83, CI=1.2-11.4), States, with obesity being one of its hyperlipidemia (OR=2.60, CI=1.3-5.1), major modifiable risk factors. The aim and age>50 (OR=2.15, CI=1.1-4.2). of this study is to determine the impact Each predicting variable was assigned a of bariatric surgery, especially score of 1 and event rate for MI was Laparoscopic Sleeve assessed with similarly increasing risk Gastrectomy(LSG), on the risk of score in PUF 2015. The risk increased developing CHD. from 8.7 per 100000 operations with a METHODS score of 0 to 3.2 per 100 with a score of We retrospectively reviewed all 4. patients who underwent Bariatric Conclusion: Surgery from 2010 to 2016. All The incidence of MI after bariatric patients between 30 and 74 years of age surgery is lower than other without a previous Coronary Heart intraabdominal surgeries, however, Disease were included in our study. mortality with perioperative MI is high. The risk score for predicting the This simple scoring system can be used incidence of CHD was measured by bariatric surgeons to identify preoperatively and at 12 months of patients who will benefit from focused follow-up. perioperative cardiac workup. RESULTS Of the 1330 patients studied, 225(16.9%) patients had all the required variables to calculate the CHD risk score. The mean age of our A119 population was 51.44±11.29years, mostly females (67%N=152) and

49 Caucasians (58.7%N=132). All the School of Medicine4 NY State major metabolic parameters improved Psychiatric Inst5 12 months after surgery (Table1). The mean percentage of estimated BMI loss Background and percentage of total weight loss at Laparoscopic adjustable gastric 12 months follow-up was 69.07% and banding (AGB) is used to treat obesity 26.65% respectively. The CHD primarily in adults. Less is known preoperative risk was 8.87±7.66% or 8- about long-term results of AGB in fold higher than the ideal risk. After 12 adolescents. We report outcomes of months of follow-up, females had a AGB at five years in teenagers with 2.71% absolute risk reduction(ARR) severe obesity. corresponding to a 42.01% Relative Risk Reduction(RRR), and males had an ARR of 5.4%(RRR:38.82%). The Methods improvement was significant after both Adolescents (14-19 years) underwent LSG and RYGB (Table 2). AGB in an FDA-approved CONCLUSION observational clinical trial. Outcomes Surgical weight-loss, especially after measured included anthropometric Laparoscopic Sleeve Gastrectomy, has measurements, co-morbidities, an important role in the reduction of the complications, and band retention. risk of developing Coronary Heart Individuals who missed visits were Disease. Further studies should assess contacted to maximize data these findings in a long-term follow- collection. Continuous variables were up. analyzed with an unpaired t-test when two groups were compared or with analysis of variance (ANOVA) when A120 more than two groups were compared. Adolescent Gastric Banding: a five- year longitudinal study in 137 Results individuals One hundred thirty-seven subjects Jeffrey Zitsman New York NY1, Mary underwent AGB (94 female, 43 male; DiGiorgi New York NY2, Janet 43 % Caucasian, 37% Hispanic, 17% Kopchinski New York NJ3, Robyn African-American; 4% other). Mean Sysko New York NY4, Lori Lynch New age and body mass index (BMI) pre- York NY3, Michael Devlin New York operatively were 17.0 + 1.2 years and NY5, Ilene Fennoy New York NY3 48.3 + 8 kg/m2. Comorbidities were Morgan Stanley Children’s Hospital of present in 71%. Maximum weight loss NY Presbyterian1 Pacira occurred by 36 months and continued Pharmaceuticals2 Morgan Stanley through five years for most Children's Hospital/NYP3 Mt Sinai subjects. Twenty-three (32%) of 72 adolescents achieved loss of 50%

50 www.obesityweek.com calculated excess weight at 5 years, with long-term weight loss and representing 17% of all morbidity in severely obese children subjects. Weight loss was associated and adolescents (aged 5-21 years) who with improvement in comorbid underwent laparoscopic sleeve conditions; weight regain resulted in gastrectomy (LSG) in our center. relapse. Complications requiring Methods additional surgery occurred 80 times in Our standardized prospective outcomes 63 patients. Twenty-six percent of research program database was queried subjects contacted at five years had for data pertaining to all nonsyndromic undergone band removal. children and adolescents who underwent LSG since the inauguration Conclusions of the program. Baseline and annual AGB helps some adolescents with visit data regarding weight loss, obesity lose weight and improve their readmissions and postoperative adverse health. Early operative morbidity is events were analyzed for the purpose of low, but 50% of patients require this study. additional surgery. Available data Results support sleeve gastrectomy and gastric 2,019 children and adolescents bypass over AGB in adolescents with underwent LSG during the study severe obesity. period. Baseline age and body mass index (BMI) were 15.2 ± 3.8 years and 46.4 ± 10 kg/m2. Male:Female ratio A121 was 1:1. Mean % excess weight loss Sleeve Gastrectomy in 2,019 (%EWL) at one (N=1,296), three Children and Adolescents: Nine (N=503), five (N=144), seven (N=55), Years Long-Term Outcomes and nine years (N=14) was 55.4 ± Aayed Alqahtani Riyadh 1, Yara 21.5%, 79.1 ± 27.6%, 84.9 ± 39.1%, Alqahtani 2, Mohamed 86.3 ± 50.6%, and 71.6 ± 49.8%, Elahmedi Riyadh Central Region2 respectively. King Saud University1 Obesity Chair, Among those who completed at least King Saud University2 five years of follow-up, 9.5% had occasional fatigability, and 19% had Background moderate-to-severe symptoms of Bariatric surgery has proven safety and gastroesophageal reflux disease efficacy in inducing significant weight (GERD). There were no bariatric- loss and co-morbidity resolution in related readmissions, significant children and adolescents. However, morbidity or mortality after surgery long-term evidence in this age group is Conclusions yet to be reported. LSG induces significant, sustained Objective long-term weight loss without To report single-surgeon experience significant safety concerns, being the

51 longest reported follow-up to date. Weight loss is shown in the table for However, a fifth of patients developed Years 1-3. In the 1st, 2nd, and 3rdyears, long-term symptoms of GERD, and a 0, 3, and 10 AT participants, tenth reported occasional fatigability. respectively, withdrew; 5 participants withdrew because they reached their weight-loss goal. Mean percent excess A122 weight-loss (%EWL) at the time of A comparative 100-participant 5- withdrawal was 43%. In the first 3 year study of aspiration therapy years, 0 AT and 20 RYGB participants versus roux-en-y gastric bypass: 2nd were lost to follow-up (LFU). In the and 3rd year results AT group one buried bumper in both Erik Wilson Houston TX1, Erik Years 2 and 3 were reported; no Noren Karlskrona 2, Jakob complication data is available on after Gruvaeus Karlskrona 2, Christian Year 1 in the RYGB group. Paradis Karlskrona 2 University of Texas McGovern Conclusions Medical School at Houston1 Blekinge The RYGB grouped experienced County Hospital2 greater weight loss than AT participants at Year 1-3, but more Background serious complications in Year 1 than Aspiration therapy (AT) is the first the AT group in 3 years. Both groups FDA-approved endolumenal procedure saw a slight trend in weight regain at for primary weight loss and is indicated Year 3 from Year 1. for patients with Class II and III obesity IWilson et al, ASMBS 2017. and for long duration of use. We earlier reported Year-1 results of a study at Blekinge County Hospital in Karlskona, Sweden comparing AT to A123 Roux-en-Y gastric bypass (RYGB) The Effects Of Endoscopic and involving ~100 participants.i We report Surgical Bariatric Interventions On on year 2 and 3 results. Gastric Emptying: A Systematic Methods Review and Meta-analysis Standard inclusion and exclusion Eric Vargas Rochester MN1, Fateh criteria for weight loss surgery at Bazerbachi Rochester MN1, Tarek Blekinge were used for both arms. The Sawas Rochester MN1, Andrew two arms were matched in age and Storm Rochester MN1, Andres baseline health status. Mean baseline Acosta Rochester MN1, Barham Abu body mass index was 42.6+7.5 and Dayyeh Rochester MN1 41.1+5.0 kg/m2for the AT and RYGB Mayo Clinic1 participants, respectively. Results

52 www.obesityweek.com Introduction: Gastric emptying is a inclusion criteria for the meta-analysis. fundamental regulator of appetite, and After SG, the pooled mean change in can have prognostic implications on gastric emptying at 3 months was a weight loss, symptoms and quality of significant acceleration in T1/2 gastric life after weight loss endoscopic and emptying by 27.5 minutes (95% CI: surgical interventions. We sought to 14.7-40.3). Significant heterogeneity characterize and quantify these changes was found (I2=92%). During IGB after a variety of bariatric endoscopic therapy, the pooled mean delay in and surgical interventions Methods: A gastric emptying was -44.7 minutes comprehensive search of multiple (95% CI: - 89.5 - 0.18). Significant databases through Jan 2018 was heterogeneity was found conducted for gastric emptying, (I2=85.5%). On priori subgroup bariatric surgery and endoscopic analysis, air-filled balloons did not bariatric therapies by 2 independent significantly delay emptying (pooled reviewers. Outcome of interest was mean T1/2=2.88 min) whereas fluid- T1/2(minutes) measured through filled balloons significantly delayed gastric scintigraphy before and after emptying (pooled mean T1/2= - 132.3 intervention. A random effects model min). Conclusion: Sleeve was used to pool the mean change in gastrectomy accelerates gastric T1/2 (minutes). Heterogeneity was emptying while fluid-filled IGBs delay calculated using the I2 statistic. Quality gastric emptying. Air-filled IGBs have assessment was performed using the no impact on gastric emptying. These Newcastle-Ottawa Scale for findings give insights into physiologic nonrandomized studies.Results: A total mechanisms of action of these of 704 citations were reviewed with interventions 9 SG and 5 IGB citations fulfilling
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A124 Cottam Salt lake City UT1, John Is Weight Loss Better if Staged Ambrose Ambrose 3, Walter Single Anastomosis Duodeno-ileal Medlin Salt Lake City UT1, Christina Bypass is Performed within the First Richards Salt Lake City UT1, Legrand Year of Sleeve Gastrectomy? Belnap Salt Lake City UT1, Samuel Hinali Zaveri Salt Lake City UT1, Amit Cottam Salt Lake City UT1, Benjamin Surve Salt Lake City UT1, Daniel Horsley Salt Lake City UT1 Cottam Salt Lake City UT2, Peter Bariatric Medicine Institute1 Bariatric Ng Raleigh NC3, Lindsey Medical Institute2 REX Surgical Sharp Raleigh NC3, Dustin Specialists Bariatric Speci3 Bermudez Raleigh NC3, Sophia Menozzi Raleigh NC3, Austin

53 Introduction: The failure rates of surgery. Sleeve gastrectomy (SG) are increasing especially in patients with super A125 obesity. The two-stage approach to EFFECT OF SINGLE single anastomosis duodeno-ileal ANASTOMOSIS DUODENAL- bypass with sleeve gastrectomy (SADI- ILEAL BYPASS WITH SLEEVE S) allows the surgeons to do the SG GASTRECTOMY ON GLUCOSE first and conversion to SADI if failure TOLERANCE TEST: is identified. Weight loss after SG stalls COMPARISON WITH OTHER by 12-18 months. However, if this is BARIATRIC PROCEDURES true then what should be the golden (ROUX-EN-Y GASTRIC BYPASS, period to perform this conversion, in SLEEVE GASTRECTOMY AND order maximize the weight loss? BILIOPANCREATIC DIVERSION) Aim: We present and compare the Luca Sessa Rome 1, Valerio weight loss outcomes of revision Spuntarelli ROME 1, Caterina SADI-S if it is done within and after Guidone Roma 1, Pierpaolo the 1st year of SG. Gallucci Rome 1, Giulia Method: Retrospective analysis of the Giannetti rome 1, Amerigo prospective kept database from 2 US Iaconelli Rome 1, Esmeralda centers were performed. Sixty-one Capristo Rome 1, Piero patients were identified and were Giustacchini Rome 1, Luigi divided into 2 groups: Group A (n=26) Ciccoritti Roma 1, Chiara received revision SADI, within the first Bellantone Rome 1, Giuseppe year of SG because of super obesity Nanni Roma 1, Geltrude and Group B (n=35) received revision Mingrone Roma 1, Marco SADI, one year after the SG due to Raffaelli Rome 1 weight loss failure or weight regain. Università Cattolica del Sacro Cuore, Results: The two groups lost Rome1 statistically similar % excess weight lost (EWL) after SG. Post-SADI, group Background. No data have been B had rapid excess weight loss in first 6 reported regarding the risk of months; however; thereafter group A hyperinsulinemic response and reactive lost more weight compared to group B hypoglycemia after single anastomosis and this difference was statistically duodenal-ileal bypass with sleeve significant (p<0.001). The EWL for gastrectomy (SADI -S). Furthermore group A and group B at 24 months was comparative studies with other bariatric 67.6% and 63.3% respectively (fig. 1). procedures are lacking. We compared Conclusion: Weight loss is better if response to oral glucose tolerance test staged SADI is performed within the (OGTT) in patients who underwent first year of SG and patients go on to SADI-S, Roux-en-Y gastric bypass lose similar weight to primary SADI-S (RYGP), sleeve gastrectomy (SG) and

54 www.obesityweek.com biliopancreatic diversion (BPD). subsequent hypoglycemia with respect to RYGB and SG. Methods. Consenting consecutive non- diabetic patients, matched for age, sex and pre-operative BMI, who underwent A126 SADI-S, RYGB, SG and BPD were Comparison of Laparoscopic Sleeve recruited. An OGTT with 75 g of oral Gastrectomy Leak Rates in Five glucose bolus was performed pre- and Staple-Line Reinforcement Options: post-operatively (2 months after A Systematic Review. surgery). Plasma insulin (pIns-μUI/mL) Paul Kemmeter Grand Rapids MI1, and glucose (pGlu–mg/dL) were Michel Gagner Montreal QC2 measured at baseline, +30, +60, +90, Grand Health Partners1 Hopital du +120, +150, +180 minutes. Severe Sacré Coeur, Montréal, QC, Ca2 hypoglycemia was defined as pGlu concentration 50 mg/dL. Background: Staple-line leaks following laparoscopic sleeve Results. Thirty-five patients were gastrectomy (LSG) remain a recruited: 9 SADI-S, 11 RYGB, 7 SG, concerning complication. Staple-line 8 BPD. Comparing preoperative and buttressing is largely adopted as an postoperative responses to OGTT, all acceptable reinforcement, but data the procedures result effective in regarding leaks have been equivocal. improvement of glycemic control with Objectives: This study compared better early results after SADI-S and staple-line leaks in five reinforcement BPD when compared to RYGB and SG options during LSG: no reinforcement as shown Figure1 reporting the mean (NO-SLR), oversewing (Suture), pIns and pGlu levels, respectively. No nonabsorbable bovine pericardial strips patients showed severe hypoglycemia. (BPS), tissue sealant or fibrin glue Significantly more patients who (Seal), or absorbable polymer underwent RYGB and SG showed membrane (APM). asymptomatic pGlu 70 mg/dL after Setting: University and Community post-operative OGTT when compared Hospitals with SADI-S and BPD (63.6% and Methods: A systematic review study 57.1% Vs 22.2% and 12.5%, of articles published between 2012- respectively, p<0.05). 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Conclusions. Similarly to BPD, SADI- Systematic Reviews and Meta- S seems associated with an Analyses guidelines. Variables of improvement in insulin sensitivity and interest included leak rates, bleeding, glucose homeostasis with a reduced and complications in addition to risk of hyperinsulinemic response and surgical and population parameters. An independent Fisher's exact tests were

55 used to compare the number of patients with and without leaks for the different Introduction: Bariatric surgery has reinforcement options. demonstrated efficacy in weight loss. Results: Of the 1,633 articles Existing studies suffer from loss to identified, 148 met inclusion criteria follow-up, and most long-term data and represented 40,653 patients. focuses on Roux-en-Y gastric bypass Differences in age (older in APM; (LRYGB). This study compares weight p=0.001), starting body mass index loss in patients >5 years from (lower in Suture; p=0.008), and laparoscopic sleeve gastrectomy (LSG) distance from pylorus (closer in BPS; to matched patients who underwent p=0.04) were observed between LRYGB. groups, but mean bougie size was Methods: We prospectively evaluated equivalent. The overall leak rate of patients who underwent LSG before 1.5% (607 leaks) ranged from 0.7% for August 2012 with follow-up data >5 APM (significantly lower than all years. LSG patients were matched 1:1 groups; p0.007) to 2.7% (BPS). with post-LRYGB patients by sex, age Conclusions: This systematic review at surgery, and preoperative BMI. of staple-line leaks following LSG Univariate and multivariate analysis demonstrated a significantly lower rate was performed with weight loss at the using APM staple-line reinforcement as longest duration the primary outcome. compared to oversewing, use of IRB approval was obtained. tissue sealants, BPS reinforcement, or Results: One-hundred sixty-five no reinforcement. Variation in surgical patients underwent LSG during the technique may also contribute to leak study period. Long-term follow-up data rates. (>5 years) was available for 85 patients (52%). There were no preoperative differences between those with and A127 without follow-up data. 6 (7%) LSG Beyond Five Years: A Matched patients were excluded as they Cohort of Sleeve vs Bypass underwent re-operation which altered Katherine Blevins Stanford CA1, Luis intestinal anatomy. Of the 79 patients Garcia Fargo ND2, Joe remaining, 75 were matched with post- Forrester Stanford CA1, John LRYGB patients. The average follow- Morton Stanford CA2, Dan up period was 6.4y for LSG and 6.5y Azagury Stanford CA2 for LRYGB (p=0.08, NS). Percent of Stanford University, Department of excess body weight loss (%EBWL) Surgery, Division of General was 37% for LSG vs 67% for LRYGB Surgery1 Stanford University, (p<0.0001). Weight loss for LSG Department of Surgery, Division of follow-up in clinic vs outside clinic was General Surgery, Bariatric and 46% vs 34% (p=0.18, NS). Minimally Invasive Surgery2

56 www.obesityweek.com Conclusion: LSG is now the most S) has become increasingly popular for common bariatric surgery in the US. patients with BMI over 50 as a primary Long-term data is needed to confirm or staged surgery. Staging allows that observed short-term favorable surgeons to do the SG first with the outcomes are maintained. Recent conversion only happening when a studies have produced divergent failure or technical challenge is results. We observed significantly less identified. weight loss at 6+ years in LSG Aim: We present the mid-term compared to matched LRYGB patients. outcomes of single anastomosis duodeno-ileal bypass (SADI) surgery for failed SG patients. A128 Method: Retrospective analysis was A Multi-Institutional Study on the performed on a prospectively collected Mid-term Outcomes of Single database from 2 different US centers. Anastomosis Duodeno-ileal Bypass as Sixty-two patients with BMI of 43.9 ± a Surgical Revision Option after 10.2 kg/m2 and excess weight loss Sleeve Gastrectomy. (EWL) of 24.7% after SG were Hinali Zaveri Salt Lake City UT1, Amit submitted to SADI (300-cm common Surve Salt Lake City UT1, Daniel channel). Patients underwent either Cottam Salt Lake City UT2, Peter planned staged SADI-S due to super Ng Raleigh NC3, Lindsey obesity or unplanned staged SADI-S Sharp Raleigh NC3, Dustin for weight loss failure after SG. Bermudez Raleigh NC3, Sophia Result: of 62 patients, 40 patients Menozzi Raleigh NC3, Austin underwent unplanned staged SADI-S, Cottam Salt lake City UT1, John and 22 patients underwent planned Ambrose Ambrose 3, Walter staged SADI-S. The mean interval Medlin Salt Lake City UT1, Christina between 2 procedures was 31.3 ± 27.8 Richards Salt Lake City UT1, Legrand months. The total mean operative time Belnap Salt Lake City UT1, Samuel and hospital stay for SADI was Cottam Salt Lake City UT1, Benjamin 108.1±67.7 mins and 1.5± 1.3 days Horsley Salt Lake City UT1 respectively. The postoperative early Bariatric Medicine Institute1 Bariatric and late complication rate was 8% and Medical Institute2 REX Surgical 6.4% respectively (table 1). There were Specialists Bariatric Speci3 no deaths. The mean EWL was 66.4% 2 years after the staged SADI-S Introduction: Insufficient weight loss surgery. (fig. 1) is one of the major concerns after Conclusion: SADI-S is a safe and an sleeve gastrectomy (SG). Recently, a effective weight loss option for surgical modification of duodenal switch (DS), revision of failed SG. However, this a single anastomosis duodeno-ileal approach needs more patients to bypass with sleeve gastrectomy (SADI-

57 understand its limitations. reoperated: 11 early for leaks (N=7,4 anastomotic), incisional hernia (N=2), A129 2 bleeding. 38 required late One Anastomosis Gastric Bypass reoperation: 8 marginal ulcer after ten years: low morbidity, low perforations, 17 intractable bile reflux bile reflux and stable excess weight (1 %) converted into a RYGB, 10 loss . bowel obstructions ( one internal hernia JEAN MARC CHEVALLIER PARIS 1, through the Petersen's space), 3 protein Tigran POGHOSYAN Paris 1, deficiences. After 10 years, mean BMI Matthieu BRUZZI Paris Paris 151, decreased to 30.3 ± 5.9 kg/m, and Richard DOUARD Paris 1 mean EWL was 76.5 % ± 12.3. Hopital Européen Georges Pompidou1 The OAGB is an effective procedure with comparable long-term outcomes to Background:One Anastomosis Gastric RYGB but technically simpler. Bypass (OAGB) is a safe and effective Endoscopic, manometric and biological alternative but controversy remains on data will soon be available. long-term complications. We report results of the OAGB at 10 years in a University Hospital performing bariatric surgery since twenty five A130 years. IMPLEMENTATION OF A Methods: From October 2006 to BARIATRIC ERAS PROGRAM AT December 2017, 1585 patients A COMMUNITY HOSPITAL underwent OAGB: a long and narrow IMPROVES BOTH gastric tube calibrated on a 32 Fr PERIOPERATIVE AND 30-DAY bougie, with a linear stapled OUTCOMES AND REDUCES gastroenterostomy 150 cm ( if COST preoperative BMI < 50 kg/m2) to 200 David Voellinger Charlotte NC1, Vicki cm (if BMI > 50 kg/m2) down from Morton Charlotte NC2, Craig the Treitz ligament. 64/106 (60 .3%), Kolasch Matthews NC1, Ellen operated before 2008, could be Carraro Charlotte NC1, Christopher followed. Duggins Charlotte NC2, James Results:There were 999 women Benonis Charlotte NC2 (63%).Mean age was 43.5 years (15.5- Novant Health Bariatric 62.4). Mean preoperative weight was Solutions1 Providence Anesthesiology2 131.9 kg ± 23.9, mean BMI 47.03 kg/m2 (± 7.07). Background: 2 out of 3 deaths were related to surgery (1 pulmonary embolism, 1 Enhanced Recovery After Surgery myocardial infarction). Morbidity rate (ERAS) programs have been shown to was 6.1 % (n=97). 49 patients were improve outcomes and cost in a variety

58 www.obesityweek.com of surgical specialties. However, decreased from 13% to 6%. 30-day minimal data has been published on data also showed improvement (Table). ERAS in bariatric surgery. This comparative analysis aims to evaluate Conclusion: the outcomes and cost during the first year of a newly implemented bariatric Implementation of a bariatric ERAS ERAS program. program in a high-volume community hospital center showed improvements Methods: in perioperative outcomes, 30-day outcomes and cost of care. More study A retrospective analysis of bariatric is needed to determine if these trends cases from a high-volume community continue and to identify areas for hospital was performed. Comparison program improvement. was made between cases performed without ERAS protocol to cases performed under ERAS protocol. Outcomes analyzed included post- A131 operative nausea and vomiting Impact of an Emergency (PONV), opioid usage, hospital length Department-based Clinical of stay (LOS), hospital cost, Observation Unit on Bariatric complications, 30-day re-admissions, Readmissions and Cost re-interventions and re-operations. Joshua Landreneau Cleveland OH1, Statistical analysis was completed Dominykas Burneikis Cleveland OH1, using chi-square with p value Andrew Strong South Euclid OH1, significance at p<0.05. Matthew Kroh Abu Dhabi 2, Stacy Brethauer Cleveland OH1, John Results: Rodriguez Cleveland CA1 Cleveland Clinic1 Cleveland Clinic 938 bariatric cases were performed Abu Dhabi2 from February 2016 to January 2018: 520 non-ERAS (404 VSG, 97 RNY), Introduction: 418 ERAS (304 VSG, 86 RNY). All Hospital readmissions are associated outcome measures improved in the with increased patient morbidity and ERAS group. PONV decreased from significant use of medical resources. 72% to 14% (p=<0.001). Opioid usage However, the services and resources decreased from 100% to 34% needed to manage these complications (p=<0.05). Hospital LOS was reduced may not warrant inpatient hospital from 2.15 to .85 days (p=<0.05) and, in admission. the ERAS group, 91% were discharged Methods: on POD1. Overall cost of hospital stay On June 26, 2016, our institution began was reduced by 10%. Complications a surgical observation pilot program

59 which consists of four dedicated embolism or cardiac pathology (n=2). bariatric patient beds in the Emergency Six patients required subsequent Department’s outpatient Clinical hospital admission (29.2%). Compared Decision Unit (CDU), with clear to the year prior, the readmission rate admission criteria. All patients decreased from 3.8% to 3.2%. The undergoing bariatric surgery from June mean per-day cost, including all 2015 through June 2017 were interventions and evaluations, was retrospectively reviewed to determine 14.3% less for bariatric surgery patients the impact of the CDU on readmissions under observation status in the CDU and cost. compared to the regular nursing ward. Results: Conclusion: Out of 625 operations performed, 22 Following bariatric surgery patients patients were observed in the CDU commonly experience symptoms that within 30 days of discharge (3.5%). warrant investigation or minor clinical The most common complaints were intervention, but may not require abdominal pain with no identified inpatient hospital admission. A pathology (37.5%) and dehydration dedicated emergency department-based (31.3%). Indications for CDU clinical observation unit facilitates admission included need for serial access to these services at decreased physical exams and/or radiological cost compared to inpatient units, and imaging with intravenous hydration may reduce readmissions following only (n=18), endoscopy (n=2), and bariatric surgery. investigating possible pulmonary

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A132 Obesity -Related Frailty: A New Introduction Bariatric Frailty Score Can Be Used Frailty is associated with adverse to Predict Postoperative Adverse outcomes in the elderly, but obesity can Outcomes, Analysis Using The be thought of as accelerated aging with MBSAQIP-2015-2016 Database similar pathology seen in young Raul Sebastian Ashburn VA1, Andrew severely obese individuals. Using the Sparks Washington DC1, Gina validated frailty accumulating deficits Adrales Baltimore MD2, Alisa model in the Canadian Study of Health Coker Baltimore MD2, Thomas and Aging-Frailty Index (CSHA-FI) Magnuson Baltimore MD2, Michael and the Metabolic and Bariatric Schweitzer Baltimore MD2, Hien Surgery Accreditation and Quality Nguyen Baltimore MD2 Improvement Program(MBSAQIP) George Washington University1 Johns 2015-2016 database, we developed a Hopkins University2 Bariatric Frailty Score (BFS) to predict

60 www.obesityweek.com 30-day adverse postoperative outcomes A133 after bariatric surgery in patients with Postoperative opioid prescribing obesity-related frailty. practices and evidence-based Methods guidelines in bariatric surgery Fifteen variables of the CSHA-FI were Danielle Friedman New Haven CT1, mapped onto 10 variables of the Saber Ghiassi Fairfield CT1, Matthew MBSAQIP. Each component of our Hubbard New Haven CT1, Andrew score was given equal weight with a Duffy New Haven CT1 minimal and maximal score between 0 Yale University Department of and 10 (Figure). Correlations and Surgery1 binary logistical regression analysis were performed between BFS and Objective. Compare opioid postoperative adverse outcomes prescribing practice for minimally including 30-day mortality. invasive bariatric surgical procedures Results with self-reported patient use and In 354,865 patients (60% sleeve satisfaction; create practice guidelines gastrectomy, 25% gastric bypass), the for postoperative prescriptions 30-day the mortality rate was 0.12%. Increasing BFS score was correlated Design. Survey administered at strongly on linear regression with postoperative office visit prolonged hospital stay (R2=0.92), unplanned ICU admissions (R2=0.88), Setting. University hospital; readmissions (R2=0.92), non-home ambulatory and short-stay surgery discharge (R2=0.81), and mortality (R2=0.67). Multivariate analysis, the Patients. All patients at initial BFS retained the highest odds ratio for postoperative visit were eligible. None mortality compared to other factors declined or excluded. 115 patients such as ASA class and Age of 65 were analyzed for 3 procedures: (Table). laparoscopic sleeve gastrectomy (LSG; Conclusion n=53), laparoscopic roux-en-Y gastric Our BFS can lead to a predictive model bypass (LRYGB; n=50), and for adverse postoperative outcomes laparoscopic gastric band removal including mortality following bariatric (LBR; n=12). Average body mass surgery. This simple tool can help index 44.8 kg/m2. Overall, 81% assess Obese Frailty in bariatric female, average age of 44 years (range patients and be used to determine 21-82). 51.0% African-American or strategies to potentially improve Hispanic/Latino. 11.3 % had active postoperative outcomes. preoperative narcotic prescriptions.

Main Outcome Measures. Number of pills prescribed (verified); proportion

61 used; duration of opioid use; Permanente2 Kaiser Permanente satisfaction with pain control; non- Freemont3 narcotic analgesic use. Introduction: Approximately 10-25% Results. 27±10 pills dispensed for of patients undergoing bariatric surgery LSG, 4.1 days of use; 28±7 pills for have a body mass index (BMI) over LRYGB, 4.6 days; 16±9 pills for LBR, 50. Studies evaluating weight loss 2.6 days. 33-74% reported retaining failure and postoperative complications more than half or all of their opioids at in this group have had conflicting the two-week visit (Figure). 56% results. This study is the largest cohort utilized non-narcotic analgesics. 91.3% to date looking at patients with reported adequate pain control. For BMI50 that includes 5 year follow- each procedure, average number of up. pills used was calculated with Methods: This is a retrospective representative values for “less than half analysis of patients from 2007-2017 left” (75% of average number of pills undergoing roux-en-y gastric bypass prescribed) and “more than half left” (RYGB) and sleeve gastrectomy (SG) (25% of average number of pills in our health system (5 hospitals, 20 prescribed). LSG 10 pills used; surgeons). We compared patients with LRYGB 14 pills, LBR 12 pills. BMI50 to those BMI<50. Operative parameters and outcomes were Conclusions. Opioid analgesics were compared. Five-year outcomes were overprescribed for the majority of our evaluated for patients between 2007- patients. Only slightly over half used 2012. non-narcotic analgesics. We now Results: 12,467 patients were identified recommend prescriptions of no more during the study period (11% with than 10-14 pills after these common BMI50). More patients in the BMI50 bariatric procedures. group had RYGB (44% v. 40%, p=0.01). We saw no significant difference in length of stay, or 30-day A134 outcomes (emergency visits, Bariatric Surgery Outcomes in reoperations, and readmissions) Patients with BMI
50 between the groups. The five-year Elizabeth Pontarelli Sacramento CA1, follow-up rate was 26%. TBWL was Gary Grinberg Elk Grove CA1, Adam not significantly different, even when Meyers Sacramento CA1, Dhanyaja controlling for type of Kadiyala Oakland CA2, Sanjoy surgery. Patients with BMI50 had a Dutta Fremont CA3, Pandu higher rate of weight loss failure at 5 Yenumula Sacramento CA1 years after SG (42.3% v. 37.4%, Kaiser Permanente South p=0.009), but not after RYGB (15.9% Sacramento1 Kaiser v. 17.3%, p=0.38). Similar rates of

62 www.obesityweek.com revisional surgery were seen at 5 years before and at 12 months after surgery (0.67 v. 0.71, p=0.85). The overall using the Chronic Kidney Disease mortality was low at 5 years (0.46%) Epidemiology Collaboration (CKD- and did not differ between groups. EPI) equation. Conclusion: Patients with BMI50 are Results not at a higher risk of postoperative Of the 2924 patients reviewed, A total complications, but may have a greater of 652 (22.29%) met the criteria for risk of weight loss failure after sleeve (CKD-EPI) equation gastrectomy compared to roux-en-y calculation. Among these, 61.96% gastric bypass. (N=404) were diabetic. Common demographics such as gender, type of procedure and initial BMI were A135 comparable between both groups Impact of bariatric surgery on (Table 1) except for age (P<0.001). The kidney function of diabetic patients hyperfiltration parameter improved - David Romero Funes Weston FL1, 8.72± 12.12(p=0.0001) in the Diabetic David Gutierrez Blanco Weston FL1, group, and -7.02± 10.21 in non- Camila Ortiz Gomez Weston 1, Rama diabetics. Furthermore, patients with a Rao Ganga Columbia MO1, Emanuele GFR <90 (Chronic Kidney Disease Menzo Weston FL1, Samuel Stage 2 or greater) had a similar Szomstein North Miami Beach FL1, significant improvement in both groups Raul Rosenthal miami FL2 (12.28±15.85 [P=0.0001] increase in Cleveland Clinic Florida1 Cleveland diabetic patients, and Clinic of FL2 11.33±14.15[P=0.0001] increase in non-diabetic patients). Total weight Introduction loss and Estimated BMI loss were also Type 2 Diabetes Mellitus (T2DM) is comparable between both groups (table the main risk factor for Chronic Kidney 2). Disease(CKD). With the increased prevalence of obesity in recent decades, the incidence of CKD has Conclusion exponentially increased. Our goal in Bariatric Surgery seems to improve this study is to demonstrate how kidney function in both, diabetic and bariatric surgery affects glomerular non-diabetic patients. Patients with filtration rate in T2DM patients and hyperfiltration, which is considered the compare it with non-diabetic patients. first step in diabetic nephropathy, and Methods patients with chronic kidney disease We retrospectively reviewed all stage 2 benefit the most from a weight patients who underwent bariatric loss surgery. surgery at our institution for the last 6 years. Kidney function was assessed

63 A136 Metabolic surgery reduces mortality Results: The literature search yielded and macrovascular complications in 2’815 potentially eligible articles. 20 patients with type 2 diabetes mellitus studies (6 RCTs, 14 controlled clinical compared to medical therapy: a trials) were ultimately included. meta-analysis Metabolic surgery reduced the all-cause Adrian Billeter Heidelberg 1, Sebastian mortality independent of duration of Eichel Heidelberg 2, Katharina T2DM in comparison to medical Scheurlen Heidelberg 2, Stefan therapy (OR 0.34, 95% CI [0.25; 0.46], Kopf Heidelberg 2, Pascal p<0.00001). Furthermore, the incidence Probst Heidelberg 2, Beat Müller- of all macrovascular complications (OR Stich Heidelberg Baden-Württemberg2 0.38, 95% CI [0.22; 0.67], p=0.0008) University of Heidelberg was also significantly reduced by Hospital1 University of Heidelberg2 metabolic surgery although the duration of T2DM reduced the effect of Background: Although metabolic metabolic surgery on the incidence of surgery has been shown to be superior macrovascular complications. to medical therapy regarding glycemic control, it remains unclear whether Conclusions: Metabolic surgery these beneficial effects ultimately result reduces mortality and the incidence of in reduced mortality and macrovascular macrovascular complications compared complications in patients with type 2 to medical therapy in patients with diabetes mellitus (T2DM). T2DM. T2DM-duration did not affect the beneficial effect of metabolic Objective: To assess the effect of surgery on all-cause mortality but metabolic surgery on the incidence of longer T2DM-duration diminished the macrovascular complications and effect on macrovascular complications. mortality in patients with T2DM compared to medical therapy. Methods: A systematic literature search was performed in MEDLINE, Web of A137 Science and Cochrane Central Register Late Relapse of Diabetes after of Controlled Trials (CENTRAL) Bariatric Surgery Should not be without any restrictions, searching for Considered as a Failure randomized controlled trials (RCTs), Ali Aminian Pepper Pike OH1, case-control trials, and cohort studies Zubaidah Nor Hanipah Cleveland OH1, comparing the effect of metabolic Gautam Sharma Cleveland OH1, Chao surgery on the incidence of diabetes- Tu Cleveland OH1, Stacy associated macrovascular Brethauer Cleveland OH1, Philip complications and mortality to a Schauer Cleveland OH1 medically treated control group. Cleveland Clinic1

64 www.obesityweek.com pressure, and lipid profile was still Background:Although the impressive observed at long-term (Table-1). metabolic effects of bariatric surgery in patients with type 2 diabetes (T2DM) Conclusion:While late relapse is a real are known, bariatric surgery is phenomenon (one-third of our cohort), criticized by late relapse of diabetes. relapse of T2DM years after bariatric surgery should not be considered as a Methods:Outcomes of 736 patients failure, as the trajectory of with T2DM who underwent Roux-en-Y cardiometabolic risk factors (including gastric bypass (RYGB) and sleeve 1.1% absolute reduction in A1c) is gastrectomy (SG) at an academic center changed by surgery. Earlier surgical (2004-2012) and had 5 year glycemic intervention would be associated with follow-up were assessed. Out of 736 less diabetes relapse in long-term. patients, 425 (58%) experienced diabetes remission (glycated hemoglobin (A1c) <6.5% off A138 medications) in the first year after Impact of Ursodeoxycholic Acid on surgery. The later subgroup was Biliary Complications after Bariatric followed to characterize late relapse of Surgery Erin Caddell MD, Jacob T2DM which was defined as fasting Palubicki MD, Joel Brockmeyer MD glucose (FBG) or A1c in the diabetic FACS, Andrew J. Borgert PhD, Kara range (126mg/dL and 6.5%, J. Kallies MS, Byron Faler MD respectively) or need for antidiabetic FACS, Yong Choi MD FACS, Shanu medication after initial remission. N. Kothari MD FACS FASMBS Dwight David Eisenhower Army Results:The median postoperative Medical Center, Fort Gordon, GA; follow-up time was 8 years (range, 5- Gundersen Health System, La 14). Of those 425 patients who initially Crosse, WI achieved remission in short-term, 136 Erin Caddell Fort Gordon GA1, Jacob (32%) had late relapse of T2DM. Palubicki Ft. Gordon GA1, Joel Independent predictors of late relapse Brockmeyer Evans GA1, Andrew were preoperative number of diabetes Borgert La Crosse WI, Kara Kallies La medications (OR:1.85, 95%CI:1.35- Crosse WI, Byron Faler Evans GA1, 2.53, p=0.0001), duration of T2DM Yong Choi The Woodlands TX1, Shanu (OR:1.08, 95%CI:1.02-1.15, p=0.012), Kothari La Crosse WI and SG vs RYGB (OR:1.95, Dwight D Eisenhower Army Medical 95%CI:1.00-3.70, p=0.049). In patients Center1 who experienced late relapse, a significant improvement in glycemic Background: Biliary complications control, number of medications after Roux-en-Y gastric bypass including use of insulin, blood (RYGB) or sleeve gastrectomy (SG)

65 may occur due to rapid weight loss. required an intervention for common Ursodeoxycholic acid (UCDA) has bile duct stones at 3, 11, and 12 years been shown to reduce the risk of biliary postoperatively. complications after bariatric surgery in a 1995 randomized controlled Conclusions: A higher proportion of trial. The impact of UCDA in patients biliary complications occurred in who have had SG is not well patients who were prescribed UCDA understood. Our objective was to compared to those who were not review the incidence of biliary prescribed UCDA. complications requiring intervention in patients after RYGB or SG and assess the timing of treatments based on A139 whether UCDA was prescribed. Buyer’s Remorse: What predicts post-decision dissonance after Methods: A multicenter retrospective bariatric surgery? review of patient medical records who Lyndsey Wallace Milwaukee WI1, underwent RYGB or SG was Melissa Helm Milwaukee WI1, completed; revisional surgeries and Kathleen Lak Milwuakee WI1, Rana patients with incomplete data were Higgins Milwaukee WI1, Jon Gould Fox excluded. Patients who had surgery Point WI1, Tammy Kindel Milwaukee from September 2001-March 2016 and WI1 were prescribed UCDA 300 mg BID Medical College of Wisconsin1 for six months postoperative at a community teaching hospital were Introduction: Bariatric surgery compared to patients who underwent continues to be the most effective long- surgery from September 2006-March term treatment for obesity and its 2016 at a military hospital and were not associated co-morbidities. Despite the prescribed UCDA. Statistical analysis benefits, not all patients may repeat the included chi-square test and Wilcoxon decision to undergo bariatric surgery Rank Sum test. based on their post-operative experience. In this study, we explore Results: Overall, 2,285 patients were the predictors of post-decision included; 1,608 underwent RYGB and dissonance following bariatric surgery. 677 underwent SG. Six hundred fifty- five (29%) patients had a history of Methods: Patients at an accredited cholecystectomy and were excluded bariatric center who underwent from comparison. Of 1,630 patients bariatric surgery between the years without a prior cholecystectomy 151 2011 and 2017 were surveyed to (9%) had a biliary complication determine factors predictive of post- (Table). Three patients with previous decision dissonance, as well as cholecystectomy before RYGB expectations, well-being and overall

66 www.obesityweek.com satisfaction. greater post-operative weight regain, failed weight loss expectations, Results: A total of 591 patients were depression, and dissatisfied body image sent surveys, of which 184 (31.1%) (Table 2). responded. Of the 184 responders, 20 (10.9%) patients would not choose to Conclusion: Post-decision dissonance undergo bariatric surgery if they had it following bariatric surgery appears do to over again (post-decision driven by inadequate pre-operative dissonance). There was no difference preparation of post-operative outcomes, in the time since surgery, age, sex, or coupled by post-operative weight type of bariatric surgery between regain and depression. This highlights groups (Table 1). Dissonant patients the importance of pre-operative were less likely to be married and counseling on managing expectations privately insured. Dissonant patients and outcomes after surgery, as well as were more likely to feel they had the need for continued post-operative inadequate pre-operative education on engagement with a bariatric program to post-operative expectations (p<0.001). address weight regain and provide These patients also had significantly mental health support. A328 patients from 54 clinics were The First Six Months of Commercial reported. 13 patients were removed Experience with a Swallowable Gas- from analysis (9 with incomplete filled Three Balloon System Results entries and 4 with starting BMI <25 in Safe and Clinically Meaningful kg/m2). Mean age was 46.3 (SD=11.1) Weight Loss years and 78% female. Mean starting Rachel Moore Metairie LA1, Michael weight/BMI were 220.9 (43.2) lbs/35.6 Seger San Antonio TX2 (5.4) kg/m2. 90% (n=438) received 3 Moore Metabolics and Tulane balloons and 7% (39) and 3% (16) University1 BMI of Texas2 received 1 balloon, respectively. Median therapy duration Background: The Obalon Balloon was 189 days, 1.5% of patients had System became available in January balloons removed in less than 60 2017. A Registry was provided to days. Mean 3-balloon weight loss was prescribing physicians to enter weight 9.1±5.8% TBWL and 20.1±13.9 loss and safety data. lbs. Maximum weight loss was 87 Methods: A retrospective analysis of lbs. Mean 2 and 1-balloon weight loss registry data collected in first 6-months was 6.6±6.3% TBWL and 14.8±14.9 of commercialization was lbs, and 5.0±6.0% TBWL and 9.5±10.7 conducted. Patient demographics, lbs, respectively. 94 patients reported weight and adverse events were 154 adverse events (17.5%). One analyzed. (0.2%) serious adverse event was Results: From January to June, 551 reported, vomiting, requiring IV fluids

67 and removal. The most common events reported were non-serious.Use adverse event reported was nausea with of the Obalon balloon system provides 38 events from 33 patients (6.1%) a low risk, effective weight loss option followed by abdominal pain with 36 for patients with obesity. events from 32 patients (5.9%).
Conclusions: Clinically meaningful
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A140 data were collected at the consult visit Utilizing Low-Dose Phentermine for and reassessed immediately prior to Preoperative Weight Loss Prior to surgery. Bariatric Surgery: A Prospective, Randomized, and Placebo- Results: Participants (n=53) were Controlled Trial predominantly female (91%) with a John Morton Stanford CA1, Homero mean age of 41±11 years. The average Rivas Stanford CA, Luis Garcia Fargo baseline weight and BMI of the ND, Dan Azagury Stanford CA treatment group (n=32) were 290±55.0 Stanford School of Medicine1 lbs. and 49.3±7.9 kg/m2, compared to 278±58.6 lbs. and 47.1±8.7 kg/m2 in Background: Preoperative weight loss the control group (n=21). From the before bariatric surgery can consult visit, the mean times to visit 1 beassociated with improved surgical and visit 2 were 5±1.5 and 13±5.0 outcomes, including reduced weeks, respectively. No significant complications and readmissions, and weight loss differences were observed greater postoperative weight loss. Here at visit 1. Relative to the control group we present results from the first at visit 2, the treatment group had randomized trial investigating the greater average %, Excess Weight Loss influence of adjuvant low-dose (10.3±8.8% vs. 2.7±8.8%, p<0.01), %, phentermine on preoperative weight Total Body Weight Loss (TBWL) loss. (4.7±4.3% vs. 1.1±3.6%, p=0.001), absolute weight loss (13.6±13.1 lbs. vs. Methods: Participants undergoing 2.3±10.0 lbs., p=0.001) and more laparoscopic Roux-en-Y gastric bypass patients achieving >10% TBWL (%, 44 or sleeve gastrectomy were randomized vs. 11, p=0.008) and less gaining to 14-weeks of low-dose phentermine weight (%, 4 vs. 39, p=0.008). No (Lomaira®) or placebo. Demographic, significant OR times, blood pressure, anthropometric, CT scans and serologic serologic or adverse events differences

68 www.obesityweek.com were observed. (n=1050). Weight loss curves were compared between high, low and non- Conclusion: Patients on a 14-week outliers as defined by their observed to course of low-dose phentermine safely expected (O:E) weight loss ratio based experienced greater weight loss relative on total body weight loss (TBWL) %. to control patients without adverse event Results: Mean predicted weight loss difference. for the study group was 86.3 lbs +/- 21.9 lbs while mean actual weight loss was 87.6 lbs +/- 37.6 lbs, resulting in a A141 mean O:E 1.01 (+/- 0.35). Low outliers Predicting Early Weight Loss Failure (n=188, O:E 0.51) had significantly Using a Bariatric Surgery Outcomes lower weight loss at 2 months (13% vs Calculator and Weight Loss Curves 15% and 16% TBWL, p<0.0001) and Oliver Varban Ann Arbor MI1, Anne at 6 months (19% vs 26% and 30% Cain-Nielsen Ann Arbor MI2, Corey TBWL, p<0.0001) when compared to Lager Ann Arbor MI2, Nazanene non-outliers (n=638, O:E 1.00) and Esfandiari Ann Arbor MI2, Elif high outliers (n=224, O:E 1.46) Oral Ann Arbor MI2, Andrew respectively. There were no significant Kraftson Ann Arbor MI2 differences in the amount of University of Michigan Health preoperative weight loss or System1 University of Michigan2 postoperative complication rates between the groups. Background: Individual weight loss after bariatric surgery can be calculated Conclusions: Weight loss curves based based on specific patient characteristics on individually calculated outcomes and procedure type. Our goal was to can help identify low outliers for determine how early after bariatric additional interventions as early as 2 surgery patients can be identified as months after bariatric surgery. failing to reach their predicted weight. A142 Why are Bariatric Medicare Patients Methods: Using a bariatric surgery Younger than 65 Disabled and Does outcomes calculator formulated by the Disability Impact Safety? Michigan Bariatric Surgery Jai Prasad Danville PA1, Jacob Collaborative (MBSC), predicted Petrosky Danvillle PA, Jason weight loss at 1 year after surgery was Kuhn Danville PA, Robert calculated on all patients who Cunningham Danville PA, G. Craig underwent primary bariatric surgery at Wood Danville PA, James a single center academic institution Dove Danville PA, Marcus between 2006 and 2015 who also had a Fluck Danville PA, Parker documented 1-year follow-up weight David Danville PA, Jon

69 Gabrielsen Danville PA, Christopher vs 78%) and had more diabetes (77% Still Danville PA, Anthony vs 51%). Those with respiratory Petrick Danville PA disabilities had a higher mean age (54 Geisinger Medical Center1 vs 50). Disability did not predict any differences in perioperative outcomes Introduction: Medicare eligibility in or diabetes remission. patients <65 (CMS<65) is determined Conclusions: While there are by the presence of long-term disability demographic differences by disability in at least one of fourteen disease in CMS<65 patients, the most common categories. About two-thirds of causes of disability do not impact Medicare patients undergoing bariatric perioperative safety or diabetes surgery are <65 years and disabled, yet remission after bariatric surgery. little is known about their disabilities. The purpose of this study was to identify disabilities in CMS<65 A143 and to evaluate the safety of bariatric Social Factors as Predictors of surgery in these patients. Outcomes in Primary Bariatric Methods: A prospectively maintained Surgery database of patients who underwent Marcoandrea Giorgi Providence RI1, bariatric surgery between January 2007 RICHIE GORIPARTHI north and December 2017 was utilized. 3146 providence RI, Cullen patients, aged <65, who underwent Roberts Providence RI, Yuqi Laparoscopic sleeve gastrectomy Zhang Woodbridge CT, Seungjun (LSG) or Roux-en-Y gastric bypass Kim Providence RI, Alicia (RYGB) were evaluated and disability Alterio Providence RI, Aevan determined by chart review. McLaughlin Providence RI, G. Results (Table): 505 patients were Roye Providence RI, Todd Stafford , CMS<65. Musculoskeletal disorders Beth Ryder Providence RI, (62%) followed by Mental health Sivamainthan (19%) and Neurologic conditions Vithiananthan Providence RI (17%) were the most frequent Brown University1 disabilities. Multiple disabilities were present in 23% of patients. INTRODUCTION: Bariatric patients Patients with musculoskeletal disability are a heterogeneous group of people. In were older (51 vs 48 years) and less this study we analyze social female (73% vs 82%). Patients with characteristics of patients undergoing mental health disability were younger primary bariatric surgery to identify (44 vs 51), more female (88% vs 74%) factors associated with different and had less diabetes (40% vs 56%). outcomes. Patients with cardiovascular disabilities were older (54 vs 50), less female (52% METHODS: A retrospective analysis

70 www.obesityweek.com was performed on all primary bariatric CONCLUSIONS: Social factors are operations from January 2015 to important outcome predictors in January 2017. Patients undergoing primary bariatric surgery that can help laparoscopic Roux-en-Y gastric bypass stratify risk and individualize (LRNYGB), laparoscopic sleeve perioperative management. gastrectomy (LSG) and laparoscopic gastric banding (LGB) were included. The social factors analyzed were: insurance status (government based vs. A144 private insurance), marital status PREOPERATIVE WEIGHT LOSS (married vs. not married patients), BUT NOT INSURANCE- employment status (employed vs. not MANDATED WEIGHT employed), ethnicity (hispanic vs. MANAGEMENT REQUIREMENT white vs. non white population). IMPROVES WEIGHT LOSS AT 2 Outcomes were: length of stay (LOS), YEARS POST-BARIATRIC hospital readmissions, complications, SURGERY re-operations, follow-up rates, BMI Yannis Raftopoulos Holyoke MA1, (change in body mass index), %EBMIL Ioannis Raftopoulos Holyoke MA1, (percentage of excess body mass index Marissa Chiapperino Holyoke MA1, loss). Lindsay Pasdera Holyoke MA1, Karen Robert Holyoke MA1 RESULTS: 303 patients were included. Holyoke Medical Center1 139 patients underwent LRNYGB (45.9%), 159 underwent LSG (52.8%), Introduction: Preoperative weight loss 4 underwent LGB (1.3%). Statistically (PWL) and insurance-mandated weight significant differences were observed management requirement (IMWMR) for the following results: increased on weight loss after bariatric surgery %EBWL (54.87 vs. 47.79, p=0.008) (BS) is assessed. and BMI (11.21 vs. 9.9, p=0.022) at Methods: Of 1407 patients who the 3-7 month follow up visit and underwent BS by one surgeon, 303 overall in the first year for private vs (21.5%) did not receive counseling for government insurance groups; for PWL (Group A: 2003-2007), 915 employed vs. non-employed patients (65%) participated in a short-term low- significant difference was found for calorie diet (LCD) without specific readmission (7% vs. 15.1% p=0.034) goals (Group B: 2007-2015) and 190 and complication rates (13% vs. 24.7% (13.5%) participated in a structured p=0.018); for married patients there individual and group behavior were higher rates of follow-up after 1 modification and LCD with a goal of year compared to non-married patients 10%TBWL preoperatively (Group C: (55.1% vs. 41.3%, p=0.017). 2015-2018). Results: PWL was greater in Group C

71 patients (A: 1.2%+11.6%, B: Benjamin Crisp Akron OH1, Zhamak 3.1%+5.0%, C: 10.5%+5.3, p<.0001). Khorgami Tulsa OK, Teodora 50% of Group C patients achieved Fatchikova Akron OH, Ali 10%TBWL compared to 9.4% and Aminian Pepper Pike OH, Michael 0% in Groups B and C respectively. Passero Akron OH, Christopher Time from initial visit to surgery Daigle Akron OH (Tsurg) was not prolonged in Group C Cleveland Clinic Akron General1 patients who achieved 10%TBWL (176.7+91.6 vs 200.4+114.34 days) but Background: was progressively increased from A significant number of patients Group A to C (A: 142.7+115, B: undergoing primary bariatric 166.0+149.2, C:188.6+104 days, procedures require home oxygen; p<.0001). IMWMR prolonged Tsurg however, the outcomes in this cohort (153.9+99.8 vs 144.3+126.1 days, are unknown. The objective of this p=.0037) without improving %TBWL study was to use the Metabolic and (4.38%+6.3 vs 3.11%+5, p=.1795). Bariatric Surgery Accreditation and Patients achieving 10%TBWL Quality Improvement Program preoperatively experienced a greater (MBSAQIP) user file to assess %TBWL and BMI change at 12 postoperative outcomes in patients on (40.6%+9.6 vs 35.5%+9.4, p<.0001 & home oxygen. 20.4+7.1 vs 16.2+6.2 Kg/m2, p<.0001) Methods: and 24 months (42.7%+11.9 vs The 2015/2016 MBSAQIP user files 35.3%+12.2, p=.0042 & 23.5+8.7 vs were combined and analyzed using 16.2+6.8 Kg/m2, p<.0001) multivariate analysis to compare postoperatively. Multiple regression patients who were and were not analysis determined that PWL was oxygen-dependent. We compared associated with superior %TBWL at 12 complication rates between (p<.0001) and 24 months (p=.0129) laparoscopic sleeve gastrectomy (LSG), controlling for demographics, BMI, Roux-en-Y gastric bypass (RYGB), surgery type, Group, comorbidities and and biliopancreatic diversion with insurance. duodenal switch (BPDDS) for patients Conclusions: Structured, goal-targeted on home oxygen. PWL improves %TBWL at 2 years Results: after BS. IMWMR delays access to In total, 324,539 primary bariatric surgery without weight loss benefit. surgery patients were included in the analysis. Of those, 2,285 (0.7%) were on home oxygen (1315 LSG; 810 A145 RYGB; 137 BPDDS). There was no Safety analysis of bariatric surgery significant difference in mortality in patients on home oxygen between patients who were or were not oxygen-dependent (OR 0.96, CI 0.51-

72 www.obesityweek.com 1.79, P=0.898). However, oxygen- who underwent laparoscopic gastric dependent patients were more likely to bypass (GB, n=1200) or sleeve experience any complication (OR 1.65, gastrectomy (SG, n=183) who had data CI 1.36-2.01, P<0.001), serious available up to 3 years after surgery. complications (OR 1.67, CI 1.30-2.15, Data collected included C-reactive P<0.001), and pulmonary protein (CRP), High- and Low- Density complications (OR 1.61, CI 1.14-2.28, Lipoproteins (HDL, LDL), P=0.007) based on variable definitions Triglycerides (TRG), Homocysteine, used. When assessing most commonly LipoProtein A, B-type natriuretic performed procedures, LSG had the peptide, Systolic Blood Pressure (SBP) lowest complication risk. When and Weight Loss. Follow-up rate at 1-3 compared to LSG, BPDDS had the years was 50% overall with no highest risk for complications (OR preoperative difference in those with 5.02, CI 4.59-5.49, P<0.001), and and without follow up. RYGB fell between LSG and BPDDS (OR 2.48, CI 2.34-2.63, P<0.001). Results: Overall, the average Conclusions: preoperative weight and body mass Oxygen-dependent patients can safely index were 286 ±53.4 lbs. and 46.6 undergo bariatric surgery, albeit with ±7.2 kg/m2 respectively. In examining higher morbidity than those not on what percent of patients had abnormal home oxygen. LSG appears to be the values pre-operatively and at 3 years safest procedural choice in this cohort. postoperatively, the following was determined. First results for GB: %, pre vs. 3 year: CRP, 82 vs., 19; HDL, 38 A146 vs. 7, LDL, 29 vs. 9; TRG, 19 vs. 1; Longitudinal Outcomes in SBP, 68 vs. 37, all p<. 0001). Second Cardiovascular Risk Factors-Sleeve for SG: %, pre vs. 3 year: CRP*, 81 vs. vs. Bypass 44; HDL*, 30 vs. 3, LDL, 16 vs. 14; John Morton Stanford CA1, Homero TRG*, 20 vs. 13; SBP, 55 vs. 46, *, p<. Rivas Stanford CA, Luis Garcia Fargo 05). The percent of patients achieving ND, Dan Azagury Stanford CA >50% Excess weight Loss at 3 years Stanford School of Medicine1 was 84 vs. 34 respectively for gastric bypass and sleeve gastrectomy. Background: Bariatric surgery is associated with cardiac risk factor Conclusion: While both procedures improvement; however, few studies provide improvement at three years, the report long-term changes in cardiac risk gastric bypass significantly improves factors through procedure comparisons. all cardiac risk factors particularly CRP, TRG and weight loss. Methods: This retrospective study included data from patients (n=1383)

73 A147 January 2018, n=2,528. Revisional Safety and efficacy of outpatient procedures were not excluded from this sleeve gastrectomy: 2,528 cases study. Patients were excluded from the performed in a single free-standing ASC if they weighed >450 pounds, if ASC anticipated surgery time was > 2 hours, Peter Billing Seattle WA1, Josiah if the patient had impaired mobility Billing Shoreline WA1, Jedediah limiting early ambulation, or if there Kaufman Shoreline WA, Kurtis were medical problems requiring Stewart Shoreline WA1, Eric postoperative monitoring beyond 23 Harris Edmonds WA1, Robert hours. Landerholm Edmonds WA1 Results: Mean age was 45.8 years. Eviva1 Mean preoperative body mass index (BMI) was 41.8. Mean operative time Background: Sleeve gastrectomy (SG) was 66.4 minutes. 184 (7.3%) 30-day is currently the most widely performed complications included 3 mortalities operation for treatment of morbid (0.12%), 66 (2.61%) re-admissions, 36 obesity. SG leads to significant weight (1.42%), re-operations, and 30 (1.19%) loss and reduction in weight related direct transfers from the ASC to a comorbidities. Procedures performed in nearby hospital. There were 26 staple ambulatory surgical centers (ASC) can line leaks (1.03%). There were no open provide several advantages over conversions. At 6 months (n=1,758) hospital-based surgery. We present average excess body weight loss results of 2,528 consecutive patients (EWL) was 55.1% and total weight loss who underwent SG in an ASC. (TWL) was 18.7%. At 1 year Objective: Assess the safety and (n=1,360), EWL was 69.3% and TWL efficacy of outpatient SG in a was 25.5%. freestanding ASC. Conclusion: With experienced Setting: Free-standing ASC, Eviva surgeons, appropriate protocols, and a Bariatrics, Seattle WA consistent operative team, SG can be Methods: Data was collected performed safely in a free-standing retrospectively for all patients ASC. undergoing SG from January 2008 –


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A202Roux-en-Y Gastric Bypass after Darren Tishler Glastonbury CT1, Failed Lower Esophageal Sphincter Andrea Stone Glastonbury CT1, Beata Magnetic Augmentation Procedure

74 www.obesityweek.com Lobel Farmington CT1, Pavlos improved. At 2months, the patient had Papasavas Hartford CT1 a 34.9%EWL and BMI of 32.9 Hartford Hospital1 kg/m2. Conclusion: Background: RYGB is a safe and feasible salvage Management of GERD in patients with procedure to revise a failed LESM in a obesity presents unique patient with morbid obesity and challenges. There are different schools recurrent GERD. Careful consideration of thought as to the type of procedure of procedures should be made prior to (anti-reflux vs. bariatric surgery) that anti-reflux procedures in patients with should be offered to the patient with morbid obesity. reflux. We present a video of a 49y/o female with a failed lower esophageal Due to abstract size restrictions, the sphincter magnetic augmentation video quality is reduced for this (LESM). The patient presented after submission. Actual video is in HD referral to the bariatric practice after developing recurrent GERD (HRQL=13, on PPI), intermittent A203 dysphagia, regurgitation and weight Laparosocpic Nissen fundoplication gain <24 months after LESM with the excluded stomach for procedure. BMI at the time of the Recalcitrant GERD after a Roux en LESM procedure was 31.9 kg/m2 Y gastric bypass. (down from 35.4 at consultation). At Rana Pullatt Mt Pleasant SC1, Karl the time of bariatric consultation, her Byrne Charleston SC2, Benjamin BMI was 38.6 kg/m2. Preoperative White Charleston SC2, Diana evaluation demonstrated the LESM Axiotis Charleston SC2, Molly beads approximately 1-2cm below the Jones Mt. Pleasant SC2, Shelby GE Junction with a small hiatal hernia. Allen Charleston SC2, Nina Methods: Crowley Charleston SC2 The video demonstrates technique and Medical University of South clinical pearls for laparoscopic Carolina1 MUSC Charleston2 identification and removal of the LESM device with a single-stage The patient is a 63 y/o white female conversion to a RYGB with who had undergone a roux en y gastric concomitant hiatal hernia repair using a bypass 10 years prior. Patient had robotic-assisted technique. excellent weight loss, however the Results: patient had significant reflux which Postoperatively, the patient did well was managed with PPI's. The patient 3 and was discharged to home on years ago underwent a lenthening of the postoperative day 2. At 30d follow-up, roux limb for presumed bile reflux, GERD and dysphagia symptoms were however the patient continued to

75 complain of significant reflux. She was then referred to us. The patient Materials and Methods: The abdomen underwent a manometry which was entered laparoscopically. We demonstrated good esophageal motility. performed circumferential dissection of Her impedence probe was significant the gastroesophageal junction and made for non acid reflux which was abnormal a window behind the esophagus. We for total number of reflux episodes both identified the posterior vagus nerve and supine and recumbent and associated preserved it at all times. We divided with her symptoms. The patient's the ligamentum teres flush with the barium UGI demosntrated no hiatal abdominal wall and dissected it free hernia, a normal size pouch with from the falciform ligament on its significant reflux upt to the thoracic vascular pedicle. We then placed a inlet. A decision was made to perform a figure-of-eight stitch to approximate Nissen fundoplication with the the left and right crura anterior to the excluded stomach. Details of the esophagus. Next we brought the surgery are demonstrated in the video. ligamentum teres behind the gastroesophageal junction wrapped it anteriorly and sutured it to itself with Ethibond. The stomach was then brought anterior to the ligamntum teres A204 and sutured to the left and right crura. LAPAROSCOPIC REPAIR OF RECURRENT HIATAL HERNIA Result: WITH LIGAMENTUM TERES Postoperatively the patient did well. CARDIOPEXY UGI was negative for leak on the 1 Rena Moon Orlando FL , Vincent following day. The patient was started 1 Kirkpatrick Orlando FL , Andre on a phase 1 bariatric diet and 1 Teixeira Orlando FL , Muhammad discharged home postoperative day 2. 1 Jawad Orlando FL One month later in follow up in clinic 1 Orlando Regional Medical Center the patient’s reflux is resolved.

Introduction Conclusion: 45 year old female who had previously Laparoscopic ligamentum teres undergone removal of gastric band with cardiopexy is an excellent anti-reflux conversion to sleeve gastrectomy and procedure in the patient who has repair of hiatal hernia 2 years prior who previously had a sleeve gastrectomy developed severe gastric reflux not and it is a useful adjunct to hiatal hernia controlled by medications. Upper GI repair to address reflux. showed a widened hiatus and EGD demonstrated a 2 cm recurrent hiatal hernia.

76 www.obesityweek.com pancreatic limb from the anastomosis, maintaining the Roux intact and doing A205 only one anastomosis to restore the Laparoscopic Resection of anatomy. We believe that making a Intussusception: Comparison small anastomosis is very important to Between the Conventional and A try to prevent recurrence in the future. Simplified Approach Ariel Shuchleib Clovis CA1, Ikemefuna Both cases demonstrated here presented Akusoba Coopersburg PA, Pearl with pain and not with a small bowel Ma Fresno CA, Daniel Swartz Fresno obstruction, and had an uneventful CA, Keith Boone Fresno CA, Kelvin postoperative course. Higa Fresno CA UCSF Fresno1

Due to the long lasting history of the A206 RYGB, it is not uncommon to see long- Laparoscopic Conversion of Gastric term complications from it; Bypass to Duodenal Switch Peter C. intussusception can be one of those. On Ng, MD, Lindsey S. Sharp, MD, a large series of patients, Dr. Elms et al. Dustin M Bermudez, MD, Erica M. (Surg Endosc 2014;28(5):1624–8) McKearney, PA-C, Jillian M. Vari, found a 0.5% rate of intussusception. PA-C, RD, John D. Ambrose, Sophia E. Menozzi The management is still debatable Peter Ng Raleigh NC1, Lindsey when those cases present, and due to its Sharp Raleigh NC2, Dustin relative small incidence it is hard to Bermudez Raleigh NC2, Erica assess what is the best treatment McKearney Raleigh NC2, Jillian option. Some people recommend Vari Raleigh NC2, Sophia placing anchoring stiches in order to Menozzi Raleigh NC3, John Ambrose prevent recurrence. However, in our Ambrose 3 practice we don’t believe that the Rex Bariatric Specialist1 Rex Bariatric problem will be solved that way, Specialists2 Research Assistant3 therefore, we resect the anastomosis most of the time. Effective options for gastric bypass revision or conversion remain limited In this video, we compare two and bypass is considered by many techniques used to resect the surgeons an end operation. Limited anastomosis; one is the traditional way reports of conversion from bypass to in which all limbs are resected and two duodenal switch suggest a higher level new anastomoses are done. The second of efficacy in weight loss. However, way is a simplified technique that adoption of this conversion type is involves transecting the bilio- limited largely by the technical

77 challenges of gastric reconstruction and Methods relative inexperience in duodenal The patient reported a history of switch. We present our technique for inhalation pneumopathy and night laparoscopic linear stapled conversion cough. GERD symptoms became from bypass to duodenal switch, resistant to Proton Pomp Inhibitor demonstrating a reproducible and safe medication. An upper Gastro-Intestinal technique. We point out the critical endoscopy revealed an esophagitis with aspects to preserving a vascularized Barrett’s esophagus and a large hiatal gastrogastrostomy, as well as a linear hernia. A gastrografin swallow stapled duodenoileostomy. Our completed by a Computed Tomography experience reported with this technique (CT scan) confirmed a large type 3 includes 30 revisions from June 2015 to hiatal hernia with gastric stenosis and December 2017. We report a leak rate residual calcification on the older scare of 3.3% (1/30). The reported leak of the gastric band. The esophagus was occured at the apex of a gastric pouch, dilated. We proposed a laparoscopic related separation of the pouch and revisional surgery. We performed first remnant. We noted no anastomotic a reduction of the hiatal hernia,, a leaks at either the gastrogastrostomy or cruroplasty, and a resection of the duodenoileostomy. calcified peri-gastric fibrosis. Secondly, we performed a revision to RYGB according to Lonroth technique. A207 Results Title : Type 3 Hiatal hernia Mean operative time was 250 minutes. complicating a mediogastric stenosis Because of two subfebrile episodes, the after gastric banding: cure of hiatal patient had a CT scan on day 4 that hernia and revision to Roux en Y revealed a bilateral pneumopathy. An Gastric Bypass. oral antibiotic medication was effective Maud Robert LYON 1, Arnaud and she was discharged at day 6. She Pasquer Lyon 2 didn’t complain of GERD or dysphagia Edouard Herriot Hospital Department anymore. of bariatric surgery1 Edouard Herriot Conclusion Hospital2 Persistent dysphagia or GERD after gastric band removal should be Introduction investigated. Residual perigastric We present the case of a 54-year-old fibrosis and hiatal hernia are 2 possible woman with a residual BMI of 35.4 causes. Residual perigastric fibrosis kg/m2 after failure of gastric banding. should be resected when the gastric She complained of persistent Gastro- band is removed and hiatal hernia has Esophageal Reflux Disease (GERD) to be treated. Revisional RYGB is the and dysphagia despite removal of the procedure of choice in case of GERD gastric band 3 years before. following bariatric surgery.

78 www.obesityweek.com anastomosis using linear stapler. A rectangle area of the previous gastric A208 pouch found to be ischemic. Decision Laparoscopic Reversal of Roux en Y was made to resect the ischemic area Gastric Bypass with an with clear demarcation. The defect was Intraoperative Challenge closed with linear stapler with Arpit Patel Brooklyn NY1, Nathaniel buttressing material. Due to the fact Kopelan 2, Alan Saber Short Hills NJ3 that the Roux limb found to be short, University of Washington1 Newark we elected to resect the Roux Beth Israel Medical Center2 Newark limb. Postoperative course, the patient Beth Israel3 did well. Gastrographine study showed no leak and no obstruction. The patient Introduction went home on POD# 2. Despite impressive effectiveness of Conclusion Roux en Y gastric bypass in the Laparoscopic reversal of RYGB to majority of patients, laparoscopic normal anatomy is safe & feasible. reversal of Roux en Y gastric bypass However, as with redo bariatric have been recently increasingly surgeries, reversal procedure demands reported. We herein present a case of attention to vascularity of gastric tissue laparoscopic reversal of Roux en Y in relation to staple lines. gastric bypass with intraoperative
challenge. A522 Presentation Nissen Re-Fundoplication With A 60-year-old female had a Sleeve Gastrectomy laparoscopic Roux-en-Y gastric bypass Theadore Hufford Cleveland OH 8 months ago. She lost 90 lb. since her St. Johns Episcopal Hospital surgery. However, she developed depression, change of taste of food, The patient is a 44-year-old female who anorexia, persistent nausea and had previously undergone Nissen intermittent vomiting. Despite fundoplication twice before with severe management with antiemetics and reflux. History is significant for CAD, nutritional counseling, she insisted to HTN, HLP, kidney stones, and proceed with reversal of her gastric OSA. The initial plan was to perform a bypass. Preoperative endoscopy sleeve gastrectomy below the previous showed post-gastric bypass changes Nissen but upon examination the with no marginal ulcer or hiatal hernia. fundus appeared to have slipped so Procedure revision of the fundoplication was After laparoscopic lysis of adhesions necessary. The sleeve gastrectomy and transection of the Roux limb just dissection was done in a normal fashion distal to the gastrojejunostomy we by dissecting the greater curvature of proceeded with gastrogastric the stomach and separating the

79 omentum away from stomach. The operative anatomy. Overall, the did proximal adhesions were carefully very well with improvement in her dissected in the area of the previous reflux disease, weight loss of 30 fundoplication and the gastro-gastric pounds and decrease in BMI from 38 to plication was noted to be loose. The 34 at her 3 month follow-up. A few slipped fundoplication was examined case series have shown that there is and the previous gastro-gastric likely a role and positive clinical plication was divided. outcome for sleeve gastrectomy below previous Nissen fundoplication. In this case however the Nissen was noted to The redundant fundus was examined be slipped upon exploration and this and resected using the endo-GIA video illustrates the possibility that in stapler up to the proximal fundus at an similar cases a re-fundoplication at the area the would allow for re- time of sleeve gastrectomy is possible fundoplication. The post-procedural and can lead to positive clinical upper GI was consistent with the post- outcome.


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A226 Methods: we report a case of a 64-year- Iatrogenic Esophageal Perforation old Female, with a BMI of 25, who had and Stenting in a Patient with previously undergone gastric bypass Gastro-Gastric Fistula several years before. She presented Gerardo Davalos durham NC1, Alfredo with symptomatic reflux and was later Guerron durhjam nc1, Dana diagnosed with a gastro-gastric fistula. Portenier Durham NC1 While performing the endoscopic Duke health1 correction of the gastro-gastric fistula with the endoscope, an iatrogenic Introduction: Iatrogenic esophageal esophageal perforation was made. The perforation is the most common cause decision was made to fix the of esophageal perforation and perforation using a deployable covered is associated with a high mortality rate stent. of 19%. With increasing endoscopic techniques performed, this Results: the stent placement went complication has become more without complications. At the second common. Esophageal stent placement post-operative week we removed the presents a safe and effective treatment stent and the perforation had option for this select group of patients. completely healed. She later went on to correct her gastro-gastric fistula

80 www.obesityweek.com without complications. internal hernia with concern for ischemia. Surgery was called and Conclusions: iatrogenic esophageal diagnostic laparoscopy was perforations are potentially fatal recommended. complications of upper endoscopic Operative procedure: Diagnostic gastro-gastric fistula repair. Esophageal laparoscopy revealed enlarged uterus stents remain important tools that have with distended bowel and collapsed proven safe and efficient at controlling bowel in the RUQ. Running the small this complication. bowel from the terminal ileum in a retrograde fashion facilitated reduction of the strangulated Petersen’s hernia. The internal hernia was reduced. The A227 patent Petersen space was closed with Laparoscopic managment of non-absorbable running suture. strangulated Petersen’s hernia in Postoperative course: The patient pregnant female after LRYGBP tolerated the procedure well. The Arpit Patel Brooklyn NY1, Alan patient went home on POD# 2. Saber Short Hills NJ2 Conclusion: With increasing number of University of Washington1 Newark laparoscopic Roux en Y gastric bypass Beth Israel2 and improving fertility after weight loss, the number of pregnant women Introduction: Management with history of RYGBP presenting with of abdominal pain in a pregnant patient internal hernias will increase. Every with a history of Roux-en-Y gastric surgeon should know how to diagnose bypass presents unique challenges. and manage internal hernia as the risk Internal hernias are the most common is life long and misdiagnosis or delay in cause of small bowel obstruction after management can result in lethal LRYGBP. Internal hernia can result in maternal-fetal outcomes. closed loop obstruction, bowel necrosis, gastric perforation, and death. A228 Presentation: A 29-year-old female 30- Laparoscopic Gastrogastric week pregnancy with a history of anastomosis for a twisted Sleeve laparoscopic Roux-en-Y gastric bypass Rana Pullatt Mt Pleasant SC1, Karl 5 years ago. She had a 24 hours of Byrne Charleston SC2, Shelby LUQ pain with vomiting. Her pain was Allen Charleston SC2, Nina attributed initially to UTI. However her Crowley Charleston SC2 pain got worse and CT scan abdomen& Medical University of South pelvis ordered. The CT scan Carolina1 MUSC Charleston, SC2 showed intrauterine gestation, swirling of mesenteric pedicle suspicious for

81 Patient is a 40 y/o female with history Management of Stricture after VBG of crohn's disease who had undergone a with Gastro-gastrostomy Sleeve Gastrectomy six months ago at Rena Moon Orlando FL1, Muhammad an outside hospital. The patient had Ghanem Dallas TX1, Andre unrelenting emesis and failure to thrive Teixeira Orlando FL1, Muhammad since the Sleeve Gastrectomy. The Jawad Orlando FL1 patient had several endoscopies, Orlando Regional Medical Center1 pneumatic dilations and stent placement with no relief from the Introduction- Vertical banded emesis. The patient was then referred to gastroplasty (VBG) is a historic us for further management. We bariatric procedure. Even though the discussed options including conversion procedure is no longer done nowadays, to a Roux en Y gastric bypass. it is imperative for bariatric surgeons to However due to her history of Crohn's have ample knowledge of the anatomy disease and her desire not to be after the procedure, the potential converted to a gastric bypass we complications and subsequently the decided on sectioning the sleeve at the operative treatment options, as the site of the twist and reanastomose failure from this procedure can be as thereby changing the axis of the sleeve. high as 70%. The procedure was completed as seen Educational Objective- To discuss the in the video and a 42 french bougie was endoscopic and surgical options for used to calibrate the anastomosis which patients with obstructive symptoms was performed in two layers. A feeding after VBG. jejunostomy tube was also placed Methods and Results- The case at during the procedure. The patient was hand is that of a 80 year female patient discharged on bariatric pureed diet. The who had a VBG done in the past with patient presented two weeks later with success in terms of weight loss, increasing abdominal pain and however she was suffering from severe tachycardia. Ct scan revealed reflux, vomiting and obstructive anastomotic leak at the site of the symptoms. Upper endoscopy(EGD) gastrogastric anastomosis, a revealed a stricture at the site of the laparosocpic washout was performed silastic ring, and a stent was placed. with drain placement. An endoscopic The band eventually eroded on the stent stent was also placed and removed after and was removed with the stent a 4 weeks with complete resolution of the month later. Another EGD was done leak. The patient is 6 months out with with dilation, however the patient resolution of her symptoms and is continued to suffer from obstructive doing well. symptoms requiring admission with total parenteral nutrition. She was eventually taken to the operating room A229 and a gastro-gastrostomy was done.

82 www.obesityweek.com Postoperatively she did well and upper inflammatory mass obscuring the gastrointestinal studies showed no leak. anatomy, this was repaired and a Discussion- The subject was an elderly feeding jejunostomy added. TPN lady, with adequate weight loss after started intraoperatively as his the VBG, hence a high-risk patient for nutritional status was not good. Post extensive surgery and in need for relief operatively he developed colonic leak of the obstruction only. Performing a with 500ml feculent drain and cough gastro-gastrostomy is ideal in these with feculent expectoration after 6th patients, although it is almost always POD suggestive of colo-bronchial accompanied by weight regain. fistula. He also complained of constipation and painful defecation. On A523 rectal exam fissure in ano with fecal GASTRO-COLO-BRONCHIAL impaction noted. After adding anal FISTULA WITH FECULENT sphincterotomy and rectal lavage his EXPECTORATION AFTER colonic leak improved remarkably. Post SLEEVE GASTRECTOMY LEAK. operative oral gastrograffin contrast Ravikanth Kongara VIJAYAWADA study also showed small amount of oral Ravi bariatric clinic, endocare hospital contrast going into colon on 15th POD this suggested gastro-colo-bronchial Laparoscopic sleeve gastrectomy(LSG) fistula. His nutritional status improved done on a 25 yr man BMI 47kg/m2 after TPN and enteral feeds with uneventful discharge on 2nd significantly and his leak subsided Postoperative day(POD). On 35thPOD gradually and completely after about 2 he presented with fever, left shoulder months on gradual withdrawal of the pain, cough with purullent drain tube and daily lavage through the expectoration and sepsis. On evaluation drain. found to have sleeve leak with gastro- bronchial fistula, left basal atelectasis and a collection near Gastroesophageal junction. Other important findings are A230 leucocytosis and hypoalbuminemia Laparoscopic Roux-en-Y because of sepsis induced catabolisam Fistulojejunostomy for a Chronic and poor nutrition. Laparoscopy with sleeve leak with Bronchopleural drainage was planned but not fistula. successful because of hard Rana Pullatt Mt Pleasant SC1, Karl inflammatory mass. Naso-jejunal tube Byrne Charleston SC2, Benjamin placed to improve nutrition. White Charleston SC2, Shelby 7days after IV antibiotics, resurgery Allen Charleston SC2, Nina and drainage of pus along with repair Crowley Charleston SC2, Diana of the sleeve leak site done. During this Axiotis Charleston SC2 process colon injured in view of

83 Medical University of South Yung Loma Linda CA, Marcos Carolina1 MUSC Charleston, SC2 Michelotti Loma Linda CA1, Daniel Srikureja Loma Linda CA, Jeffrey The patient is a 33 y/o Black female Quigley Redlands CA1, Keith with multiple comorbidities who had a Scharf Loma Linda CA1, Aarthy Sleeve gastrectomy done presented Kannappan Loma Linda CA1 with a leak and an abscess 12 days after Loma linda university1 her sleeve. She was treated with IR drainage and abx. The patient was then NONE managed with Pneumatic dilation of the sleeve. We also placed endoscopic pig tail drainage, however the patient over A232 the next few months had high fevers Intussusception Post-Roux-en-Y with a bronchopleural fistula and Gastric Bypass: Laparoscopic destruction of the left hemidiaphragm. Management Compilation The patient would have violent Gerardo Davalos durham NC1, Sugong coughing spells when she ingested Chen Durhem NC1, Dana anything per oral and she had a fistula Portenier Durham NC1, Alfredo through her posterior chest and was Guerron durhjam nc1, Kunoor Jain- managed with a ostomy bag. A Spangler Durham NC1 septotomy was also tried, however this Duke health1 did not manage the fistula. We then decided on a fistulo jejunostomy as the Background: Intussusception is an fistula had not healed for 6 months. uncommon and unclear complication Technical details of the surgery are that presents in 0.3% of cases after described in the Video. The Roux-en-Y gastric bypass (RGYB). fistulojejunostomy tract was dilated With the rapid increase of bariatric with a TTS balloon 4 weeks after the surgery its incidence is expected to Surgery. The patient was then followed increase in the coming years. However, closely with complete healing of the broad consensus regarding fistula and the thoracic collection with management in these patients has not no recurrence of the fistula. been reached.

Methods: We present a compilation A231 describing 3 accepted methods to Robot assisted takedown of manage intussusceptions gastrocutaneous fistula and laparoscopicaly after RYGB. First case conversion of sleeve gastrectomy to was managed by manual reduction RNY gastric bypass only. Second case was managed with Crystal Alvarez Redlands CA, Juan reduction and enteropexy. Third case Quispe Loma Linda CA, Esther was managed operatively, with

84 www.obesityweek.com resection of the affected section and and an elongated non-functional roux posterior anastomosis. limb. There were no ulcers or foreign bodies adjacent to the fistula. Results: all patients were discharged Symptomatic GGF occurs in up to 6% during the first operative day with no of RYGB. Fistula can result from the complications. incomplete division of the stomach during the creation of the pouch or by a Conclusions: Although reportedly leak with abscess formation adjacent to uncommon, with the increase of the staple line, which then drains into bariatric surgery procedures, the remnant stomach. intussusceptions might become more Although GGF may be treated prevalent in the future. Awareness of conservatively, patients with this complication is critical for prompt symptomatic GGF will require diagnosis and treatment. With no technically challenging revisional universal agreement regarding its procedures. management; reduction, enteropexy Dissection was performed to identify and resection are currently proven the gastric pouch, the gastrojejunal techniques for this complication. anastomosis, and the gastric remnant. After exposure of these structures, a fibrous area was visualized between the A524 gastric reservoir and the gastric Gastro-gastric Fistula, "Candy remnant. After complete identification, Cane" Roux Syndrome and Hiatal the GGF was transected with a linear Hernia. stapler. Napoleon Cieza New York NY1, The staple line was subsequently Subhash Kini New York NY1 reinforced with continuous 3– 0 Mount Sinai - St. Luke's1 polypropylene sutures, and the integrity of the gastric pouch staple line was The patient is a 45-year-old female who determined intraoperatively by a leak in 2008 underwent a Roux en Y gastric test. bypass. Postoperatively she had There was also preferential entry of the remission of her HTN, OSA and endoscope into the "candy cane" roux adequate weight loss. She was lost to limb. A 3 5 cm blind limb was follow-up and returned nine years later resected with a linear cutting stapler. with intermittent abdominal pain. The patient had complete relief of her Preoperative workup consisted of EGD symptoms immediately postoperative and Upper GI contrast study which and at six month follow-up showed a proximal Gastrogastric fistula

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A209 demonstrating dilated roux limb and Complications of Roux-en-O gastric duodenum. Post-operative explorations bypass were negative and an entero- Pearl Ma Fresno CA1, Ikemefuna enterostomy was also performed. When Akusoba Coopersburg PA2, Ariel explored at our facility, diagnosis of Shuchleib Clovis CA2, Daniel Roux-en-O anatomy was suspected Swartz Fresno CA2, Keith based on symptoms and confirmed Boone Fresno CA2, Kelvin intraoperative with twisting of jejunal Higa Fresno CA2 mesentery. In order to restore her to UCSF Fresno/ALSA1 UCSF Fresno2 standard RYGB anatomy, the biliopancreatic limb required to be Introduction: disconnected from gastrojejunostomy, Roux-en-O anatomy after Roux-en-Y jejunojejunostomy and entero- gastric bypass (RYGB) is a rare and enterostomy divided and recreated infrequent complication from incorrect completely. Patient was discharged on anatomical identification. Generally, post-operative day 4 and off antacids at the biliopancreatic limb is inadvertently 2 month follow up. anastomosed to the gastric pouch and patients may present as a partial small bowel obstruction with most frequent Conclusion: complaint of abdominal pain, nausea, Roux-en-O Gastric Bypass is an and bilious emesis. Difficulty in uncommon occurrence however can diagnoses can delay adequate lead to major complications. It requires treatment. a high degree of suspicion with post- operative RYGB patient presenting with bilious emesis. This can be Case Report: difficult to diagnose with imaging We are presenting a 39 woman referred studies and ultimately may require to our center 15 weeks after her robotic referral to tertiary bariatric center if assisted RYGB performed at another patient symptoms are continually facility with several weeks of severe unexplained. nausea, bile reflux requiring several months of total parental nutrition. She had undergone multiple studies A210 including upper endoscopy dilations of Laparoscopic RYGB in a Patient gastrojejunostomy with noted bile in with a History of an Angelchik gastric pouch, and CT scan imaging Prosthesis Bradley Kushner MD., J.

86 www.obesityweek.com Chris Eagon, MD. Washington rind that was densely adherent to the University School of Medicine, liver, stomach, and diaphragm Department of Surgery, Division of requiring a three-hour Minimally Invasive Surgery, St. adhesiolysis. Otherwise, we used a Louis, MO. standard retrocolic, retrogastric Roux- Bradley Kushner St. Louis MO1, J. limb with a circular stapled Chris Eagon St. Louis MO1 gastrojejunostomy. Postoperatively, Washington University in St. Louis1 dietary tolerance was normal, but her course was complicated by a self- The Angelchik prosthesis is a silicone- limited bile leak. based elastomer shell approved by the FDA in 1979 for the surgical treatment To our knowledge, this is the first of severe GERD. The device, fitted reported case of a bariatric surgery in a around the GE junction, was associated patient with a history of a prior with numerous complications including Angelchik device. Recognition of immediate and long-term dysphagia motility effects and the intense fibrosis rates of up to 70%, migration, and and scarring that the Angelchik erosion, and the device was withdrawn prosthesis causes to surrounding from the market in the late 1980’s. structures is critical to surgically care for these patients. We describe a case of a 68-year-old female with an Angelchik prosthesis who desired bariatric surgery. She had A211 well-controlled heartburn and mild Robot-assisted Reversal of intermittent dysphagia and initially Biliopancreatic Diversion (BPD) due preferred a sleeve to severe malabsorption gastrectomy. Preoperative evaluation Mario Masrur Chicago IL1, Roberto included EGD and barium swallow Bustos Chicago IL1, Gabriela showing no erosion or migration but Aguiluz Chicago IL1, Alberto distal esophageal compression from the Mangano Chicago IL1, Lisa Sanchez- device. Esophageal manometry showed Johnsen Chicago Illinois1, Chandra a hypertensive, poorly relaxing lower Hassan CHICAGO IL1, Pier Cristoforo esophageal sphincter and impaired Giulianotti Chicago IL1 esophageal body motility. Fearing UIC1 exacerbating her dysphagia postoperatively with a sleeve Introduction. BPD has a successful gastrectomy, removal of the Angelchik outcome achieving weight loss, device and creation of a Roux-Y gastric attributed mainly to the malabsorptive bypass was recommended. Intra-op, effect. The reversal rate is 0.2%-7% we found that the Angelchik had which is necessary when there is formed a thick, calcified pericapsular excessive malabsorption. We present a

87 case of a 31-year-old female with BPD patients do not respond to conservative reversal. therapies, a reversal of BPD is Methods. The patient had an initial pertinent. BMI of 50 and underwent BPD surgery 7 years previously outside of the U.S. Referring issues were persistent nausea, vomiting and diarrhea post-surgery and A212 was currently experiencing BM 3-20 Chronic Marginal Ulceration and times/day. She had initial extreme Gastrogastric Fistula: Complications weight loss (BMI= 11) and required a From a 360 Degree Twist of the Roux feeding tube. The patient was first seen Limb at the Gastrojejunostomy in our center due to bowel obstruction Ikemefuna Akusoba Coopersburg PA1, that resolved with medical Ariel Shuchleib Clovis CA, Pearl management. She was conservatively Ma Fresno CA, Daniel Swartz Fresno treated for malabsortive syndrome, CA, Keith Boone Fresno CA, Kelvin clinical improvement was not Higa Fresno CA completely achieved and had an UCSF Fresno/ALSA1 additional 8.36lb weight loss. Considering the severe impact in her Introduction: Gastrogastric fistula is a quality of life (QOL), with PO complication after bariatric surgery that intolerance and frequent diarrhea has several etiologies including episodes, she underwent BPD reversal incomplete division of the stomach, 10 months after first presenting to our marginal ulceration and anastomotic center. The patient’s pre-operative BMI leak. Marginal ulceration may also was 24. arise after bariatric surgery secondary Results. The gastric pouch was to tobacco or non-steroidal anti- detached from the jejujum and inflammatory drugs. Here we present a reconnected to the excluded remnant patient with both complications stomach, then the jejunoileal secondary to a 360-degree twist of the anastomosis was undone by resecting roux limb at the gastrojejunostomy. the anastomosis. Two different anastomosis were created for the Presentation: The patient is a 46-year- bowel: a jejunojejunal and a side to old female with chronic abdominal side ileoileal. Patient tolerated the pain, nausea/emesis, gastroesophageal surgery well, with adequate pain reflux disease, diarrhea and weight management, tolerating diet, no recidivism. She underwent nausea/vomiting, discharged on POD 4 laparoscopic roux-en-y (LRYGB) in without complications. 1999 and stated she had these Conclusions. BPD can produce severe symptoms from the beginning. EGD malabsorption and greatly impact demonstrated a stenotic patients’ QOL. In such situations where gastrojejunostomy, chronic marginal

88 www.obesityweek.com ulcers and a gastrogastric fistula. UGI We are presenting a patient with series demonstrated a stenotic roux morbid obesity who also has a complex limb. She underwent an exploratory cardiac and pulmonary surgery history laparoscopy, lysis of adhesions, including tetralogy of Fallot, subtotal gastrectomy, revision of her pulmonary AVMs, pulmonary gastric bypass, small bowel resection hypertension, Blalock-Taussig shunt, with two anastomosis and pulmonic valve replacement and trans- approximation of type 2 long limb annular right ventricular patch, as well bypass to affect resolution of her as an iatrogenic paralyzed left symptoms. hemidiaphragm due to phrenic nerve injury. She required 6 liters of oxygen Outcomes/Results: The patient was preoperatively and had significant discharged post-operative day 1 on a dyspnea with exertion. Her clear liquid diet. On post-operative day preoperative BMI (body mass index) 30 she had lost 20 pounds and her BMI was 43. She underwent laparoscopic was 43 Kg/M2 from 46 Kg/M2 (14% sleeve gastrectomy with plication of the excess weight loss). At post-operative left hemidiaphragm. The procedure was day 120 she had lost 40 pounds and her uncomplicated and her postoperative BMI was 40 Kg/M2 (27% excess chest x-ray demonstrated a normal weight loss). All her preoperative appearing left diaphragm as compared symptoms have resolved. to her preoperative imaging. She was discharged to home on postoperative Conclusion: Unexplained pain and day 3 without incident. At her 1 month inability to tolerate a diet immediately postoperative visit, her BMI had after bariatric surgery should prompt decreased to 39 and her oxygen investigation. A 360-degree twist of requirements had decreased to 3 liters the roux limb at the gastrojejunostomy with exertion. She did not require any is an unusual cause of marginal unplanned hospitalizations and did not ulceration and gastrogastric fistula but need her rescue inhaler since surgery. should be in the differential. At 6 month follow-up, her BMI had continued to decrease to 35. Similarly, her oxygen requirements had not A213 increased over this time period. This Surgical Treatment of Paralyzed case demonstrates that laparoscopic Left Hemi-diaphragm with diaphragm plication can be successfully Laparoscopic Sleeve Gastrectomy performed from an abdominal approach and Diaphragm Plication and may contribute to improvement in Kellen Hayes Cleveland Heights OH1, pulmonary function when combined Ali Aminian Pepper Pike OH with concomitant weight loss from Cleveland Clinic1 bariatric surgery.

89 A214 placed through the pouch into the Conversion of Laparoscopic Roux en remnant. The bougie is removed and Y Gastric Bypass to Single replaced with an oral gastric tube. The Anastomosis Duodenal Switch/SIPS: anterior layer was then completed. ICG A technique to make a safer gastro- was used to ensure adequate blood gastric anastomosis supply of this anastomosis. The small Andrew Godwin Oyster Bay NY1, Sarah bowel was then measured 300cm Pearlstein New York NY1, Mitchell proximal to the ileocecal valve and a Roslin New York NY2 hand-sewn postpyloric anastomosis Lenox Hill Hospital1 Chief Bariatric created in a loop configuration. The surgery at Lenox Hill2 patient did well and was discharged on a diet with no complication. Introduction: Patients with recidivism Conclusion: The technique employed to following Roux-en-Y Gastric Bypass preserve multiple branches of the (RYGB) is a challenging and ever- gastroepiploics is highlighted with increasing issue. Conversion to indocyanine green to view the gastro- SADS/SIPS is an option that often gastric anastomosis results in significant weight loss. Ensuring adequate blood supply in this re-operation can be difficult, and A215 complications can often be due to Endoscopic Removal of an Eroded inadequate blood supply to the gastro- Gastric Band into the Colon gastric anastomosis. Mohammad Farukhi San Antonio TX1, Case: We present the case of a 52 year Michael Seger San Antonio TX1 old Female who originally underwent BMI of Texas1 laparoscopic RYGB in 2004 at a weight of 280 pounds, postoperatively nadired Laparoscopic adjustable gastric to 130 and at presentation regained to banding (LAGB) is not as common of 214 pounds (BMI 39) with return of an operation in the bariatric community diabetes and hypertension. as it once was but we continue to see Methods: Antecolic roux limb was patients with complications from divided off the gastric remnant. The previous gastric banding. Intraluminal duodenum was divided 3cm post- erosion into the stomach is a rare, but pyloric. The pouch was divided just well documented complication proximal to the gastrojejunal affecting up to 2% of patients in the anastomosis with horizontal fire and 42 literature. Intraluminal erosion into the bougie placed to resize the pouch. The stomach and colonic is even more rare, remnant stomach was mobilized and is only reported in a few case preserving 6 to 8 branches of the right reports. This is the first attempt at total gastroepiploic. The posterior layer of endoscopic removal. Ourvideo the anastomosis done and the bougie is illustrates a 68-year old female who

90 www.obesityweek.com presented to us after a routine robot-assisted laparoscopic revision of colonoscopy found band tubing the large gastric pouch and revision of intraluminally in the transverse colon. the gastrojejunostomy. Our procedure began by removing her port and disconnecting the tubing. Operation: The above surgery was Endoscopically, we used a Soehendra performed without complication. There lithotripsy device to divide the band were extensive adhesions between the and we used a snare to remove the pouch, roux limb and remnant stomach, entire band with the tubing still dissection of which was facilitated by attached. There was no evidence of a the robotic platform. Full exposure of fistula or leak in the postoperative the anatomy confirmed a non-excluded period. The patient did very well with fundus which was resected. Upon no complications. excision of the previous gastrojejunostomy, it was reconstructed via a two-layer hand-sewn technique. A216 Robot-assisted laparoscopic Outcome: The patient was discharged gastrojejunostomy revision for on post-operative day 4. The patient chronic marginal ulcer was readmitted once 3 weeks later for Peter Lundberg Allentown PA1, Maher dehydration following a viral illness El Chaar Allentown PA unrelated to the bariatric procedure. St Luke's Weight Management Center1 There were no major 30-day complications. Background: Revisional procedures and robot-assisted laparoscopy are undergoing mutual growth in the field A217 of bariatric surgery. Greater adhesions Robotic revision of gastric sleeve of the re-operative field as well as gastrocolic fistula to RYGB patient-specific anatomy may benefit Christopher De Jesus New York NY1, from using robotic platforms, which Julio Teixeira Scarsdale NY2 enable finer laparoscopic dissection via Lenox Hill Hospital1 Northwell Lenox three-dimensional movement of the Hill Hospital2 robotic instruments and the elimination of surgeon tremor. Robotic revision of gastric sleeve gastrocolic fistula to RYGB Patient: A 46 year-old woman presented to our practice with weight This is the case of a 51 year old patient regain (BMI 38 kg/m2) and a marginal with a significant medical history of ulcer following a roux-en-Y gastric morbid obesity with severe diabetes bypass several years earlier. After a mellitus requiring insulin pump with a thorough work-up we recommended past surgical history of a laparoscopic

91 adjustable band, with weight loss and a jp at the repair site. This was regain, converted to a laparoscopic eventually complicated by a gastrocolic sleeve gastrectomy which was fistula noted on preoperative imaging. complicated by a large leak and The patient presented to our outpatient intrabdominal sepsis requiring clinic in seek of a revision as he was operative takeback with placement of a permanently placed nothing per os. feeding jejunostomy and placement of


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A218 artery was separated and occluded with The application of intermittent the gauze compression of wound for splenic artery occlusion in iatrogenic 10min and got successful splenic injury-A case of LSG hemostasis. Results: The patient Xiaocheng Zhu Xuzhou discharged 3 days after the operation. the Affiliated Hospital of Xuzhou One month after the operation, the Medic weight of the patient decreased from 115kg to 100kg, BMI from 38.8 to Objective: To evaluate the feasibility 33.8, BP: 120/70 mmHg. No other and safety of intermittent splenic artery special was found at the first month occlusion in iatrogenic splenic after the surgery. injury. Methods: The patient with Conclusions: Intermittent splenic obesity, female, 29 years old. Main artery occlusion is a simple and complaint: The weight continued to effective therapeutic method to grade I- gain for two years. Ht: 172cm, Wt: II iatrogenic splenic injury. 115Kg, BMI: 38.8Kg/m2. BP:145/90mmHg. Biochemical indicators: Fasting blood-glucose: 5.53mmol/L
Triglyceride A219 (TG): 1.24mmol/L
Cholesterol Roux-en-y Gastric Bypass after (CHOL): 4.2mmol/L. B-ultrasound: Billroth II Gastrectomy Kyle Leneweaver Long Island City Fatty liver. Preoperative diagnosis: 1 1 Hypertension, Fatty liver, Obesity. NY , Darshak Shah Plainview NY , Sanjeev Rajpal Valley Stream NY1 Operation plan: Laparoscopic sleeve 1 gastrectomy. Iatrogenic splenic injury Flushing Hospital Medical Center occurred when extracting the resected gastric specimen. We first used gauze Intro: Various reconstructions have compression of wound to stop bleeding been described following distal for 20min and failed. Then the splenic gastrectomy for peptic ulcer disease,

92 www.obesityweek.com with Billroth II being one of the most disease. Roux-en-y gastric bypass is an common. This creates a difficult excellent solution for the management scenario when these patients present to of morbid obesity in these patients. bariatric centers for management of morbid obesity later in life. Procedure: 52 year old female referred A220 for bariatric surgery for management of Laparoscopic Repair of Congenital morbid obesity. Preoperative imaging Diaphragm Hernia with Gastric demonstrated the distal gastrectomy Bypass with gastrojejunostomy reconstruction Kellen Hayes Cleveland Heights OH1, and gastritis with a small ulceration. Philip Schauer Cleveland OH1 Plan was for Roux-en-y reconstruction. Cleveland Clinic1 Results: In the operative suite port placement was consistent with our We are presenting a 35 year old patient standard approach for a laparoscopic with morbid obesity as well as gastrectomy with the exception of the symptoms of severe gastroesophageal right subcostal port exchanged for a reflux disease who, with preoperative 15mm trocar. Extensive lysis of imaging, was diagnosed with a large adhesions was needed for sufficient paraesophageal hernia. He underwent visualization and identification of the laparoscopic repair of the hernia as well Billroth II gastrojejunostomy. The as gastric bypass and was found at the proximal limb was found to be 65cm time of surgery to have a large primary and appropriate for primary use in diaphragmatic hernia instead of a Roux-en-y reconstruction. The gastric paraesophageal hernia. The defect did pouch and jejunojejunostomy were not appear to be either a Morgagni or created in the standard fashion allowing Bochdalek hernia as it was centrally resection of the remnant stomach and located in the diaphragm, just lateral to previous gastrojejunostomy. The the left crus. The hernia was repaired formation of a new gastrojejunostomy primarily and buttressed with mesh. was performed using a circular end-to- This was followed by a gastric bypass end stapling device with transorally procedure. The procedure was inserted anvil. The mesenteric defect uncomplicated and he was discharged was closed completing the revision to a home on postoperative day 2, tolerating Roux-en-y revision. The patient a liquid diet. At 1 month of follow-up, recovered well and was discharged on he was tolerating both liquid and solid postoperative day 4. At 30 day follow- food without difficulty. His reflux up, the patient had lost 23 pounds and symptoms had resolved and his body was tolerating her diet. mass index had decreased from 43 to Conclusion: Billroth II reconstruction 38. This case demonstrates the following distal gastrectomy is a classic identification and repair of a large option for treatment of peptic ulcer primary diaphragmatic hernia in

93 conjunction with gastric bypass for operation was advised. both weight loss as well as resolution of obesity-related comorbidities and Operation: A laparoscopic excision of reflux symptoms. the gastric pouch, proximal roux limb, and proximal gastric remnant followed by esophago-jejunostomy was A221 performed. The extent and density of Laparoscopic excision of anastomotic the patient's adhesions, as well as her stricture and remnant gastrectomy prior complications, prohibited with conversion to esophago- preservation of the gastric pouch. jejunostomy Peter Lundberg Allentown PA1, Maher Outcome: An upper GI study on post- El Chaar Allentown PA operative day 1 was negative, and the St Luke's Weight Management Center1 patient was discharged home on post- operative day 2. There were no 30-day Background: Complications at the complications. She remained NPO for 2 gastro-jejunostomy following roux-en- weeks before slow advancement to a Y gastric bypass (RYGB) are well clear liquid diet. Her parenteral characterized and include leak, nutrition was discontinued 1 month bleeding, marginal ulcer, gastro-gastric after discharge. fistula, and anastomotic stricture. While conservative therapies and even some re-operative options can preserve the gastric pouch, repeat interventions and A222 recurrent disease may require Magnetic Sphincter Augmentation conversion to esophago-jejunostomy. for Refractory Reflux Following Laparoscopic Sleeve Gastrectomy Patient: A 57 year-old woman who Ryan Horsley Scranton PA1, Gordian underwent a RYGB in 2001 presented, Ndubizu Wilkes Barre PA1, Anthony initially, to our clinic with weight Petrick Danville PA1 regain due to gastro-gastric fistula in Geisinger1 2016. Operative repair was complicated by a leak requiring prolonged Introduction: GERD can occur de parenteral nutrition. Her recovery was novo in up to 30% of patients after further hampered by the development Sleeve Gastrectomy (LSG). Most of a marginal ulcer and subsequent patients are successfully managed with anastomotic stricture that proved lifestyle modifications and medical refractory to all pharmacologic and therapy. However, GERD refractory to endoscopic therapies. With the patient medical therapy is difficult to manage suffering from chronic malnutrition and with many patients requiring dependent on parenteral nutrition, re- conversion Laparoscopic Roux En Y

94 www.obesityweek.com Gastric Bypass (LRYGB). Recently, following LSG in patients with normal Magnetic Sphincter Augmentation esophageal motility. Special (MSA) has been proposed as a less consideration should be given to those morbid alternative for the relief of patients with a relative or absolute GERD. contraindication to conversion to LRYGB. Case Report:A 37-year old female developed worsening GERD one year following LSG. Prior to LSG, the A223 patient did not require acid suppression. Rescuing the Failed Sleeve She achieved 39.8 kgs of total body Gastrectomy from Conversion to weight loss but experienced increasing Gastric Bypass atypical GERD symptoms, dysphagia, William Stembridge Annapolis MD1, and odynophagia. Impedance-pH Melissa Brooks Annapolis MD1, Vivek monitoring and High-Resolution Kumbhari Baltimore MD2, Alejandro Manometry confirmed pathologic acid Gandsas Lutherville MD1 reflux and demonstrated a type 1 hiatal Anne Arundel Medical Center1 Johns hernia, with normal esophageal Hopkins GI2 motility. Her symptoms were not controlled with a high dose PPI and The Roux-en-Y gastric bypass H2-antagonist. Endoscopy, barium (RYGBP) is considered to be the gold swallow, and CT-Abdomen-Pelvis standard surgical procedure for weight confirmed a hiatal hernia without loss, as well as the default esophagitis or other pathology. operation for patients suffering from complications following Sleeve The patient’s surgical history was Gastrectomy. Despite the universal notable for eight prior abdominal recognition of its overall benefits, the surgeries including ventral hernia RYGBP still carries a set of crippling repairs with mesh placement and potential complications. significant adhesive disease. Risk of RYGB was significant, therefore “off- This video demonstrates a compilation label” use of MSA was planned after of different surgical techniques aimed appropriate consent. to rescue a failed sleeve from being revised to a RYGBP. While short One month post-operatively, the patient strictures or sharp angulation at the denied symptoms of GERD and incisura can be managed with a tolerated a stage IV diet without further Heineke-Mikulicz, like need of PPIs. stricturoplasty, a relaxing seromyotomy, similar to that described Conclusion:MSA should be considered by Heller, is always preferred for in the management of refractory GERD longer gastric stenosis. Weight regain

95 due to residual fundus or dilated sleeve She initially experienced satisfactory can be addressed by fundectomy or re- weight loss, however subsequently had sleeve gastrectomy, respectively. significant weight re-gain despite compliance with dietary advice and Intractable gastro-esophageal reflux continued exercise. Her BMI was still due to intra thoracic sleeve migration is 43 when she was seen in the outpatient addressed by conducting an aggressive setting. She was thus consented for dissection of the thoracic esophagus distalization of her bypass. A three port and posterior cruroplasty with technique was utilized. After obtaining esophagopexy. In addition, endoscopic entry into the abdomen with a 5mm methods are also described as a cost optical port, a second 5mm port was effective approach to help alleviate the placed in the left upper quadrant, and a symptoms of a failed sleeve third 12mm port was placed in the left gastrectomy. lower quadrant. The roux limb was identified and traced back to the While these video images represent a jejunojejunostomy. A 60mm stapler small cohort of patients, our was then used to divide the roux limb experience and results in offering these just before it entered the anastomosis “rescue” approaches to our patients has preserving as much length as possible. been encouraging. Multicenter studies The terminal ileum was then identified are still needed to validate the safety and a point on the small intestine and functionality of these procedures in 250cm proximal to ileocecal valve was hopes of sparing patients from chosen for the new anastomosis. A 3-0 unnecessary conversion to gastric Vicryl "stay-suture" was placed and bypass. enterotomies made with electrocautery. The anastomosis was then created with another firing of the 60mm stapler. The common enterotomy was closed with a A224 running 3-0 Vicryl in two layers. The Laparoscopic Distalization of Gastric patient tolerated the procedure well and Bypass recovered without complication. She Christopher Taglia Eastchester NY1, was discharged on post-operative day Sarah Langdon Santa Barbara CA1, #1 on a regular diet and has since David Thoman Santa Barbara CA1 followed up as an outpatient. Though Santa Barbara Cottage Hospital1 still early, she has already experienced weight loss. The patient is a 37 year-old female with a history of super morbid obesity who had previously undergone a A225 laparoscopic roux-en-Y gastric bypass Double trouble after gastric bypass – 5 years ago with a 120cm roux limb. regurgitation and hypoglycemia

96 www.obesityweek.com Stephan Axer Torsby GE-anastomosis was derotated, the Torsby Hospital candy-cane was pexied to the fundus. Anticipating that the kinking of the CC A Background: Vomiting and generated a delayed emptying of the regurgitation after laparoscopic gastric alimentary limb (AL) eventually bypass (LGBP) are considered to be contributing to hypoglycemia, the JJ- alarming signs after gastric bypass. anastomosis was revised. The AL was These symptoms are often related to divided close to the JJ-anastomosis and ileus, internal herniation or trocar site re-inserted to the CC 150 cm distally to hernias requiring reoperation. the JJ. This migration resulted in a Hypoglycemia is a metabolic lengthening of the bilary limb (from 50 complication observed in a subset of cm to 200 cm) and a corresponding postbariatric patients. shortening of the CC. The patient was discharged from Method: hospital after one day. After six weeks Case-report based on operation video- she had lost 8% of body weight, could sequences discontinue treatment with Acarbose and did not have any episode of Result: regurgitation or vomiting. A 48-year old woman who had undergone a LGBP in 2010 presented Conclusion: with morning regurgitations, Rotation of the GE-anastomosis ought postprandial hypoglycemia (treated to be considered in patients with with Arcabose) and weight regain. regurgitation after LGBP. Kinking at Laparoscopy revealed two distinct the JJ-anastomosis might contribute to findings: Rotation of the gastro-entero hypoglycemia. Revision of the anastomosis (GE) and kinking of the anastomosis seems to be a therapeutic common channel (CC) close to the option. jejuno-jejunal anastomosis (JJ). The


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A233 Crowley Charleston SC2, Amanda Laparoscopic Biliopancreatic Peterson Johns Island SC2, Molly Diversion with Duodenal Switch- Jones Mt. Pleasant SC2, Diana Technical Considerations in the High Axiotis Charleston SC2, Benjamin BMI patient. White Charleston SC2, Shelby Rana Pullatt Mt Pleasant SC1, Karl Allen Charleston SC2, Doris Byrne Charleston SC1, Nina Kim Charleston SC2

97 Medical University of South Rex Bariatric Specialist1 Rex Bariatric Carolina1 MUSC Charleston, SC2 Specialists2 Research Assistant3

The first part of the video describes the Single anastomosis duodenal switch technical considerations of the continues to gain greater Duodenal dissection and the acceptance. The predominant performance of an omega loop to roux technique focuses on a total greater configuration. The second portion of curve moblization as well as hand sewn the video describes technical duodenoileostomy. We present a modifications in the high BMI patient totally stapled linear technique that including a retrocolic approach and offers speed, reproducible results, and stapled technique of the duodenoileal widely patent afferent and efferent anastomosis. limbs. We demonstrate the technique, touching base on the critical aspects of duodenal anastomotic stapling, A234 important to consistent results. Laparoscopic Single Anastomosis Duodenal Switch by Linear Triple Staple Technique Peter C. Ng, MD, A235 Lindsey S. Sharp, MD, Dustin M Conversions of Gastric Restrictive Bermudez, MD, Erica M. Procedures to Single Anastomosis McKearney, PA-C, Jillian M. Vari, Duodenal Switch (SADS/SIPS) PA-C, RD, John D. Ambrose, Sophia Varun Krishnan New York NY1, E. Menozzi Mitchell Roslin New York NY1 Peter Ng Raleigh NC1, Lindsey Lenox Hill Hospital1 Sharp Raleigh NC2, Dustin Bermudez Raleigh NC2, Erica This is a video detailing the conversion McKearney Raleigh NC2, Jillian of adjustable gastric band or sleeve Vari Raleigh NC2, Sophia gastrectomy to single incision duodenal Menozzi Raleigh NC3, John Ambrose switch. We present 2 patients who Ambrose 3 underwent these conversions.

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98 www.obesityweek.com Avoidance of Diagnosis of Obesity in with a PCP outside our system were Patients Referred for Bariatric excluded because of difficulty in Surgery review of scanned records. Ann Rogers Hershey PA1, Ashton Brooks Hershey PA1, Myunghoon Results Kim Hershey PA2 Penn State Hershey Medical 654 patients entered the SWLP during Center1 Penn State College of the study period. 313 patients were Medicine2 excluded either because they sought revision or because they had outside ASMBS 2018 Obesity Diagnoses physicians, without access to our EHR. Abstract Of the 341 included patients, 120 (35%) came with a prior diagnosis Background referencing overweight or obesity. The remaining 221 (65%) had no such Obesity was recognized as a disease by diagnosis. the AMA in 2013. Despite this, literature suggests that primary care Conclusion providers (PCPs) frequently fail to document patient weight status. The majority of patients referred for Increased documentation of obesity is bariatric surgery within our own system associated with increased behavioral still came without a stated diagnosis of treatment. obesity. We found “hint” diagnoses such as “weight gain” or “sedentary Methods lifestyle” but the failure to specifically mention obesity by internists, family We reviewed electronic health records practitioners, endocrinologists, etc., (EHRs) of all patients entering our was widespread. Patients with surgical weight loss program (SWLP) undiagnosed obesity are even less between October 2013 and September likely to be referred for treatment. 2015, screening for diagnoses mentioning obesity prior to entry. These included: morbid obesity, increased BMI, obesity, central obesity, A237 mild obesity, obesity hypoventilation Problematic Alcohol Use after syndrome, metabolic syndrome, and Bariatric Surgery: Sleeve even overweight. We identified patients Gastrectomy versus Gastric Bypass with a PCP or obesity specialist within Lisa Miller-Matero Detroit MI1, Julia our health system, aware that some Orlovskaia Detroit MI1, Aaron trainees were being counseled that such Hamann Detroit MI1, Kellie diagnoses were “insulting.” Patients Martens Beverly Hilld MI1, Aaron

99 Bonham Ann Arbor MI2, Arthur proportion of patients who underwent Carlin Detroit MI1 SG endorsed AUD at 1-year post- Henry Ford Health System1 University surgery compared to RYGB (p= .02; of Michigan2 9.8% vs 4.2%). However, there was a trend suggesting that patients who Research suggests that patients may underwent RYGB had a higher develop problematic alcohol use proportion of AUD at year-2 post- (AUD) after undergoing bariatric surgery (p= .06; 21.1% vs 12.4%). surgery. However, most of the research conducted has been with patients who Patients may develop a new alcohol use underwent Roux-en-Y gastric bypass disorder after bariatric surgery. Risk (RYGB) and less is known about may vary across time and surgery type. alcohol use after sleeve gastrectomy (SG). The purpose of this study was to examine changes in AUD in the two years following bariatric surgery and to determine whether there is an influence A238 of surgery type. Prevention of Nutrient Deficiencies following Sleeve Gastrectomy, Roux- Patients who underwent SG (n= 7,679) en-Y Gastric Bypass and the or RYGB (n= 1,372) within a statewide Duodenal Switch 1 clinical registry and completed the Ciara Lopez Windermere FL , Dennis 1 Alcohol Use Disorders Identification Smith Celebration FL , Lauren 1 Test, assessing alcohol use pre-surgery Lapp Celebration FL , cynthia 1 and at 1 and 2 years post-surgery were buffington Celebration FL 1 included. Florida Hospital Celebration health

Patients had a mean age of 45 years, Introduction. Micronutrient were predominantly female (79.7%) deficiencies are common following and Caucasian (70.2%), with an bariatric procedures. In this study, we average preoperative Body Mass Index examine the effectiveness of a program of 47.89. There was no change in the encouraging compliance to proportion of patients with AUD from multivitamin/mineral (MVM) baseline to 1-year post-surgery; supplementation and postoperative however, there was a significant MVM adjustment on micronutrient increase from baseline to 2 years (p= levels over the first postoperative year .01; 8% vs 13.7%). Of those without for 3 bariatric surgeries, laparoscopic AUD at baseline, 4.2% had AUD 1- sleeve gastrectomy (LSG), Roux-en-Y year post-surgery. Two years post- gastric bypass (RYGB) and duodenal surgery, 9.5% had new onset AUD. switch (DS). Controlling for baseline AUD, a higher Methods. The study included 29 LSG,

100 www.obesityweek.com 29 RYGB, 29 DS patients similar in age, gender, and preoperative ASA scoring. Patients were advised to take A239 MVM supplements at intakes  those Bariatric surgery does not increase recommended for each procedure by the ability to work – a Danish the ASMBS Guidelines Committee nationwide registry study (2016). Vitamin and minerals were Claus Juhl Esbjerg 1, Rene monitored at 0, 3, 6, and 12 months Holst Oslo 2, Jon Michael Gran Oslo 2, postoperatively and supplement intakes Lene Hymøller Mundbjerg Esbjerg 1, were adjusted to treat low and deficient Charlotte Røn Stolberg 6700 1, Gert nutrients. Frank Thomsen Esbjerg 1 Results. The data show that patient Hospital of South West adherence to the recommended MVM Jutland1 University of Oslo2 regimen and postoperative MVM adjustment following LSG and RYGB Background resulted over the first year in significant Several factors affect a person’s ability (p<0.05) increases in levels of to work. These include factors Vitamins D, B12, B1 and stabilization associated with severe obesity such as of folate, calcium, iron, ferritin, physical and mental health. People with hemoglobin, albumin and severe obesity may be expected to work PTH. Following the DS, high patient less while surgery-induced weight loss compliance (96%) to the supplement may increase a person’s ability to work. program and MVM adjustments Methods significantly improved early We performed a nation-wide case- postoperative declines in folate, control register study. Four thousand thiamin, albumin, iron, and nine hundred and twenty-seven cases ferritin. However, even with who had undergone laparoscopic aggressive DS nutrient monitoring, gastric bypass surgery (LGB) (Obese) calcium levels significantly decreased, were identified in the Danish National vitamin D worsened (42% Patient Registry. By the Danish Civil insufficiency/deficiency), and PTH Registry each person was matched with increased (30% high). two controls with respect to age, gender Conclusions. Adherence to ASMBS and residence municipality (Control). recommended MVM intake coupled Employment status from twelve months with postoperative replacement of low before to six years after the operation or deficient micronutrients, improves or was extracted from The Danish normalizes vitamin and mineral levels National Labor Market Authority's following SG and RYGB and for most, Database which includes information but not all micronutrients, following on public transfer incomes. By logistic DS. regression analysis, we assessed the effect of LGB on working ability

101 stratified by education level. post-surgical bariatric patients. High- Results medication burden coupled with At baseline, obese people worked less bariatric surgery place these patients at than controls (Obese 0.658, controls high-risk for medication harm. 0.775,  0.117) (1.000 denotes the entire group working full-time). This METHODS: As part of a pilot accounted for people with lower program, a pharmacist specialist was education (Obese 0.669, controls 0.767, integrated into the ambulatory care  0.098), intermediate education setting within an academic teaching (Obese 0.691, controls 0.850,  0.159) bariatric surgery center of excellence to and higher education (Obese 0.765, provide comprehensive pharmacy controls 0.823,  0.058) (all p<1e-5). consultative services pre-operatively. In The proportion at work declined over our preliminary assessment, from a 4- time presumably due to the financial month sample of cases January to April recession. LGB had no impact on 2017, bariatric patients took an average working proportion up to year six of 7.2 (0 – 20) medications prior to postoperative. admission. Per case, over half of the Conclusion medications required an intervention by Obese people eligible for LGB work a clinical pharmacist (53%, average of significantly less than matched 3.8 interventions per case). We controls. LGB does not diminish this identified an unsafe care gap for difference nor do obese people seem comprehensive medications reviews more vulnerable during a period of and patient education prior to surgery; recession. patients were often unaware of necessary medication changes that occurred postoperatively. A large A240 portion (35%) of the patients within the Slimming Down Medication Errors pilot were on high-risk medications Through Pharmacist Specialist (insulin, anticoagulants, sedative- Integration into the hypnotics). Within our pilot group Multidisciplinary Collaborative Care 100% of cases had errors in original Team medication lists with an average of 5.4 Nicole Nguyen San Francisco CA (1 – 19) medication errors reconciled UCSF Medical Center by pharmacists. Key performance metrics collected included the number of interventions made for medically BACKGROUND: Bariatric surgery can high-risk patients and total number of have a profound effect on the interventions (including change in absorption of medications and there is agent, dose, formulation, limited available evidence in published discontinuation, and initiation of high- literature to guide therapy changes in risk medication tapers).

102 www.obesityweek.com reviewed. Prevalence of chronic pain CONCLUSION: Integration of a diagnosis codes, number of visits with dedicated pharmacist specialist into the pain management and behavioral multidisciplinary collaborative care health, opiate prescriptions, and team pre-operatively can improve frequency of cancelled/no-show visits medication safety. were assessed. Results: Overall, 1859 patients underwent bariatric surgery during the study period. Mean age and BMI were A241 44.9±10.5 years and 47.2±6.2 kg/m2; An Examination of Chronic Pain in 81% were women. Patients with a Patients undergoing Bariatric chronic pain diagnosis had a higher Surgery number of behavioral health Afton Koball La Crosse WI1, Kara appointments, appointment no-shows Kallies La Crosse WI2, Andrew or late cancellations, and longer Borgert La Crosse WI2 duration of opiate use. Those with Gundersen Health System1 Gundersen chronic pain diagnosis had higher Medical Foundation2 %TWL at 1 year and 5 years postoperative. (Table). Background: Pain/disability are Conclusions: Individuals with chronic common in individuals seeking pain histories had more problematic bariatric surgery. Research suggests engagement with the healthcare system that pain/physical function improves (now-shows/late cancels), more following bariatric surgery; however, problematic medication use (long-term this may stagnate after the first opiate use) and required more mental postoperative year. In contrast to health treatment. Interestingly, evidence of pain-related improvements, individuals with chronic pain had better there is also a growing body of weight loss outcomes. Exercise literature suggesting that pain improvements as a result of improved medication use increases post-surgery, physical functioning and/or reduced indicating that chronic pain may appetite from opiates are possible continue to be a challenge after explanations for this finding. bariatric surgery despite weight loss. This study seeks to examine the relationship between individuals experiencing chronic pain and bariatric surgery outcomes. A242 Methods: Medical records of patients in Contemporary racial and ethnic this study who underwent bariatric disparities in bariatric surgery in the surgery from September 2001 through United States December 2017 were

103 Allison Bruff Philadelphia PA1, Michael Mazzei Philadelphia PA1, Results Satyajit Reddy Philadelphia PA1, Riyaz 879,669 bariatric operations were Bashir Mount Laurel NJ1, Michael performed between 2005 and 2013 Edwards Philadelphia PA1 (NIS database). Bariatric operations Temple University Hospital1 decreased 10% (76% to 66%, p <0.001) among Caucasian and increased 5.5% Background (10.7% to 16.2%, p <0.001) and 3.5% Obesity prevalence continues to (9.1% to 12.6%, p = 0.015) among increase and disproportionately impact Black and Hispanic patients, ethnic minorities. Review of the respectively. 303,193 primary bariatric bariatric literature highlights both the operations were identified from the lack of representation of ethnic MBS-AQIP database, primary sleeve minorities in the published data and gastrectomy (65.9%) and gastric bypass may represent a lack of access to an (27.3%). 69%, 18% and 13% were effective treatment option for those Caucasian, Black and Hispanic, most severely impacted by obesity. respectively. Sleeve gastrectomy was performed equally among ethnic Study Aim groups. Open gastric bypass was To evaluated current trends in bariatric performed more commonly among surgery among ethnic groups in the Black and Hispanic (RR = 1.58 and U.S. 1.71, p =0.005) patients. A higher proportion of Black patients (29.5% vs Methods 21%, p <0.005) had a BMI >50. Using the 2005-2013 National Inpatient Sample (NIS) and the 2015-2016 Conclusion Metabolic and Bariatric Surgery Despite improving trends in bariatric Accreditation and Quality operations among ethnic minority Improvement Program (MBS-AQIP) patients, there remains significant database, we identified patients who disparity in access to bariatric surgery had a bariatric operation. Descriptive among those who are statistics and regression analyses were disproportionately impacted by the performed. obesity epidemic.

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A255 Tryptophan and Bariatric Nutritional Metabolomics

104 www.obesityweek.com carol wolin-riklin Bellaire TX1, Shinil the body and can only be acquired Shah Houston TX1, Erik through dietary intake. Trp deficiency Wilson Houston TX1 has no defined characteristics to McGovern Medical School at UT facilitate an isolated diagnosis but Health1 rather presents within a multifacted diagnostic enigma entangled within Introduction: Anatomic alterations in other nutrient deficiencies. Bariatric the gastrointestinal tract following surgical changes can impact Trp bariatric surgery can have an adverse absorption and increase Trp impact on the gut metabolome. degradation due to inflammation and Tryptophan (Trp) is an essential amino disease processes. Research is needed acid and a precursor of to assess Trp levels impact on gut neurotransmitters,eniacin and has also homeostasis and gut integrity. been correlated with bowel integrity. Screening criteria after bariatric surgery Bariatric surgery may impact Trp needs to be developed if low/deficient absorption and/or degradation affecting Trp levels are identified as a risk factor the integrity of the bowel to absorb negatively impacting the gut nutrients. metabolome.

Case Presentation: Adult male presented to surgery clinic 15 months A256 following a revision of roux-en-y Nutrition supplement after bariatric gastric bypass (2004) to biliopancreatic surgery: Does it really make diversion/duodenal switch (5/9/2016). difference? He reported chronic diarrhea, bruising, Wah Yang Guangzhou 1, Songhao skin changes, blood clots in the legs, Hu Guangzhou 1, Pik Nga fatigue and dizziness and up to four Cheung Guangzhou 1, Cunchuan alcoholic drinks daily. TRP deficiency Wang Guangzhou Guangdong 1 was noted at presentation to the clinic The First Affiliated Hospital of Jinan (Table1). He was started on pancreatic University1 enzymes, Trp supplementation and parenteral nutrition. Background: Reliable information on As parenteral nutrition was weaned off, the vitamins and micronutrients status bariatric diet reinforcement, pancreatic is still unclear in preoperative and enzymes, and oral Trp supplementation postoperative in Chinese bariatric continued. Diarrhea, bruising, skin patients, the necessity of nutrition changes, fatigue and dizziness were supplement should have the clinical resolving. Alcohol consumption evidence. continued to be an ongoing struggle. Objective: To investigate the pre- and Discussion: Trp is not synthesized in post-operation vitamins and

105 micronutrients status and analyze its follow-up, but no meaning results in relationship with surgical types long term (more than 2 year) follow up. (LRYGB and LSG).

Methods: Measurements of vitamins A257 and micronutrients were obtained at 10 years follow-up after Bariatric baseline and 1, 3, 6 ,12 and 24 months Surgery(BS): body composition, after surgery. The data was analyzed weight and diabetes and compared according to surgical Andréa Z Pereira S.Paulo types and with or without nutrition UNIFESP supplement. Introduction:BS is the best treatment Results: 414 of 668 patients had full for severe obesity and its associated co- medical record underwent bariatric morbid medical conditions, such as, surgery were involved in this study. diabetes. It results in greater weight Vitamins deficiencies were common in loss for longer periods.Objectives:To both pre- and post- operation, evaluate weight, diabetes and body especially for vitamin B1 (25.1% pre), composition 10 years after vitamin C (21.4% pre) and vitamin E BS.Methods:In 2008, we evaluated 19 (19.7% pre). Micronutrient parameters patients (10 diabetic and 9 non- were also low in Zinc (29.1% pre) and diabetic) undergone Y Roux gastric transferrin (14.2% pre). Vitamin C and bypass , Obesity and Bariatric Surgery ferritin had significant improvement in Department, UNIFESP, S.Paulo, patients with regular nutrition Brazil. In 2018, 7 patients were re- supplements (P<0.05). Vitamin B1 and evaluated by ultrasound, in a Vitamin D were also improved transversal plane, the lower limbs; fat- significantly in 3 and 9 months with muscle measurements were performed supplements after surgery (P<0.05). at 15 cm from the superior pole of the Higher level of ferritin found in patella in the proximal direction on the LRYGB than that in LSG (P<0.05). No quadriceps muscle in the ventral, statistical significance found in gender middle line of the thigh. Friedman and and among surgical approaches 2 years Pearson’s statistical tests were postoperatively (P<0.05). used.Results:We evaluated 7 female patients were 54 (±20 years), 4 were Conclusions: Vitamins and diabetics in 2008, however none is micronutrients deficiencies are very diabetic nowadays. The baseline weight common in both pre- and post- was 119 (±25kg) and after 10 years of operation among Chinese patients BS was 79(± 16 kg). The right muscle undergoing bariatric surgery. The and fat thickness in baseline was, nutrition supplement therapy truly respectively, 3,3(±0,7 cm) and makes a difference sometime in the 2,0(±0,6 cm), after 10 years was

106 www.obesityweek.com 2,2(±0,6 cm) and 1,2(±0,6 cm). In positive and significant (p<0,005) baseline, the left thigh muscle and fat correlation between weight and muscle thickness were 2,0(±0,6 cm) and after thickness after 10

10 years, respectively, 2,0(±0,6cm) and years(rp:0,8).Conclusion:After 10 0,5(±0,3cm). The reduction of muscle years of follow-up all patients showed and fat thickness and weight 10 years maintenance of their weight loss after BS was significant compared to without recovering fat mass or muscle the baseline (p<0,005). We found a thickness and diabetes.
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A258 consisted of complete FCI data pre and Food Cravings after Bariatric postoperative. Food cravings were Surgery: Sleeve Gastrectomy versus categorized as sweets, Roux-en-Y Gastric Bypass carbohydrates/starches, high fats, and Afton Koball La Crosse WI1, Kara fast-food fats. Level of craving was Kallies La Crosse WI2, Luis based on a 5 point likert scale. Ramirez La Crosse WI2 Statistical analysis included Gundersen Health System1 Gundersen paired t tests, ANOVA, and Spearman Medical Foundation2 Correlation. Results: Forty-nine patients completed Background: Food preferences and a preoperative and 3-month cravings change following bariatric postoperative FCI; (28 RYGB and 21 surgery; however, little research has SG). Overall, 84% were women; the examined differences by surgery type. mean age was 43.4±11.0 While Roux-en-Y gastric bypass years. Preoperative and 3-month BMI (RYGB) has long been considered the were 46.1±5.9 and 39.9±4.8 kg/m2, gold-standard in bariatric surgery, respectively. A significant decrease in sleeve gastrectomy (SG) is increasing food cravings was observed from pre to in popularity. The objective of this postoperative in both groups; however, study was to examine changes in food no differences were noted when cravings during the early postoperative comparing RYGB to SG (Table). Early period following bariatric surgery and total weight loss was not correlated identify any differences between SG with changes in food cravings (r= - and RYGB. 0.12; P=0.431). Methods: Patients scheduled to undergo Conclusions: Both RYGB and SG either SG or RYGB were prospectively resulted in decreased frequencies of enrolled and completed the Food food cravings based on a prospective Craving Inventory-II (FCI) study using a validated survey. No preoperatively and at 3 months differences were observed for RYGB postoperative. Inclusion criteria

107 versus SG in the early postoperative A total of 123 patients were included. period. 10.2% of the sample presented iron deficiency prior to surgery. After surgery, the prevalence of iron deficit A259 was 9.1%, showing a statistically MICRONUTRIENTS significant difference (p<0.0001). 6.5% DEFICIENCIES AND presented Vit.B12 deficit prior to HYPOVITAMINOSIS BEFORE surgery. After surgery, the prevalence AND AFTER LRYGB of deficit was 4.3%, showing a Maximo Agustin Schiavone Martinez 1, statistically significant difference Maximiliano Farinelli Pilar, Bs As. 2, before and after surgery (p=0.0098). Nicolas Paleari Pilar 1, Gabriel 79.1% of the sample presented a Vit.D Menaldi Pilar 1, Maria Eugenia deficit prior to surgery. After surgery, Garcia Buenos Aires 1, Marta Gomez the prevalence of deficit was 46.5%, Gottschalk Buenos Aires 1, Virginia showing a statistically significant Asti Pilar, Buenos Aires 1, Maria difference(p<0.0001). Finally, the Gloria Linzoain Buenos Aires 1, prevalence of pre-surgical PEDRO MARTINEZ hypocalcemia was 2.6%, while the DUARTEZ Buenos Aires 1 postsurgical hypocalcemia was 3.9% Hospital Universitario (p=0.1181). Austral1 Universidad Austral2 With bariatric surgery, 33.33% of iron deficit was resolved, 66.66% of Objectives: hypovitaminosis-B12, 50% of 1- To analyze the pre-surgical and post- hypovitaminosis D. However there was surgical prevalence of iron deficiency, a 25% of new cases of iron deficit, 50% vitamin-B12, vitamin-D and calcium. of vitamin B12 and 15% of 2- Analyze if there are deficiencies that hypovitaminosis-D after surgery. resolve with bariatric surgery. Conclusions: 3- Analyze if there are deficiencies that A majority of these deficiencies begin begin after bariatric surgery. before surgery. There are also non- Materials and methods: negligible percentages of micronutrient We analyzed 156 patients operated in deficit and hypovitaminosis that resolve year 2017. Exclusion criteria: acute or with surgery, chronic pathologies that may affect the metabolism of micronutrients (metabolic, neoplastic, infectious, A260 hematological), gastric sleeve, gastric INADEQUATE VITAMIN D does band, incomplete laboratory data. not interfere with body weight The variables were analyzed prior to reduction in women of childbearing surgery and 6 months after surgery. age after Roux-en-Y Gastric Bypass. Results:

108 www.obesityweek.com Jean-Marie Molasoko LES MUREAUX postoperative years. In addition, the CT C H P EUROPE participants were subdivided according to pre-operative vitamin D levels in Methodology: This is an analytical, adequacy (G1), deficiency (G2) and longitudinal and retrospective study insufficiency (G3). Serum calcium and with 40 women of childbearing age parathormone (PTH) concentrations underwent prior to RYGB. We were also evaluated. calculated body mass index (BMI), weight loss (WL), overweight,% of Conclusion: The present study suggests weight loss and surgical success. To that inadequate of vitamin D does not investigate the influence of serum interfere in the reduction of body vitamin D levels on body weight weight in the follow-up of two-year reduction, the variables were analyzed after RYGB and gives attention that in the preoperative period (T0), first vitamin D may present a differentiated year (T1) and second year (T2) after response in the postoperative period, in surgery and stratified according to BMI detriment to the preoperative period. obtained in the 1 st and 2 nd

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A243 postsurgical changes. This study Prevalence and Correlates of explored correlates of discontinuation Psychiatric Medication one month post-surgery. Discontinuation One Month After Bariatric Surgery Methods: During the pre-surgical Kasey Goodpaster Cleveland OH1, psychological evaluation, candidates Leslie Heinberg Cleveland OH2, completed the Minnesota Multiphasic Ninoska Peterson Cleveland OH3 Personality Inventory-2-Restructured Cleveland Clinic Bariatric & Metabolic Form (MMPI-2-RF) and a clinical Institute1 Cleveland Clinic2 Cleveland interview. In a one-month postsurgical ClinicI3 psychology group, patients completed a questionnaire assessing complications, Background: Approximately half of benefits, pre-surgical psychiatric bariatric candidates take psychiatric medication use, and whether medications. Sudden discontinuation medications were re-started post- can cause serious adverse effects, surgically. Differences between particularly amidst the stress of patients who re-started medications

109 (n = 522) and discontinued (PSYMED- Health or Appearance? Factors , n = 70) were analyzed using chi Motivating the Decision to Seek square and t-tests. Bariatric Surgery Rebecca Pearl Philadelphia PA1, Results: Among patients taking Thomas Wadden Philadelphia PA, psychiatric medication pre-surgery (N Kaylah Walton Odenton MD, Kelly = 592, 49.3% female, 35.1% Allison Philadelphia PA, Jena Caucasian, Mean intake BMI = 50.3), Tronieri Philadelphia PA, Noel 11.8% discontinued post-surgery. Williams Philadelphia PA PSYMED- was associated with race Perelman School of Medicine at the (p = .05), with a higher percentage of University of Pennsylvani1 Latino/a (66.7%) and Asian (50.0%) patients discontinuing than Caucasians Background: Few studies have (14.1%) and African Americans explored the factors and people who (9.1%). PSYMED- was associated influence patients to seek bariatric with younger age (p = 0.048) and being surgery. Along with health benefits, prescribed fewer psychiatric patients may desire dramatic changes in medications (p = 0.011). PSYMED- appearance. had lower mean MMPI-2-RF scores on Methods: The Reasons for Bariatric infrequent responses (p = 0.012), social Surgery survey was administered to avoidance (p = 0.017), and patients seeking surgery at a university- introversion/low positive emotionality based hospital. The survey included: (a) (p = 0.046) scales. PSYMED- was not 15 potential reasons motivating surgery associated with psychiatric diagnosis, (rated 1-10; higher scores signify post-surgical mood improvement, self- greater importance); (b) 7 potential esteem, body image, or medical people who influenced patients’ complications. decision to seek surgery (1-10); (c) dissatisfaction (1-7) with 11 body parts; Conclusions: A significant minority of and (d) desire for the surgery to change patients discontinue psychiatric each body part (1-10). medications post-surgery. Those who Results: Informed consent and surveys are younger, take fewer psychiatric were obtained from 208 patients medications, and endorse less seeking surgery (52.9% black, 77.9%

emotional distress pre-surgery may see female, Mage=42.0±12.3years, MBMI=46. less value in ongoing treatment.Given 7±8.5kg/m2). Factor analysis of the the potential for rebound symptoms, reasons for surgery yielded a five- education about medication adherence factor solution: Work, Psychosocial, and appropriate tapering is vital. Longevity, Physical Health, and Quality of Life (QOL). Physical Health was the highest-rated factor A244 (M=9.9±0.4), followed by Longevity

110 www.obesityweek.com (9.7±0.9) and QOL (8.7±1.4). Paired the impact of depression on outcomes comparisons showed significant such as weight loss and patient differences between all factors. satisfaction, are mixed. “Myself” was the highest-rated person influencing the decision to seek surgery This study includes patients who (M=10.0±0.3), followed by healthcare underwent Roux-en-Y gastric bypass practitioner (7.1±3.1), and someone (RYGB) or sleeve gastrectomy (SG) who had surgery (6.9±3.3). Participants within a statewide clinical registry reported the greatest dissatisfaction between 2015-2017. Participants self- with their stomach (6.5±1.1), thighs reported depressive symptoms (Patient (5.4±1.7), and arms (4.9±1.8), and the Health Questionnaire-8; PHQ-8), greatest desire to change these body satisfaction with surgery, and weight parts (Ms=9.3±1.4, 7.4±2.7, and pre-surgery, 1-year (N= 6664), and 2- 6.8±2.8, respectively). years (N= 1991) post-surgery. Conclusions: Health and longevity were the primary reasons motivating Participants had a mean age of 46, were patients to seek bariatric surgery. predominantly female (78.9%), Patients also reported strong body Caucasian (79.6%), and had a mean dissatisfaction and desire for surgery to preoperative BMI of 47.4. Compared to change their appearance. Healthcare baseline, fewer patients endorsed practitioners and patients who had clinically significant depression (PHQ- bariatric surgery can play a significant 810) at 1-year (p<.0001; 13.9% vs role in patients’ decision to seek 7.2%) and 2-years post- surgery. surgery (p<.0001; 9.5%). However, when including participants with both year 1 and 2 PHQ-8 scores, prevalence A245 rates of depression were significantly Relationship between Depression, higher at year 2 (p<.0001; 9.5% vs Weight, and Patient Satisfaction Two 5.3%). Higher PHQ-8 at baseline was Years after Bariatric Surgery related to less weight loss (percent total Kellie Martens Beverly Hilld MI1, weight loss; %TWL) at 1-year post- Aaron Hamann Detroit MI1, Lisa surgery (r= -.11, p<.001) but not at 2 Miller-Matero Detroit MI1, Chazlyn years (p=.06). Post-operative Miller Detroit MI, Aaron Bonham Ann depression was related to lower %TWL Arbor MI, Arthur Carlin Detroit MI1 at 1 year (r= -.11, p<.0001) and 2 years Henry Ford Health System1 (r= -.14, p<.0001). Baseline depression was also associated with lower patient Research suggests that depression satisfaction after 1 and 2 years (r= - improves in the first year after bariatric .08; p< .001). surgery. However, findings regarding longer term depressive symptoms and This study suggests that preoperative

111 depression improves up to two years candidates. This study utilized a post-bariatric surgery, but the retrospective chart review (n=247) of prevalence of depression may begin to patients (mean age=42.29, SD=11.34; increase after the first year. Depression, mean BMI=47.61, SD=8.26) assessed both pre- and post-bariatric surgery, at a pre-surgical psychological may impact weight loss and patient evaluation using the Graded Chronic satisfaction. Pain Scale (GCPS), Pain Catastrophizing Scale (PCS), and measures of depression and anxiety. Based on data from samples with chronic pain and obesity, a lower PCS cut-off score (>24) was used to indicate A246 clinically significant pain Pain Perceptions in Bariatric catastrophizing. High-intensity pain Surgery Candidates: The Role of was reported by 49.2% of participants, Pain Catastrophizing and elevated PCS scores occurred in Colleen Schreyer Manchester MD1, 13.2% of patients. Participants with Jesica Salwen-Deremer Baltimore elevated PCS scores identified a higher MD2, Amanda Montanari Scituate MA2, number of body regions as painful; Breanna Holloway Baltimore MD2, back, knee, and foot pain were most Janelle Coughlin Baltimore MD2 prevalent. Elevated PCS was also Johns Hopkins University School of significantly associated with higher Medicine1 Johns Hopkins School of pain grade, intensity, and disability Medicine2 scores on the GCPS, controlling for age, gender, BMI, depression, and Positive correlations between pain anxiety (ps<.001). Like other clinical perception and pain catastrophizing populations, pain ratings are associated have been observed across clinical with pain catastrophizing in individuals populations. Higher levels of post- seeking bariatric surgery. Clinical operative pain are associated with pain interventions targeted to improve pain- catastrophizing, anxiety, and morphine related coping skills may be indicated consumption. Bariatric surgery in bariatric patients who report elevated candidates frequently report chronic pain catastrophizing to potentially pain, and recent data demonstrate that reduce the post-surgical initiation of higher pre-surgical pain ratings predict opioid-based analgesics. use of opioid-based analgesics in post- surgical candidates at long-term follow- up. This study examined the role of A247 pain catastrophizing as a predictor of The BARS Study: Patient chronic pain grade, intensity and Understanding and Use of Alcohol disability in bariatric surgery after Bariatric Surgery

112 www.obesityweek.com Lisa Miller-Matero Detroit MI1, Joseph consumed alcohol post-surgery did so Coleman Detroit MI1, Leah within the first year after surgery LaLonde Ypsilanti MI1, Kellie (54.8%; n= 178). Neither receiving Martens Beverly Hilld MI1, Aaron education prior to surgery nor Hamann Detroit MI1, Arthur understanding risks were related to Carlin Detroit MI1 alcohol consumption post-surgery (p> Henry Ford Health System1 .05).

Patients who undergo bariatric surgery Although patients recall receiving are at increased risk of developing education about not using alcohol after alcohol problems, yet many patients surgery, many patients do not appear to consume alcohol after surgery. The understand the risks involved with purpose of this study was to evaluate alcohol consumption. Despite receiving whether patients who underwent this education, many patients are still bariatric surgery recalled receiving consuming alcohol after surgery. It education about alcohol prior to having appears that additional interventions are surgery and to investigate their alcohol needed to decrease alcohol use after use patterns. bariatric surgery.

Patients (N= 567) who underwent bariatric surgery from 2014-2017 A248 completed a survey in March-April Alcohol Use Disorders and 2018 regarding their knowledge of Psychiatric Hospitalizations After risks associated with alcohol use and Bariatric Surgery patterns of current alcohol Wynne Lundblad Pittsburgh PA1, consumption. Rachel Kolko St. Louis MO1, Alexis Fertig Pittsburgh PA, michele The majority of patients (93.1%, n= levine Pittsburgh PA, Marsha D. 528) recalled receiving education about Marcus Pittsburgh PA the risks of alcohol use prior to having University of Pittsburgh Medical surgery. However, 36.4% (n= 194) Center1 were unsure how alcohol could impact the body differently post-surgery. More Background: While bariatric surgery is than half of patients consumed alcohol a highly effective treatment for severe since undergoing bariatric surgery obesity, numerous studies demonstrate (57.7%, n= 325), of which 72.9% (n= an increased risk of suicide and alcohol 237) consumed alcohol within the past use disorder (AUD) in postsurgical month. Of those who had alcohol in the patients. Presurgery psychological past month, 9.7% (n= 23) had more evaluation is challenging in part than 6 drinks on at least one occasion. because of patients’ tendency to More than half of patients who underreport psychiatric symptoms and

113 substance use prior to surgery. Thus, presurgery and 27.7% (n=13) of clinical diagnoses and impairment patients postsurgery. Suicidality severity are likely to be occurred in 67.9% (n=55) of underappreciated at that time, postsurgery patients; 81.8% (n=18) of preventing identification of and patients admitted with AUD also intervention for some high-risk endorsed suicidality. All patients with candidates. Limited data exist on AUD postsurgery had no documented patients who present with serious AUD presurgery. It is unknown how psychiatric impairment after bariatric many patients had undetected surgery. presurgical AUD versus those with de Methods: Using a retrospective chart novo postsurgical AUD. review, we characterized patients Discussion: This is the first study to admitted to a psychiatric hospital examine AUD and suicidality in between 2010-2014 with a history of patients admitted to a psychiatric bariatric surgery (N=81). Of the 47 hospital post-bariatric surgery. As patients with available presurgery hospitalization is a rare and serious psychological evaluations, 36 had outcome, we recognize this represents a presurgery psychiatric diagnoses. small subset of bariatric surgery Results: Depressive disorders (n=16, patients. Future directions include 34.0%) were the most common comparing this group to bariatric presurgery diagnoses. AUD was surgery patients not requiring inpatient present in 2.1% (n=1) of patients psychiatric care.
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A249 problems are also associated with Insomnia and night eating syndrome poorer post-surgical weight loss. in bariatric surgery patients Factors in these relationships are not Jesica Salwen-Deremer Baltimore well understood; thus, we examined the MD1, Colleen Schreyer Manchester impact of insomnia on weight-gain MD, Amanda Montanari Scituate MA, related eating behaviors. Breanna Holloway Baltimore MD, Method: We conducted a retrospective Janelle Coughlin Baltimore MD chart review of 247 patients (mean age Johns Hopkins School of Medicine1 = 42.29, SD=11.34; mean BMI= 47.61, SD=8.26) participating in a pre- Background: Sleep problems are bariatric surgery psychological associated with obesity and evaluation. Sleep, eating, and other consumption of calorie dense foods, psychosocial measures were abstracted particularly in individuals seeking from charts. A step-wise linear bariatric surgery. Sleep onset latency regression was conducted to evaluate

114 www.obesityweek.com the association between insomnia and Differences in eating behavior one night eating. year after gastric bypass. Results: ~25% of participants had Verónica Vázquez-Velázquez México 1, subthreshold insomnia, 16.3% had Valeria Soto Fuentes Mexico City SD1, clinically significant insomnia, and Mauricio Sierra Salazar MEXICO 52.7% had general sleep disturbance; CITY 1, Juan Pablo Pantoja Mexico 17.5% reported binge eating and 5.3% MEX1, Samuel Ordoñez Ortega Ciudad reported night eating. de México 2, Eduardo García After controlling for age, gender, and García MEXICO CITY 1 BMI (F(3, 227)=1.91, p=.13), and Inst. Nac. Ciencias Médicas y impulsivity, general sleep disturbance, Nutrición1 Zone 30 Medical Hospital2 binge eating, anxiety, and depression (step 2, F(8, 222)=16.67, p<.001), Objective: To compare the eating insomnia significantly predicted night behavior of patients with 50% of eating, F(9,221)=16.67, p<.001; excess weight loss and those with Fchange (1,221)=7.71, <50% one year after gastric bypass. beta=.27, p=.006). Worse insomnia Method: A total of 77 patients (52 was predictive of night eating, F(2, women, 25 men) who completed one 238)=34.17, p<.001. Dimensions of year follow-up after gastric bypass sleep quality were probed and revealed were included. The Three Factor Eating that only sleep onset latency was Questionnaire (TFEQ), which measures predictive of night eating cognitive restraint (CR), disinhibition (beta=.16, p=.009). (D) and hunger (H), was applied before Conclusions: The present study and after surgery. The percentage demonstrates an association between excess weight loss (%EWL) was insomnia, particularly sleep onset obtained and patients were divided into latency, and night eating, even after two groups: <50%EWL as insufficient controlling for WL (IWL) and 50%EWL as covariates. Understanding other health successful WL (SWL). behaviors that can contribute to Results: A 19.5% (n = 15) had IWL. disordered eating is critical, and sleep The IWL had lost on average 39.9% disturbance may be a treatable cause or against SWL patients who lost 70.5% maintaining factor in night of EW. The IWL had more feelings of eating. Assessment and treatment hunger than SWL (H 4±2.9 vs. 2.2±1.9, recommendations will be discussed. p<.001), but the same CR (15.7±3.9 vs. 16±3.4, p=.793) and D (4.9±2.6 vs. 3.7±2.4, p=.100) after one year. Conclusions. Feeling of hunger was A250 greater in IWL patients, this can lead Patients with insufficient weight loss them to eat more, even when is and with successful weigh loss: expected that the surgery has the

115 greatest effect (within the first 12 Preoperative psychosocial functioning, months). Less favorable weight in particular mood and binge eating outcome underscores the importance of disorder, may contribute to suboptimal hunger as an indicator to be closely weight losses. Both conditions share monitored, to evaluate the origin of the the common psychological construct of hunger (either by assessing the size of impulsivity, which may impact the the pouch or aspects related to cravings long-term results of bariatric surgery. or anxiety) and addressed over the long Objective: Investigate the relationship term following surgery. Replication of between baseline psychopathology, these findings would suggest potential disordered eating, and impulsivity in targets for education and intervention patients seeking bariatric surgery. to mitigate poor outcomes. Methods: A prospective cohort of 253 patients seeking bariatric surgery were assessed for psychopathology and A252 disordered eating using the Structured The Relationship between Clinical Interview for DSM-5 (SCID- Psychopathology, Disordered Eating, 5), the Eating Disorder Examination and Impulsivity in Patients Seeking Bariatric Surgery Version (EDE-BSV), Bariatric Surgery and self-report questionnaires. Jacqueline Spitzer Philadelphia PA1, Impulsivity was measured via the Stop David Sarwer Philadelphia PA1, Kelly Signal Task (SST), Stroop Test, and Allison Philadelphia PA2, Rebecca Delay Discounting Task (DDT). Ashare Philadelphia PA2, Thomas Results: Prior to surgery, 46% of the Wadden Philadelphia PA2, Courtney 228 patients who completed a SCID-5 McCuen-Wurst Philadelphia PA2, interview had a current psychiatric Caitlin LaGrotte Philadelphia PA1, diagnosis and 65% had a lifetime Alberly Perez Philadelphia PA1, diagnosis. Presence of a current Colleen Tewksbury Glenside AL3, Noel diagnosis was positively associated Williams Philadelphia PA3, Michael with DDT (i.e., greater impulsivity) and Edwards Philadelphia PA4, Jingwei the disinhibition and hunger subscale Wu Philadelphia PA1 scores of the Eating Inventory. Current Temple University1 University of and lifetime diagnoses were positively Pennsylvania2 University of associated with the EDE global scores Pennsylvania Health System3 Temple and the shape and weight concern University School of Medicine4 subscales. Finally, higher EDE weight concern scores were associated with Background: Approximately 20-30% of worse response inhibition measured via patients who undergo bariatric surgery the SST (p-values <0.05). experience suboptimal weight loss or Conclusions: A current psychiatric significant weight regain, within the diagnosis was associated with first few postoperative years. impulsivity. Both current and lifetime

116 www.obesityweek.com diagnoses were associated with shape consist of four speakers who will and weight concerns. Future work consider different elements of post- should focus on whether the operative eating pathology: eating relationship between these variables is disturbance rather than disorder, the associated with postoperative meaning of eating disorders, triggers outcomes. for eating disturbance and blurring lines between self-management and self-harm. The panellists will highlight the clinical relevance of these topics, summarize the available empirical data, provide, case examples and discuss ways of incorporating assessment and intervention for these issues into our A253 consultations with post-operative Proposal for Masters in Behavioral patients. Health session: Beyond Diagnosis: The Meaning and Function of Post- Dr Vanessa Snowdon-Carr, D.Clin.Psy, WLS Eating Disturbance Clinical Psychologist Bariatric Surgery vanessa Snowdon-Carr Taunton 1, 2 Department, Musgrove Park Hospital, Stephanie Sogg Boston MA , Jacqueline Taunton UK Doyle London NW1 2PG 2, Allison 2 Dr. Stephanie Sogg, PhD, Clinical Grupski Washington DC Psychologist, MGH Weight Center, Bariatric Surgery Department, Massachusetts General Hospital, and Musgrove Park Hospital, UK1 clinical 2 Harvard Medical SchoolUSA psychologist Dr Allison Grupski, PhD, Clinical Psychologist, National Center for The aim of this symposium is to Weight and Wellness, Washington DC, explore how we understand the USA function and impact of pathological Dr Jacqueline Doyle, Clinical eating behaviour following bariatric Psychologist, UCLH Centre for Weight surgery. Whilst bariatric surgery teams Management, Metabolic and Endocrine are successful in identifying eating Surgery and Department of Child and disturbance post-operatively, the Adolescent Psychological Medicine, function of such behaviour is often UK assumed to come from a desire either to modify weight or as a result of difficulty managing post-operative eating requirements. The actual picture A254 can be more complex and has important Food insecurity is associated with implications for treatment lower rates of bariatric surgery and recommendations. This panel will

117 longer timeframe to completing employment statuses, examined surgery differences in surgery completion rates Lisa Nackers Madison WI1, Yiwei and t-tests described differences in Xu Madison WI, Luke Funk Madison length of time until surgery between WI, Sally Jolles Madison WI, Jacob High/Marginal (i.e., food secure) and Greenberg Madison WI, Anne Low/Very Low (i.e. food insecure) Lidor Madison WI classifications. Results: Of the sample University of Wisconsin School of (N = 250, mean age = 47.6 years, Medicine and Public Health1 79.2% female), 13.6% were food insecure. Mean BMI was significantly Background: Food insecurity, or the higher in food insecure versus food inability to acquire sufficient and secure patients (53.0 vs 48.1 kg/m2, p = nutritious foods, is associated with 0.002). Food insecure patients were obesity. Bariatric surgery can less likely to undergo bariatric surgery effectively treat obesity; however, it compared to food secure patients remains unknown whether food (55.9% vs 29.6%, p = .008; OR = insecurity impacts persons with obesity .37, p = .037). Of those completing who pursue bariatric surgery. This surgery, food insecure compared to study examined whether food food secure patients took longer to insecurity was associated with undergo surgery (34.7 vs 27.1 difficulty obtaining surgery and time to weeks, p = .035). Conclusions: Food surgery in patients entering a insecurity is associated with lower multidisciplinary bariatric surgery bariatric surgery completion rates and program. Methods: Patients who may contribute to slower progression to presented for bariatric surgery surgery. Future studies should explore evaluation completed the validated barriers underlying these associations 2012 USDA US Household Food and resources to assist those patients Security Survey Module: Six-Item most at need, but unable to successfully Short Form. Logistic regressions, obtain bariatric surgery. adjusting for insurance, marital, and

 
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A158 Comparison of robotic revisional revisional weight loss surgery using weight loss surgery and laparoscopic the MBSAQIP database.

118 www.obesityweek.com Benjamin Clapp El Paso TX1, Robert revisional bariatric cases, which was of Jones El Paso TX2, Alan Tyroch El 8% of total cases. Of these revisions Paso TX2, Christopher Dodoo El paso 91% were laparoscopic, 6% were TX2, Evan Liggett 2 robotic and 3% were other (open, hand Benjamin Clapp MD PA1 TTUHSC assist). LRWLS accounted for 22,547 Paul Foster School of Medicine2 and RRWLS for 1,525. RRWLS took longer (160 min vs. 108 min p<0.001), INTRODUCTION: Bariatric surgery but there was no statistically significant is the most effective treatment of difference in postoperative morbid obesity, diabetes mellitus and complications. The groups were many other diseases. The most similar in BMI, age and other common bariatric operations in the demographic measures. Mortality was U.S. are the sleeve gastrectomy and the stastically similar for both groups. gastric bypass, respectively. The third most common is revisional bariatric CONCLUSIONS: RRWLS shows no surgery. benefit over LRWLS in the MBSAQIP The MBASQIP database was database regarding rates of examined to determine the short term complications or death. There is a outcomes of the robotic approach to prolonged OR time. revisional weight loss surgery (RRWLS) versus the laparoscopic revisional weight loss surgery (LRWLS) technique. We hypothesized that there is no improvement in A159 outcomes using RRWLS. PERIOPERATIVE OUTCOMES OF BARIATRIC SURGERY IN METHODS: Data was extracted from THE SETTING OF CHRONIC the MBASQIP database spanning the STEROID USE: A MBSAQIP 2015-2016 years. 354,865 patients were DATABASE ANALYSIS included in this study. Using the Michael Mazzei Philadelphia PA1, specified CPT codes Michael Edwards Philadelphia PA1 ("43644","43645","43659", "43770", Temple University Hospital1 "43775") there were 319,820 procedures identified. After applying Introduction: Chronic steroids the exclusion criteria (age >80 years, represent treatment options for many ASA 5, patients on dialysis and BMI chronic diseases, but predispose to both less than 30 or greater than 70), there weight gain and surgical complications. were a total of 24,072 that remained for They therefore represent a unique the analysis. interface between obesity, chronic disease, and surgical risk. As the RESULTS: There were 24,072 benefits of bariatric surgery for

119 controlling metabolic disease become bariatric surgery is safe in patients more apparent, patients with chronic using corticosteroids, with an illnesses on corticosteroids are acceptable 30-day postoperative risk increasingly being referred for surgery profile. despite an unclear safety profile. The Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) database A160 represents the largest bariatric-specific Risk Factors and Predictors of clinical dataset for comparing outcomes Hypoglycemia after Bariatric in this complex patient population. Surgery in the LABS Consortium Methods: Using the MBSAQIP Laura Fischer Oklahoma City OK1, database, we identified patients on Jonathan Purnell Portland OR, Nora chronic corticosteroids who underwent Fino Portland OR, Carrie LSG or LGB in 2015 or 2016. An Nielson Portland OR2, Mary-Elizabeth unmatched cohort analysis, as well as a Patti Boston MA, Bruce Wolfe Portland propensity-matched cohort analysis, OR2 was performed of patients on University of Oklahoma1 Oregon corticosteroid therapy compared to Health and Science University2 those without. Results: Of the 302,140 patients who Hypoglycemia is increasingly underwent LSG or LGB in 2015-2016, recognized as a bariatric surgery 4,947 (1.63%) were on chronic complication, and can be severe and corticosteroids. Patients using steroids disabling in some patients. were older with significantly higher Identification of risk factors and rates of comorbid conditions, except predictors of hypoglycemia, both smoking. HLOS, unplanned ICU before and after bariatric surgery, admission, reoperation, readmission, would allow insight into this potentially bleeding, leak, pulmonary and dangerous complication and guide infectious complications were preoperative identification of high-risk significantly higher in steroid users; individuals. Methods: 1,959 however, in a matched analysis of participants who underwent Roux-en-Y 9,014 patients, steroids were not found gastric bypass (RYGB, n=1,448) or to be independent risk factors for adjustable gastric banding (AGB, poorer outcomes except for an n=511) from the Longitudinal increased rate of leak (Table 1). Assessment of Bariatric Surgery Conclusions: Steroid use does not (LABS) consortium were included. independently predict poorer outcomes Pre-operatively and at seven annual among bariatric surgery patients. With follow-up visits, patients completed appropriate patient selection based on hypoglycemia symptom surveys and associated comorbid factors, primary clinical data were collected. Logistic

120 www.obesityweek.com regression was used to calculate odds Laparoscopic Sleeve Gastrectomy ratios for hypoglycemia during follow- and Roux en Y Gastric Bypass in the up, in association with potential Elderly Population predictors. Results: Preoperatively, Onur Kutlu Doral FL1, Grigoriy hypoglycemic symptoms were reported Klimovich Miami FL1, Nestor de la in 41.8% with diabetes (DM) but were Cruz-Munoz Doral FL1 uncommon (<10%) with prediabetes University of Miami1 (PreDM) or without diabetes (NonDM). NonDM individuals who Introduction: Controversy remains for underwent RYGB had the highest bariatric surgery in elderly patients. incident hypoglycemia (31%). In Due to growing morbidly obese elderly multivariate analysis, preoperative population, treatment outcomes need to hypoglycemia was the strongest be evaluated predictor of postoperative symptoms (p<0.0001) (Table 1). In NonDM and Material and Methods: MBSAQIP PreDM RYGB patients, SSRI/SNRI database was utilized. Laparoscopic use was significantly associated with sleeve gastrectomy and gastric bypass incident hypoglycemia cases performed in 2016 were included. (p=0.025,p=0.016) (Figure 1). This Patients were divided in to two groups association was also seen in the RYGB based on age (60> and under 60) and DM subgroup that had never used later de-novo and revisional surgery. diabetes medications (p=0.017). We sought to identify the factors SSRI/SNRI association was not affecting mortality and post-operative significant in any AGB group. Non- complications (pneumonia, renal DM RYGB patients had significantly failure, ICU admission, intubation, lower weight loss at seven years when DVT, Pulmonary embolism, leak, new hypoglycemia was experienced in sepsis, transfusion, c. difficile, hospital the first post-operative year (p=0.045). stay, and death within 30 days). Conclusion: Preoperative Possible confounders; age, sex, primary hypoglycemia is the strongest predictor operation, revisional surgery, surgeon of post-bariatric hypoglycemia. In specialty, smoking, diabetes, RYGB patients not on diabetes hyperlipidemia, renal insufficiency, medications, SSRI/SNRI use is functional status, previous MI, previous associated with significantly increased cardiac surgery, DVT, hypertension, risk of postoperative hypoglycemia. BMI, albumin level, hematocrit levels, operative time were corrected by binary logistic regression. The analyses were A161 initially done for the entire cohort, later Perioperative Outcomes, Safety separating the cohorts for de-novo and profile, and Factors affecting revisional surgery. The effect of Mortality and Complications of advancing age (>60), and other factors

121 affecting mortality and each Safety of weight loss procedures in complication were separately patients with end stage renal disease identified. (ESRD) had already been tested and many reports in the literature showed Results: 160,599 patients were these procedures are safe in this identified, 17,610 were over 60 years. patients’ population. However, these 7.1% underwent revisional surgery. studies didn’t compare specifically the Compared to younger patients, odds of 2 most commonly performed weight death for age >60 was similar in the loss procedures in the United States entire cohort(p=0.747) and in the de which are sleeve gastrectomy (SG) and novo group (p=0.181). Advancing age gastric bypass (RYGB). was associated with almost twice the Objective: odds of death for revisional surgery (OR:1.842, 95%CI:1.223-2.773, The aim of this study is to determine p=0.003) and higher risk of whether there is a difference between complications. (SG) and (RYGB), in ESRD patients, in terms of unfavorable outcomes in Conclusion: Advancing age is not a risk 30-day postop. factor for de-novo bariatric surgery. Age>60 was an independent risk factor Methods: for death and complications in revisions. We analyzed the data of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program A162 (MBSAQIP) that included 186,772 Is Sleeve Gastrectomy Superior to patients. We looked up only patients Roux- en-Y Gastric bypass in with ESRD on dialysis, who underwent patients with End Stage Renal either laparoscopic SG or RYGB as a Disease? Analysis of MBSAQIP Data primary procedure. Univariate analysis, Adel Alhaj Saleh Lubbock TX1, Grant was done. T-test and Chi square were Sorensen Lubbock TX2, John used for comparing continuous and Griswold Lubbock TX1, Amir categorical variables respectively and Aryaie Lubbock TX1 Fischer’s exact test for significance, P Department of Surgery/ Texas Tech value < 0.05 was considered significant University Health Sciences Center1 School of Medicine, Texas Results: Tech University Health Sciences Center2 We identified 380 patients underwent SG, while only 80 underwent RYGB. Background: Fifty six % female, mean BMI= 46 kg/m2 + 7.5, (table #1). No statistical

122 www.obesityweek.com difference in most of compared was queried for primary SG, GB, variables in SG and RYGB groups LAGB+SG or LAGB+GB conversions (table#1). Only, readmission rate (22% based on CPT codes. Binary and RYGB versus 11% SG) and length of nominal variables were compared using operation (142 + 77 minutes RYGB Chi-square and Fisher exact test; versus 87+ 41 minutes SG), were continuous ones – using Student T-test. higher in RYGB. (P=0.04 and 0.0001 Bernoulli correction was applied by respectively). accepting significance at a 2-tailed P < 0.01. Conclusion: Results: 9,122 patients underwent There are no differences between LAGB+SG (68.9%) or LAGB+GB the SG and RYGB in terms of safety in (31.1%). Primary SG was performed in the first 30-day postop. 199,898 and GB in 80,700 cases. Revision patients were older and had A163 lower BMI. In primary and LAGB Comparative analysis of 30-days conversion groups, morbidity and outcomes of single stage conversion mortality were statistically higher with of laparoscopic adjustable gastric GB. Comparison of primary GB and band (LAGB) to sleeve gastrectomy LAGB+GB outcomes demonstrated no (SG) or gastric bypass (GB): 2015- significant difference with the 2016 PUF MBSAQIP data. exception of leak, while all parameters Sandra Wischmeyer Ellicott City MD1, with exception of mortality and Anne Sill Baltimore MD1, Andrew readmission were statistically worse in Averbach Baltimore MD1 LAGB+SG compared to primary SG. Saint Agnes Hospital1 Conclusion: Single stage LAGB+SG Background: Increasingly LAGB is and LABG+GB were both associated converted to other bariatric procedures. with acceptably low morbidity and Conversion to SG is often considered a mortality. LAGB+SG was significantly safer choice while some authors believe safer than LAGB+GB. With exception GB produces better long-term of leak, primary GB outcomes were not outcomes despite higher initial significantly different from morbidity. LAGB+GB. Contrary to that, all variables except mortality and Objectives: To compare the short term readmission were significantly worse safety of single stage LAGB+SG and for LAGB+SG compared to primary LAGB+GB as well as primary SG and SG. GB.

Methods: MBSAQIP PUF 2015-2016 A164

123 First look at the Outcomes of the predicted less likelihood of bleeding Different Sleeve Gastrectomy (SG) requiring transfusion: SLR alone Surgical Techniques Reported in [adjusted odds ratio (AOR) .70, 95% MBSAQIP: What Did We Learn? CI .54 - .90, p = .006) and both SLR Maher El Chaar Allentown PA1, Jill and OS (AOR .50, 95% CI .33 - .77, p Stoltzfus Bethlehem PA2 = .002). In addition, SLR and OS St Luke's University Hospital1 st luke's significantly and independently University and Health Network2 predicted less likelihood of SAE (AOR .76, 95% CI .64 - .91, p = .003). Introduction: Conclusion: Controversies exist regarding the most Based on the MBSAQIP database , our appropriate surgical technique in study demonstrated that SLR results in performig SG. The objective of this lower postoperative bleeding, but not study is to compare the outcome of the leak rates. In addition, when combined various surgical techniques utilized in with OS, SLR results in lower overall performing SG based on the MBSAQIP 30-day complication rates. database. Methods: Using the MBSAQIP 2016 PUF we A165 compared the four SG techniques ( Perioperative outcomes following Staple Line Reinforcement [SLR] robotic bariatric surgery: an alone, SLR and Oversewing [OS], no MBSAQIP analysis SLR or OS, OS alone). Our primary Rana Higgins Milwaukee WI1, Melissa outcomes were OSI (Organ Space Helm Milwaukee WI1, Tammy Infection) including leak; and bleeding Kindel Milwaukee WI1, Jon Gould Fox rates and our secondary outcomes were Point WI1, Semeret Munie 1 30-day SAE (Serious Adverse Events) Medical College of Wisconsin1 and readmission rates. First, we conducted separate chi square tests of Background: The majority of bariatric association. Next, we created four surgery is performed laparoscopically, separate direct multivariate logistic with a gradually increasing utilization regression models for our primary and of robotics. The aim of this study was secondary outcomes. to compare 30-day post-operative Results: outcomes in laparoscopic and robotic SG with both SLR and OS resulted in bariatric surgery procedures. the lowest incidence of bleeding and SAE compared to all the other Methods: The Metabolic and Bariatric techniques (0.3% and 1.9% for Surgery Accreditation and Quality bleeding and SAE respectively, Improvement Program (MBSAQIP) p<0.05). The following SG techniques 2015 and 2016 datasets were queried significantly and independently for primary laparoscopic and robotic

124 www.obesityweek.com bariatric procedures, Roux-en-Y gastric must be overcome to increase bypass (RYGB) and sleeve gastrectomy efficiency. (SG). Analyses were performed comparing 30-day post-operative outcomes of the robotic and A166 laparoscopic approach. How safe are Laparoscopic Sleeve Gastrectomy and Laparoscopic Results: There were 282,214 primary Roux-en-Y Gastric Bypass in super- minimally-invasive bariatric super-obese patients? An procedures, 93.3% laparoscopic and investigation from Metabolic and 6.7% robotic. There was no significant Bariatric Surgery Accreditation and difference in overall complications for Quality Improvement Program SG (5.3% laparoscopic, 5.4% (MBSAQIP). robotic p=0.667) or RYGB (10.6% Amlish Gondal Tucson AZ1, Chiu- laparoscopic, 10.8% robotic, p=0.731). Hsieh Hsu Tucson AZ1, Matthew Operative time was longer robotically Mobily Tucson AZ1, Iman Ghaderi 2 for SG (72.8 minutes laparoscopic, The University of Arizona1 University 101.2 minutes robotic, p<0.0001) and of Arizona2 RYGB (116.9 minutes laparoscopic, 153.7 minutes robotic, p<0.0001). Introduction: Readmission rates were higher for It is known that super-super-obesity robotic SG (3.2% laparoscopic, 3.6% (BMI>60 Kg/m2) is associated with robotic, p=0.029), and RYGB (6.0% higher complication rates after laparoscopic, 7.0% robotic, p=0.003). bariatric. Surgery. Laparoscopic Sleeve There was a longer length of stay for Gastrectomy (LSG) has become the robotic SG (1.64 days laparoscopic, most commonly performed procedure 1.75 days robotic, p<0.0001), but not in these patients but the choice of for RYGB. There was no difference in procedure remains controversial. Some reoperation or mortality for robotic SG studies show better weight loss results or RYGB. (Table 1) with Laparoscopic Roux-en-Y Gastric Bypass (RYGB) as compared to LSG. Conclusion: Robotic bariatric surgery However, comparative safety of these has a similar overall complication and procedures has not been studied at a safety profile as laparoscopic bariatric large scale in this group of patients. surgery. Increased length of stay in Methods: robotic SG and readmission for both Perioperative data for patients with robotic SG and RYGB highlight BMI  60 who underwent primary potential quality initiatives that can be LRYGB or LSG was obtained from addressed. Longer operative times Metabolic and Bariatric Surgery indicate a potential learning curve that Accreditation and Quality Improvement Program’s (MBSAQIP)

125 participant use file 2016. The 30-day outcomes were compared. Objective: To determine if pre- Results: operative DiaREM score predicts A total of 7607 patients were studied diabetes remission after 1-year post- with the majority of the patients bariatric surgery (Roux-en-Y Gastric undergoing LSG (68%). There were 2 Bypass (RYGB), Sleeve Gastrectomy deaths per 1000 operations in each (SG), Adjustable Gastric Band (AGB), group (p =0.86). When compared with Duodenal Switch (DS)) in a population LSG group, RYGB patients had higher with morbid obesity and type 2 rates of all cause morbidity (10.6% diabetes. vs. 6.0%, p<0.001), reoperation (2.4% vs 0.9%, p<0.001), readmission (7.1% Background: Bariatric surgery has been vs 4.4%, p<0.001), re-intervention proven to be highly effective in (3.1% vs 1.2%, p<0.001) and return to controlling diabetes. However, not all emergency not requiring admission patients who undergo the procedure (7.0% vs 10.5%, p<0.001). LRYGB achieve diabetes remission. The group had longer mean operative length DiaREM score has been used to predict and hospital length of stay (p<0.001 for diabetes remission in patients with both). RYGB, but there are no studies that Conclusion: show its performance amongst the Laparoscopic gastric bypass in patients other bariatric surgery procedures. with super-super-obesity has higher complication rates as compared to Methods: Adult patients with Type 2 laparoscopic sleeve gastrectomy. diabetes who underwent bariatric However, these results should be surgery at the Duke Metabolic and interpreted in the context of long-term Weight Loss Center between follow-up of clinical outcomes (weight 01/01/2000 and 04/10/2017 and with 1- loss, resolution of comorbidities and year follow-up were included. Diabetes complications) after both procedures. remission was defined as HbA1c < 6.5% and no diabetes medication. The association of pre-operative DiaREM scores on 1-year diabetes remission A167 was assessed through logistic DiaREM scores predict diabetes regression, controlling for age, gender, remission after bariatric surgery race, procedure type, pre-operative Alfredo Guerron durhjam nc1, Gerardo BMI, hypertension, and Davalos durham NC1, Dana hyperlipidemia. Portenier Durham NC1, Hui-Jie Lee Durham NC1, Leonor Results: 349 patients were included in Corsino Durham NC1 the study. By increasing one-unit in Duke Health1 pre-operative DiaREM scores, the odds

126 www.obesityweek.com of 1-year remission decreases by about cohort study of patients who underwent 19%(OR:0.81, 95%CI:0.77-0.85, gastric bypass at a tertiary care center. p<0.001). In terms of outcomes by Cases were identified from a procedures, there was no significant prospective database of patients difference in remission between RYGB receiving high resolution esophageal and SG (OR:0.76, 95%CI:0.32-1.76, manometry (HRM) for dysphagia. p=0.99). Compared to the Roux, ABG Controls were randomly selected, using patients have decreased odds of a randomization protocol, from all remission (OR:0.19, 95%CI:0.07-0.54, patients who underwent RYGB and did p=0.001) while DS patients have an not have a diagnosis of dysphagia. increased odds remission (OR:2.33, Weight, BMI, symptoms, dietary logs, 95%CI:0.95-5.72, p=0.003). and HRM findings were assessed. Chi- squared t-test, and multiple logistic and Conclusion: Baseline DiaREM score is linear regression calculations were a strong predictor of diabetes remission used. at 1-year post-surgery independent of bariatric procedures. Results: 49 patients with dysphagia following RYGB were included, as were 115 controls. Groups had similar A168 demographics. Mean WR was greater Dysphagia predicts greater weight in cases than in controls (15.7 vs. 10.3 regain after Roux-en-Y gastric kg, respectively; p=0.01), as was bypass percent WR as a fraction of lost weight Thomas Runge Durham NC1, Pichamol (median 24.1% vs. 19.5%, p=0.03). Jirapinyo Chestnut Hill MA2, Walter Regain of 15% or more of nadir weight Chan Boston MA2, Christopher was more common in cases vs. controls Thompson Boston MA2 (54% vs. 38%, respectively, p=0.034) University of North Carolina1 Brigham when adjusting for baseline BMI, age and Women's Hospital2 at surgery, and race. Dietary histories suggested that, among those with Background/Aims: A significant dysphagia, patients with increased minority of patients complain of reliance on soft or liquid calories dysphagia following Roux-en-Y gastric gained more weight. bypass (RYGB). Our observations suggest some of these patients increase Conclusion: More than half of patients intake of calorie-dense liquid and soft with dysphagia following RYGB regain foods. We therefore hypothesize that significant weight. Screening for and dysphagia may promote weight regain aggressively managing dysphagia in (WR) in this patient population. these patients is important to help limit weight regain. Methods: This was a retrospective

127 hypertension and type of surgery significantly influenced weight loss at 3 A169 and 5 years on univariate Predictors of Long Term Weight analysis. However, patients with Loss after Bariatric Surgery diabetes, hypertension and sleeve William Chang Fort Gordon GA1, gastrectomy were significantly older Devon Hawkins Ft. Gordon GA1, Joel than comparable control Brockmeyer Evans GA1, Byron group. Multivariable analysis to Faler Evans GA1, Balakrishna control for the effects of age showed Prasad Fort Gordon GA1 that only type of surgery but not Eisenhower Army Medical Center1 diabetes or hypertension was still associated with poor %TWL and BMI Background: Bariatric surgery change at 3 and 5 years. provides sustained weight loss and Conclusion: While presence of improves comorbidities. However, long hypertension and diabetes initially term data has shown that patients appeared to be associated with weight gradually regain weight after 1 year. recidivism, their impacts were Several factors have been associated negligible on multivariable analysis. with poor weight loss after bariatric However, age and sleeve gastrectomy surgery. We investigated factors are independent risk factors. Caution associated with poor weight loss should be given when performing following laparoscopic sleeve laparoscopic sleeve gastrectomy on gastrectomy and Roux-en-Y gastric patients with advanced age. bypass. Methods: Retrospective review of 247 patients who underwent laparoscopic A170 sleeve gastrectomy or Roux-en-Y Endoscopic Sleeve Gastroplasty in gastric bypass between 2010-2012 at Children and Adolescents with Eisenhower Army Medical Center and Obesity: Outcomes During the First followed for 5 years postoperatively. Year Factors of age, type of surgery, sex, Aayed Alqahtani Riyadh 1, Yara hypertension, depression, and diabetes Alqahtani 2, Abdullah Al- are analyzed in univariate and Darwish Riyadh 3, Mohamed multivariate analysis with percent total Elahmedi Riyadh Central Region2 weight loss (%TWL) and BMI change King Saud University1 Obesity Chair, as primary endpoints measured at 3 and King Saud University2 Obesity Chair, 5 years. KSU3 Results: Average BMI change increased until 1 year (11.9) and Background decreased to 10.3 and 9.0 at 3 and 5 Endoscopic sleeve gastroplasty (ESG) years post-surgery. Age, diabetes, utilizes full-thickness sutures that

128 www.obesityweek.com restrict the stomach to a sleeve-like Conclusions configuration. Herewith, we report our ESG is safe and effective in obese experience with pediatric patients who pediatric patients. Abdominal pain and underwent Primary ESG. nausea occur in half of patients during Objectives the first week. To report weight loss, morbidity, and revisions, during the first year in children and adolescents who A171 underwent ESG. National Post-Bariatric Surgery Methods Outcomes in Patients with Kidney Our prospective pediatric bariatric Disease outcomes database was queried for data Colleen Tewksbury Glenside AL1, on pediatric patients who underwent Jordana Cohen Philadelphia PA2, ESG under our standardized protocol Samuel Torres Landa Philadelphia and clinical pathway. ESG was offered PA2, Octavia Pickett- as day-case. Blakely Philadelphia PA2, Noel Results Williams Philadelphia PA2, Kristoffel The 55 patients in this study had a Dumon Philadelphia PA2 baseline body mass index (BMI) and University of Pennsylvania Health age of 33.0 ± 5.0 and 17.3 ± 2.5 (range: System1 University of Pennsylvania2 11-21) years, respectively. Fifty-one (92.7%) were females. Mean % excess Introduction: Limited evidence exists weight loss at one (n=45), three (n=31), evaluating post-operative bariatric six (n=24), nine (n=13), and twelve surgery outcomes in patients with pre- months (n=5) was 46.7 ± 29.6%, 58.7 ± dialysis chronic kidney disease (CKD) 39.2%, 66.0 ± 42.2%, 79.2 ± 49.5%, or end stage renal disease (ESRD) and 60.0 ± 48.3%, respectively. One requiring dialysis. The objective of this patient (aged 19.8 years) requested study was to compare post-bariatric removal of endoscopic stitches due to surgery outcomes in patients with CKD abdominal pain. During the first week, or ESRD to patients without CKD. 30 (54.5%) required oral analgesia and antispasmodics for abdominal pain and Methods: We performed a nausea, and 18 (32.7%) visited the retrospective cohort study using the emergency room (ER). During the first, Metabolic and Bariatric Surgery third, sixth, and ninth months, 53.3%, Accreditation and Quality 38.7%, 33.3% and 15.4% reported Improvement Program (MBSAQIP) taking oral analgesia.There were no ER dataset (2015-2016). Multivariable visits after the first week. One patient logistic regression models were used had Redo-ESG after one year. There with and without propensity score were no hospital admissions, mortality, matching to compare patients with or significant morbidity. CKD or ESRD to patients without

129 CKD regarding the risk of developing John Morton Stanford CA1, Kristopher 30-day mortality, reoperation, Huffman Chicago IL, Arielle intervention, and readmission. Grieco Chicago IL, Stacy Results: There were 323,034 non-CKD Brethauer Cleveland OH, Anthony patients, 1,694 CKD patients, and 925 Petrick Danville PA, David Provost , ESRD patients who underwent bariatric Wayne English Nashville TN, Matthew surgery. Compared to non-CKD Hutter Boston MA, Teresa patients, those with CKD or ESRD Fraker Chicago IL, Eric were older and had higher rates of DeMaria Richmond VA, Samer hypertension, diabetes mellitus, Mattar Seattle WA, Cliff Ko hyperlipidemia, cardiac disease, Stanford School of Medicine1 obstructive sleep apnea, and ASA class 4 (p<0.001). After both adjusting and Background matching for important comorbidities The hospital volume and patient and surgical risk factors, CKD and outcome relationship is well established ESRD patients had a significantly in bariatric surgery; however, the increased risk of 30-day reoperation, impact of surgeon volume is not as intervention, and readmission rates, but well-defined. no difference in mortality risk compared to non-CKD patients. Methods Using MBSAQIP data registry for Conclusions: Bariatric surgery is a safe 2016, 30-day morbidity following procedure for patients with kidney primary laparoscopic sleeve (SG) and disease with regard to mortality risk. gastric bypass (GB) for ages 18-75 was However, CKD patients do experience examined. Utilizing nested regression more reoperations, interventions, and models, the relationship between readmissions compared to the general operative morbidity and surgeon and population. Providers should counsel hospital volume for 2016 was CKD patients on the greater risk of examined, with adjustment for these adverse outcomes following characteristics of the patients, surgeons, bariatric surgery. Future research and hospitals. should focus on potential interventions to reduce reoperation and readmissions Results in these patients. 106,223 laparoscopic sleeve gastrectomy and 38,697 laparoscopic gastric bypass surgeries were reviewed. Within this population, there were 1819 A172 and 1468 surgeons performing SG and Hospital vs. Surgeon Volume and GB respectively with 77.7 % of Bariatric Surgery Outcomes-What surgeons operating at a single hospital. Matters Most?. Additionally, 776 and 694 hospitals

130 www.obesityweek.com performed SG and GB respectively. significant at p < .0001, p = 0.0184, Surgeon volume was divided into respectively. The adjusted odds ratio terciles for both procedures (SG, <20, for morbidity (low-volume vs. high- 20-65, >65 and GB, <6, 6-26, >26). volume surgeon) was 1.336 for SG and Hospital volume was divided into 1.528 for bypass. Surgeon volume terciles for both procedures (SG, <66, accounted for a large proportion of the 66-151, >151 and GB, <17, 17-56, apparent effect of the hospital volume, >56). For Sleeve, unadjusted sleeve 71% and bypass 70%. continuous surgeon volume and hospital volume were significant at p = Conclusion: The association of hospital .0003, p = 0.0626, respectively. For volume upon bariatric morbidity is Bypass, unadjusted continuous surgeon explained partly by surgeon volume. volume and hospital volume were

 
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A173 were randomly divided into 2 groups, Jejuno-ileal loop bipartition (JILB): receiving either JILB (n=8) or Sham a novel stand-alone or sleeve plus (n=8) procedure. JILB was performed procedure as Figure 1. Age-matched naïve mice Xiong Zhang Shanghai 1, Peng served as normal controls. Body Zhang Shanghai 1 weight, food intake, fasting plasma Shanghai Pudong Hospital1 glucose (FPG), fasting plasma insulin (FPI) and oral glucose tolerance test Background: Clinical outcome of (OGTT) were measured in vivo before sleeve gastrectomy (SG) can be and 2, 4, and 8 weeks after the surgery. leveraged by addition of intestinal GLP-1 was measured before and 15 manipulations, i.e. duodeno-jejunal min after oral glucose challenge at the bypass (Sleeve+DJB) or duodeno-ileal 9th week postoperatively. bypass (SADI-S). We designed a novel jejuno-ileal loop bipartition (JILB) Results: Comparing with sham procedure as shown in Figure 1, which animals, JILB did not affect food can be potentially added to SG too. The intake, but led to significant lower body purpose of present study was to weight, lower FPG, lower FPI and investigate the efficacy of JILB on improved glucose tolerance at all weight loss and diabetes remission. measuring time points postoperatively. In addition, GLP-1 level in JILB group Methods: High fat diet-induced obese was significantly higher than sham mice with typical diabetic phenotypes group after oral glucose challenge.

131

Conclusion: JILB is a promising Study Design: A retrospective procedure that leads to excellent weight analysis of 511 consecutive DS loss and diabetes remission. JILB procedures performed between June 1st, reduces effective length of intestine 2015 and December 31st, 2016 at a finabsorption, but without excluding single institution. The primary any portion of intestine from food endpoints in patients having either a passage or causing blind loop 100 cm, 150 cm, or 200 cm CC were: syndrome. It can be either a reversible percent excess weight loss (%EWL) at stand-alone procedure for children and 6, 12, 18, and 24 months; vitamin A adolescents, or a sleeve plus procedure. levels at 6, 12, and 24 months; and albumin levels at 6, 12, 18, and 24 months postoperatively. A174 Longer Common Channels In Results: For patients with pBMI >50, Duodenal Switch Improves Vitamin %EWL for the 100cm and 150 cm A Absorption And Albumin Levels, length CC groups at 18 months was But Can Negatively Impact Weight 68% vs. 58%, Loss In The Super Obese Patient: respectively (p<0.05). Patients with Implications For The Single pBMI<50 had %EWL of 79% and 90% Anastomosis Duodenal Switch. in the 100cm and 150 cm CC groups, Lindsey Sharp Raleigh NC1, Dustin respectively (p>0.1). Rates of vitamin Bermudez Raleigh NC1, Tricia A deficiency were also lower in the Burns Raleigh NC1, Krista longer CC groups (12% vs. 23% at 12 Herrell Raleigh NC1, Erica months postop) (p<0.05). At 12 and 24 McKearney Raleigh NC1, Peter months, the albumin levels (g/dl) were Ng Raleigh NC1, Jillian Vari Raleigh 3.9 in the longer CC length groups and NC1 3.6 in the 100cm CC length group UNC/Rex Healthcare1 (p<0.05).

Introduction: The impact of common Conclusions: Longer CC lengths do channel (CC) length on vitamin not seem to negatively impact overall absorption, albumin levels, and overall weight loss in short term follow-up, weight loss is not fully known. except in patients with pBMI > 50. Vitamin A and albumin levels are Hypothesis: Longer CC lengths also higher in patients with longer CC performed in lower BMI patients limbs. should result in lower risk of vitamin A deficiency and improved albumin levels, without negatively impacting A175 overall weight loss.

132 www.obesityweek.com Preoperative Intragastric Balloon for 14.4kg and mean BMI reduction was reduction of surgical risk in 273 9,1 kg/m2. BIB group had only minor patients with BMI > 50kg/m complications (nauseas, vomits, Afonso Sallet São Paulo 1, Carlos gastroesophageal reflux) and one case Pizani São Paulo 1, Thomaz of early balloon withdrawal (within 2 MONCLARO São Paulo 1, Ana months) due to patient intolerance. We Caroline Fontinele São Paulo 1, Dirceu found that 88% of patients showed Santos São Paulo 1, Marcelo satisfactory results with improvement CARNEIRO Sao Paulo 1, Eduardo in hypertension, diabetes, sleep apnea Sticca São Paulo 1, Sansiro de and with surgical risk reduction from Brito São Paulo 1, Carlos De Souza ASA III/IV to ASA II. All these Filho São Paulo 1, PAULO patients were submitted to bariatric SALLET SAO PAULO SP1 surgery (RYGB 82%, LAGB 10% or Instituto de Medicina Sallet1 BPD 8%) without major complications. There was no mortality. Only 12% of Patients with BMI > 50kg/m usually patients needed a two-stage surgery. has a higher surgical risk, BIB is an effective non-surgical complications and risk of mortality. In technique to prepare BMI > 50 patients, addition, they frequently present reducing the severity of major difficulty managing associated complications and changing surgical diseases. The use of the intragastric risk. balloon (BIB) is well established in the literature as an alternative for acute weight loss of patients with clinically severe obesity associated with control A176 of decompensated comorbidities. REVISIONAL SURGERY AFTER The objective was to analyze the use of SLEEVE GASTRECTOMY: BIB as a preoperative procedure aiming GASTRIC BYPASS OR an initial weight loss and reduction of DUODENAL SWITCH? surgical risk. Ainitze Ibarzabal Barcelona From November 2000 to December Barcelona1, Amanda 2017, 273 patients with Jimenez Barcelona 2, Dulce superobesity(mean BMI=55) were Momblan Barcelona 2, Gabriela Chullo treated with the BIB for at least four Llerena Barcelona 2, Ana de months before surgical treatment. Hollanda Barcelona 2, Violeta Associated severe grade diseases were Moizé Barcelona 1, Víctor Turrado- arterial hypertension (40%), diabetes Rodríguez Barcelona 2, Julio Jimenez- (15%), sleep apnea (32%) and Lillo Barcelona , Josep osteoarthrosis (25%). Vidal Barcelona 2, Antonio M. The mean percent excess weight loss Lacy Barcelona 2 was 26,7%, mean weight loss was

133 Hospital Clínic de Barcelona1 Hospital Effect of RYGB on pre-conversion Clinic Barcelona2 BMI not reached statistical significance (41.3±4.4 Kg/m2 vs. 39.2±6.4 Kg/m2, Introduction: Sleeve Gastrectomy p=0.141). DS effect on HbA1c, fasting (SG) is one of the most performed plasmatic glucose, lipid profile and surgical techniques. However in case of blood pressure was significantly greater weight loss failure (WLF) there are than RYGB (p<0.05 for all controversies about which technique comparisons). should be performed. Conclusions: DS after SG is more Objectives: The aim is to compare the effective to treat weight loss failure and mid- and long-term results of patients obese-related comorbidities than undergoing revisional surgery (RS), RYGB. In the mid-long term RYGB Duodenal Switch (DS) or a Roux-en-Y have limited impact on BMI. Gastric Bypass (RYGB).

Methods: We included seventy-four subjects with RS from SG to RYGB or to DS due to weight loss failure between 2005 and 2016. A paired t test was used to evaluate changes between A177 baseline and last follow-up time points Disparity in peri-operative outcomes within a particular group. Longitudinal among ethnic minority compared to changes on BMI, lipid profile, blood caucasian patients following pressure, fasting plasmatic glucose and bariatric surgery Allison Bruff Philadelphia PA1, HbA1c were compared between groups 1 using linear mixed-effects models with Michael Mazzei Philadelphia PA , Michael Edwards Philadelphia PA1 the Maximum Likelihood method. 1 Temple University Hospital Results: Seventy-four subjects were included (DS: 41/RYGB: 33). No Background significant differences between-groups Bariatric surgery remains a safe and in age, sex, BMI, EWL (%) or effective treatment for severe obesity. metabolic co-morbidities prevalence Ethnic minorities are disproportionately were found prior RS. Mean follow-up impacted by obesity, but are less likely after RS was similar between groups to undergo bariatric surgery. There (DS: 59.2±32.4 months vs. RYGB: remain controversies about whether 47.2±36.9, p=0.144). At last follow-up there is disparity in outcomes among DS was related to a significant pre- ethnic minorities following bariatric conversion BMI reduction (41.6±5.7 surgery. Kg/m2 vs. 31.8±5.1 Kg/m2, p=0.002).

134 www.obesityweek.com Study Aim complication rates were lower among To examined perioperative outcomes Hispanic patients compare to White among ethnic groups following primary and Black patients. Selection bias may bariatric surgery. have contributed to these findings as Black patients were older and had a Methods higher BMI and preoperative rates of Patients who had a primary bariatric hypertension and renal disease. Further operation in 2015-2016 were identified studies are needed. from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBS-AQIP) A178 database. Descriptive and multivariate Metabolic and Bariatric Surgery 30 regression analyses were performed. day Post-op Readmission Reduction Gwendolyn Crispell Gainesville FL1, Results Jeffrey Friedman Gainesville FL1 Over 303,000 patients had a primary UF Health Shands1 bariatric operation. Only 18% and 12.7% were Black and Hispanic Background: In 2013, the Centers for patients, respectively. Mean age, body Medicare and Medicaid Services began mass index (BMI) and length of stay tying reimbursement for Metabolic and (HLOS) were 45.1±11.9 years, Bariatric surgery to readmission rates. 45.1±8.4 kg/m2and 1.79 ±1.9 days. September of 2016 the need to improve Mean BMI and HLOS were our readmission rates was evident by a significantly higher for Black patients rate of 19-21%. Patients were (p< 0.001). Overall mortality was frequently presenting to the Emergency 0.11%. Black patients had a Room (ER) seeking medical care post- significantly higher rate of mortality, operatively. unplanned ICU admission, reoperation, Objectives: The overall goal was to readmission, intervention and other decrease the observed readmission rate complications, compared to White by 15% in 12 months. The second goal patients (Table 1). Hispanic patients was to improve patient understanding were overall younger, smaller and of discharge instructions and healthier, and had significantly lower compliance. complication rates compared to White Setting: University Hospital, United patients. States Methods: PDSA (Plan, Do, Study and Conclusion Action) A drill down for common Black patients had a higher rate of cause of readmission was identified as mortality and other complications PO intolerance (nausea, vomiting or following bariatric surgery, compared dehydration). The plan to improve the to other ethnic groups. Overall rate were multiple initiatives over a

135 period of 6 months. The initiatives included education, protocols and Introduction: Sleeve gastrectomy is culture change in three settings, becoming the most popular bariatric outpatient, inpatient and clinic. procedure in the world. However, there Results: The observed 30 day is ongoing debate as to what the readmission rate in a total of 269 appropriate surgical procedure is for a patients went from 18% to 5% over a failed sleeve gastrectomy. In this study, period of 15 months. The observed rate we aimed to compare revisional of ER presentations also decreased surgery in patients who underwent from 32% to 15%. The number of prior sleeve surgery using a gastric outpatient IVF infusions increased bypass versus re-sleeving. slightly from an average of 2-3 patients Methods: A retrospective analysis of a per quarter to 3-4 per quarter. prospectively maintained database Patients are able to provided of laparoscopic explanation of how to keep hydrated sleeve gastrectomies (LSG) was after surgery, where to seek medical performed between January 2006 and assistant for rehydration and signs and March 2017. Data analyzed included symptoms of dehydration both verbally age, weight loss, postoperative and written. complications and long-term outcomes. Conclusions: This quality Results: 40 patients who had LSG and improvement project decreased use of then revisional surgery were included, intensive resources for hydration and of which 32 (80%) were female. 24 had standardized efforts to improve their revisional operation with a gastric hydration resulting in reduced patient bypass (60%). Mean body mass index readmission. (BMI) was 48.5 (±11.1) kg/m2. Basic demographics were the same, and other long-term results were similar between the groups. BMI in the primary sleeve A179 was similar in both groups (47.92 in the Revisional surgery results after bypass group vs. 49.3 in the re-sleeve sleeve gastrectomy. A retrospective group, p=0.703), as was BMI before cohort study comparing gastric revision (40.6 in the bypass group vs. bypass to re-sleeving 41.2 in the re-sleeve group, p=0.842), Zvi Perry Cote Saint Luc, Quebec H4W and the same was true about the BMI 2E4 YT1, Mohammed Al Abri Montreal after revisional surgery (35.7 vs. 36.9, QC2, Amin Andalib Westmount QC2, p=0.609). Olivier Court Montreal Quebec2, Discussion and Conclusions: Sebastian Demyttenaere Westmount 2 Controversy exists regarding technical McGill University Hospital - Montreal aspects of revisional LSG. In our study, general1 McGill University Hospital2 re-sleeving and gastric bypass post sleeve showed similar results in weight

136 www.obesityweek.com loss and BMI post-surgery. There was %Estimated Weight Loss(%EWL) no impact on short or long-term results were fit using generalized least squares and complications. Longer follow up is techniques with an autoregressive-type needed to determine if this small correlation structure assumed. improvement in excess weight loss Results remains significant. A total of 8815 BMI readings from 1166 patients were included in our model with up to 10-year follow. The A180 mean age was 47 years with a Variables Associated with Weight preoperative BMI 42.3kg/m2. Younger Loss after Laparoscopic Sleeve age, Males, African Americans, Gastrectomy: A 10-year follow-up Diagnosis of Essential Hypertension, and 8800 BMI Statistical Model Sleep Apnea and Preoperative BMI Analysis. (Table 1) were found to have a Federico Perez Quirante Weston significant independent impact on Florida1, Lisandro Montorfano Weston weight loss over time, this impact being Florida1, David Gutierrez variable depending on the time of the Blanco Weston FL1, Emanuele BMI measurement. Figure 1 Menzo Weston FL1, Samuel exemplifies the predicted impact of one Szomstein North Miami Beach FL1, of the multiple measured variables on Raul Rosenthal miami FL2 our statistical model(Gender) on the Cleveland Clinic Florida1 Cleveland overall weight-loss up to 10 years of Clinic of FL2 follow-up with the other preoperative variables held fixed. Introduction Laparoscopic Sleeve Gastrectomy is the most performed bariatric surgery in Conclusion the US. Variables that can predict the Our data suggest that multiple amount of surgical weight loss at long- preoperative variables can be used to term follow-up are still not well predict surgical weight loss after understood. The aim of our study is to Laparoscopic Sleeve Gastrectomy. analyze the preoperative factors that Further prospective studies are needed could predict weight loss after LSG. to be done in order to validate our Methods findings. We retrospectively reviewed all patients that underwent LSG from 2012 to 2016. A statistical model was created to determine the effect of multiple A181 preoperative variables on weight loss. Patients undergoing intra-gastric The statistical model to predict balloon achieve approximately 50% %Estimated BMI Loss(EBMIL) and of their target weight loss in the first

137 month postoperatively: a Metabolic preoperative diagnosis rates of GERD and Bariatric Surgery Accreditation and diabetes were 21.5% and 12.2%, and Quality Improvement Program respectively. 98.2% of patients were analysis. discharged within 24 hours of the Priscila Armijo Omaha NE1, Dietric procedure. One patient was admitted to Hennings Omaha NE2, Melissa the ICU, and 7.3% received Leon Omaha NE1, Dmitry postoperative treatment for Oleynikov Omaha NE2, Vishal dehydration. Reoperation and Kothari Omaha NE2 readmission rates were 1.1% and 2.7%, Unviersity of Nebraska Medical respectively, mainly due to nausea, Center1 University of Nebraska vomiting, and poor nutritional status Medical Center2 (N=12). Intervention rate was 3.4%. Patients in this cohort achieved a mean Introduction %TBWL of 5.5% (SD: 4.1%), and Intra-gastric balloon placement can mean TBWL of 5.6kg within 30-days provide a mean percent total body postoperatively (N=66; 24-30days). weight loss (%TBWL) of 10.2% at six- Conclusion month follow-up. We aimed to evaluate Our data shows that patients met 30-day outcomes and safety of patients approximately 50% of their target undergoing intra-gastric balloon weight loss 30 days after intra-gastric placement. balloon placement. We hypothesize this Methods to be due to increased nausea, vomiting The Metabolic and Bariatric Surgery and dehydration. The rapid degree of Accreditation and Quality weight loss in the first 30 days is likely Improvement Program (MBSAQIP®) due to intolerance of oral nutrition, not was queried for adult patients who physiologic or behavioral changes. underwent primary intra-gastric balloon placement in 2016. Demographics, and preoperative risk factors were A182 collected. Postoperative outcomes Ultrasonographic regression of included %TBWL, complications, Hepatic Steatosis after Bariatric readmission, reoperation, and Surgery intervention rates. Statistical analysis Camila Ortiz Gomez Weston 1, David were performed using SPSS 23.0. Romero Funes Weston FL1, Mauricio Results Sarmiento-Cobos Weston 1, Rene 564 patients were included, with Aleman 1, Emanuele Menzo Weston majority being female (79.4%), FL1, Samuel Szomstein North Miami Caucasian (89.9%), mean age of Beach FL1, Raul Rosenthal miami FL2 48±11.6 years, and mean preoperative Cleveland Clinic Florida1 Cleveland BMI of 33±12.5 kg/m2. 4.3% of Clinic of FL2 patients were smokers, and

138 www.obesityweek.com Postoperative ultrasounds were done at INTRODUCTION an average of 0.13±0.06 and 2.15±2.16 Obesity remains the major risk factor years respectively. Pre-operative for developing non-alcoholic fatty liver ultrasounds of 51%(n=49) patients, disease (NAFLD), and. bariatric reported hepatic Steatosis, compared to surgery has widely demonstrated a 30%(n=29) postoperatively (p=0.0058). beneficial effect on it. We report our A binary logistic regression model data on NAFLD ultrasonographic comparing the pre-operative and post- regression after bariatric surgery. operative presence of fatty infiltration METHODS in ultrasound of patients undergoing We retrospectively reviewed all bariatric surgery determined an OR=1.7 patients who underwent bariatric with statistical significance (p=0.031). surgery between 2010 and2017 at our institution. Patients with preoperative CONCLUSIONS and at least one-month postoperative Similarly to other studies, our findings abdominal ultrasound were included. suggest that bariatric surgery regresses Data collected included baseline ultrasound signs of fatty liver demographics, BMI, ALT/AST ratio, infiltration. and comorbidities. R version 3.3.1
statistical software was used to apply A526 Paired t-test and chi-square in order to Use of Non-invasive Positive Pressure determine statistical significance. A Ventilation in Patients with Severe binary logistic regression model was Obesity Undergoing Upper used to predict the probability of Endoscopy Procedures bariatric surgery improving fatty liver Makram Gedeon Hartford CT infiltration. Bristol Hospital RESULTS Of the 3020 Patients reviewed, Background: Patients being evaluated 95(3.14%) patients met inclusion for bariatric surgery often undergo criteria. We observed a predominantly preoperative upper endoscopy. Patients female distribution 81%(n=75), with a with obesity are at increased risk for mean age of 52.44±13.16 years, and a sedation related adverse events during mean BMI pre-operatively endoscopy. of 45.37±8.71 kg/m2. Gastric bypass was the most prevalent procedure Objectives: The study evaluated the 73.96%(n=71), and the post-operative effect of non-invasive positive pressure BMI was 31.34±6.63 kg/ m2.The ventilation (NIPPV) in patients with mean ALT/AST ratio was severe obesity undergoing upper 1.17±0.39 and 0.98±0.31 preoperative endoscopy. and postoperative respectively (p=0.0169). Preoperative and Setting: Community hospital

139 endoscopy suite, Bristol Hospital, CT. The impact of staple line reinforcement on perioperative Methods: Randomized controlled trial staple line leak and bleeding rates assessed the effectiveness of NIPPV in following sleeve gastrectomy: An patients undergoing upper endoscopy. analysis of MBSAQIP data registry Patients were randomized into Matthew Cunningham- experimental group NIPPV or control Hill Philadelphia PA1, Michael group. Primary endpoints were Mazzei Philadelphia PA1, Michael desaturation events (SpO2 <=94%) and Edwards Philadelphia PA1 desaturation events requiring Temple University Hospital1 intervention (SpO2<=90%). A secondary endpoint was the use of Introduction: Staple line NIPPV as a rescue maneuver in reinforcement (SLR) is a common patients who developed a clinically technique perceived to decrease leak significant desaturation event. and bleeding rates after sleeve gastrectomy (SG) for morbid obesity. Results: 56 patients with a BMI 40-60 There is currently no consensus SLR were randomized (N=28 treatment and method, nor is its clinical efficacy truly N=28 control). The relative risk of a known. SLR use and method is left to desaturation event for the control group each surgeon. compared to the experimental group was 4.00 (95% CI=1.53, 10.07). There Study Aim was a statistically significant difference To determine if staple line in the risk of a desaturation event reinforcement reduces leak and requiring intervention between the two bleeding rates after sleeve gastrectomy. groups (9 total patients 16.1%, 1 patient 3.6% in the experimental group and 8 Methods: Using the MBSQIP patients 28.6% in the control group, database, we identified patients who p=0.029). All of the patients in the underwent a SG with and without SLR control group who developed a in 2015 and 2016. Univariate analysis desaturation event requiring using Wilcoxon rank-sum and chi- intervention were rescued using square tests of unmatched and 1:1 NIPPV. propensity-matched data was performed to compare outcomes Discussion: This study demonstrated between these cohorts. the effective use of NIPPV as an adjunct to decrease the incidence of Results: 212,538 SG cases were adverse events in patients with severe identified, among which SLR was used obesity undergoing upper endoscopy. in 143,563 (67.5%). In unmatched analysis, bleeding and reoperation rates A183 were significantly higher in the no-SLR

140 www.obesityweek.com cohort (p <0.001; p = 0.005). In procedures to determine if patient analysis of cohorts matched by age, preoperative pain expectations BMI, and common preoperative influence acute postoperative opioid comorbidities, bleeding and reoperation needs. rates remained significantly higher in those without SLR utilization (p = Methods: 0.003; p <0.001). Readmission, mortality, leak and SSI rates were A single institution, prospective lower in the SLR cohort, but not survey-based study of initial sleeve statistically significantly so (Table 1). gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) patients between Conclusions: Staple line reinforcement September 2017 and February 2018 appears to significantly reduce bleeding was completed. Patients underwent and reoperation rates following sleeve standardized preoperative teaching. gastrectomy and has no significant Surveys were administered impact on staple line leak rates and preoperatively, at 1-week and 1-month other complications. While further postoperatively assessing pain level, prospective studies factoring in SLR expectations, and medication use. method and staple characteristics are needed, this large database analysis Results: supports the use of SLR during SG to reduce the risk of perioperative Seventy-two patients were studied. The bleeding. median age was 43 years (IQR 35-53), and median BMI was 43.6 (IQR 40.3- 48.9). 81% underwent SG while 19% A184 underwent RYGB. Preoperative pain How Many Pills are Enough? Opioid expectations were as follows: 8.8% Use and Postoperative Pain Levels in expected a 0-2 pain level, 32.5% a 3-4 Bariatric Surgery Patients. pain level, 37.5% a 5-6 pain level, and Melissa DeSouza Portland OR1, Tarin 21.3% a 7-10 pain level. Patient- Worrest Portland OR1, Elizabeth predicted expected pain did not Dewey Portland OR1, Vanessa correlate with reported postoperative Shay Portland OR1, Farah pain (p=0.11, Table 1). Time to opioid Husain Portland OR1 discontinuation is shown in Figure 1. Oregon Health and Science University1 For patients that received the median opioid prescription, 450mg morphine Background: equivalent, 50% had 20 or more pills remaining after a week, and 32% had Bariatric patients are at risk for 20 or more pills remaining after a postoperative chronic opioid use. We month. Patient accuracy in predicting studied opioid use following bariatric postoperative pain was not

141 associated with amount of opioid used Italy3 “Micros Clinic” Ragusa, (p=0.16). Italy4 Dept. Of General Surgery, University of Milan, Milan, Italy5 Chief Conclusions: of Dietetics and Clinical Nutrition Unit, “San Martino University”, Genova, Despite standardized preoperative Italy6 Dept. Of General Surgery, teaching, bariatric surgery patients “Istituti clinici Zucchi” San Donato cannot accurately predict their Group, Monza, Italy7Department of postoperative pain. Patients were Experimental Medicine-Medical mostly able to stop opioids after a Physiopathology, Food Science and week, however, most patients had Endocrinology Section, Sapienza excess medication, indicating over- University of Rome, Rome, prescription of opioids. Studies on Italy.8 Chief of General Surgery dept., preoperative teaching and appropriate “FateBeneFratelli Hospital”, Erba, opioid prescribing are arranted in this Italy9 patient population Introduction: Elipse® Balloon(Allurio n Technologies, Natick, MA USA) is a novel weight loss device that does not require endoscopy or sedation for either A185 placement or removal. Our aim was to Effects of a New Procedurless assess the effects of Elipse® on Intragastric Balloon (Elipse®)on metabolic outcomes associated with Metabolic Syndrome and Pre- obesity. diabetes: Italian Group’s Experience on 324 patients with overweight and Methods: Elipse® is swallowed inside obesity a dissolvable vegetarian capsule and 1 ALFREDO Genco Rome , Cristiano filled with 550 mL of fluid. It remains 2 Giardiello Napoli Caserta , in the stomach for 4 months and then, 3 MARCELLO LUCCHESE FIRENZE , after opening spontaneously, is 4 Michele Rosa MODICA , Marco naturally excreted. Data were collected 5 Rovati Milano , Samir Giuseppe from the Italian Elipse Group. 6 Sukkar Genova , Andrea 7 8 Formiga Monza , Ilaria Ernesti Rome , Results: 324patients (59%female) with 9 marco zappa MONZA mean age of 45.77±11.1 years, mean Department of Surgical Sciences, weight 103.99±23.6kg and mean BMI Sapienza University of Rome, of 36.8±6.15 (27-45 kg/m2) were 1 Italy Chief of General Surgery dept., included. The baseline metabolic data “Pineta Grande Clinic”, Caserta, are shown in Table 1. After 16 weeks, 2 Italy Chief of Bariatric Surgery dept., the mean weight loss was 14.3 kg, total “Fondazione Poliambulanza”, Brescia, body weight loss was 13.75%,mean

142 www.obesityweek.com percent excess weight loss was 51.3% data to this database. This database and the mean BMI reduction was theoretically captures adverse events of 4.98kg/m2. Four balloons (1.3%)were bariatric surgery at U.S. COEs. removed early due to intolerance. One An alternative method to track emptied balloon (0.3%) was naturally complications is to use payor databases excreted early after 90 days. There which collect billing data and ICD-9 were no bowel obstructions or any diagnoses. The Texas Inpatient Public other serious adverse events. There was Use Data File (PUDF) uses hospital a statistically significant improvement discharge information to compile data for some components of metabolic on admission and discharge syndrome and a positive effect on diagnoses. There were over 700,000 glucose metabolism (Table 2). records included in 2015. We hyopothesize that complications rates Conclusion: Elipse®,a procedureless will be different comparing the two intragastric balloon, is safe and databases. effective in inducing weight loss and results in a significant reduction in Methods: The Texas Inpatient PUDF obesity-related metabolic diseases and MBSAQIP were queried for including metabolic syndrome and pre- patients undergoing bariatric surgery in diabetes. the year 2015. Admission diagnoses of morbid obesity with a discharge diagnosis of bariatric surgery status and A186 also the ICD-9CM and CPT codes for Comparison of peri-operative bariatric surgeries were bariatric complications using two queried. Common postoperative large databases: does the data add complication codes were also included up? (leak, sepsis, hemorrhage, skin and soft Benjamin Clapp El Paso TX1, Robert tissue infection, DVT/PE, pneumonia, Cullen 2, Christopher Dodoo El paso prolonged ventilation). TX2, Carl Devemark El Paso TX2, Elizabeth De La Rosa El Paso TX2, Results: There were 137,291 patients Jesus Gamez 2, Alan Tyroch El Paso in MBSAQIP and 9474 patients in the TX2 PUDF that underwent bariatric Benjamin Clapp MD PA1 TTUHSC surgery. Although the patient Paul Foster School of Medicine2 populations were similar, patients in the PUDF had greater adjusted and Introduction: MBSAQIP database is a unadjusted Odds Ratio (OR) for prospective database that looks at short common complications. There was no term (30 day outcomes) of bariatric significant difference in mortality rates. surgery. Every ACS verified Center of Excellence (COE) in the U.S. submits Conclusion: There is a significant

143 difference in the rates of perioperative patients in the claims based database complications of bariatric surgery when had statistically significant higher rates different databases are used. The of complications.

 
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A187 on hypothyroid patients and their Impact of Bariatric Surgery on medication use. Thyroid Function and Medication use in Patients with Hypothyroidism METHODS Cristian Milla Matute Davie FL1, Maria We retrospectively reviewed all Fonseca Mora Weston FL1, David patients who underwent bariatric Romero Funes Weston FL1, Emanuele surgery between 2010 and Menzo Weston FL1, Samuel 2016. Charts were reviewed to identify Szomstein North Miami Beach FL1, patients with an active diagnosis of Raul Rosenthal miami FL2 hypothyroidism before bariatric Cleveland Clinic Florida1 Cleveland surgery, demographic variables and Clinic of FL2 perioperative data were analyzed on a 12 month after surgery period. SPSS INTRODUCTION software was used to apply chi-square. Obesity is associated with multiple comorbidities including RESULTS: hypothyroidism. The correlation between obesity and hypothyroidism Of the 1,581 patients reviewed, 35 revolves around several mechanisms, (2.2%) had an active diagnosis of including adipokines which impact hypothyroidism. The patient population thyroid function, a hypothalamic- was predominantly 82% (n=29) female pituitary-adipose axis, and the and white 80% (n=28), with a mean stimulatory effect of leptin on thyroid age of 47.70±12.45 years. The most activity. The aim of this study is to prevalent procedure was RNYGB 88% describe the effects of rapid weight loss (n=31), followed by LSG 12% (n=4).

144 www.obesityweek.com At 12 months the BMI decreased by 13.15kg/m2 (p<0.0001), with a INTRODUCTION: Type 2 diabetes percentage of estimated BMI loss mellitus is a disease correlated (%EBMIL) of 75.30±23.34%. The with obesity. Obese patients has mean thyroid stimulating hormone suppressed incretin effect and measurement preoperatively was inbalance of glycemic homeostasis. 3.01±2.52 (u/dl) versus 2.5±2.3 (p= Studies have shown improvement in 0.153). The mean Thyroxine DM2 after Roux-en-Y gastric bypass measurement preoperatively was (RYGB). The mechanisms of glycemic 1.43±1.38 versus 1.29±1.24 control may be long-term and short- postoperatively measurement (p= term. The mechanisms of early action 0.021). Regarding thyroid replacement are linked to caloric restriction, hormone therapy, preoperatively the improvement of insulin resistance, mean dosage was 86.73±65.9 (mcg) pancreatic beta cell function and return versus 73.52±60.04 postoperatively (p= of the incretin effect through the 0.071). increase of GLP1 and GIP, but data are conflicting. METHODS: Eleven CONCLUSIONS diabetic obese patients underwent Thyroid function seems to improve 12- RYGB with gastrostomy in gastric month post-bariatric surgery. Further remnant after initial 10% weight loss. larger studies are needed to corroborate Patients were submitted to assessment these conclusions. of enterohormones, glycemic profile and Oral Glucose Tolerance Test(OGTT) in the preoperative period in a time curve that was compared to the postoperative period by Oral Via A188 and Gastrostomy Via up to 7 days after Glycemic metabolism and the procedure. RESULTS: Mean enterohormonal evaluation in early preoperative weight was 120.97 ± postoperative Roux-en-Y gastric 17.02 kilograms, mean BMI 44.06 ± 6, bypass in morbidly diabetic obese 59 kg/m2, mean fasting blood glucose patients: comparison the oral and 194.55 ± 62.45 mg/dl and glycated gastrostomy route hemoglobin 8.74 ± 1.64%. 77.7% of Marco Santo Sao Paulo , Gustavo the patients presented remission of Fernandes , Filippe Mota São Paulo 1, DM2 evaluated by the OGTT. GABRIELA ZANDONADI Significant decrease in glycemia, GONCALVES SAO PAULO , Andrea insulinemia and HOMA-IR was also Bastos , Daniel Riccioppo Sao Paulo observed, regardless of the route of Sao Paulo, Denis Pajecki , roberto de administration. There was a significant Cleva São Paulo increase in GLP1 and University of São Paulo1 reduction of GIP by the postoperative

145 oral route. Ghrelin did not change. Preoperative encounters were CONCLUSION: A reduction in abstracted from the electronic medical glycemia and peripheral insulinal record and categorized by type. The resistance relationship between the frequency of was observed in early postoperative preoperative contacts and the duration days of RYGB, independent of the food of the preoperative assessment period route. The change in entero-hormones with postoperative weight and follow was only observed in the postoperative up were assessed by mixed models and oral route. logistic regression over the first 24 postoperative months.

Results: The preoperative frequency of A189 encounters and duration of the The Relationship between the preoperative assessment process were Frequency and Duration of the not associated with postoperative Preoperative Assessment Process and percent weight loss or postoperative Early Postoperative Weight Loss follow up in the first two years. A Colleen Tewksbury Glenside AL1, greater number of individual visits with Jingwei Wu Philadelphia PA2, Kelly the bariatric surgery team (-0.26%, Allison Philadelphia PA3, Heather 95% CI -0.47%, -0.05%; P = 0.02) and Gardiner Philadelphia PA2, Kristoffel more frequent visits with the Dumon Philadelphia PA3, Noel psychologist (-1.46%, 95% CI -2.79%, Williams Philadelphia PA3, David -0.12%; P = 0.03) were associated with Sarwer Philadelphia PA2 smaller weight loss. University of Pennsylvania Health Conclusion: These results suggest that System1 Temple University2 University the intensity and length of the of Pennsylvania3 preoperative assessment period, which is often mandated by third party payers, Background: The frequency of clinical is unrelated to early postoperative visits and duration of the preoperative weight loss. Additional individual visits assessment process prior to bariatric with clinical team members were surgery is often dictated by third party associated with smaller weight losses. payers. Few studies have investigated if These professionals may be using their these encounters are associated with clinical experience to identify potential greater postoperative weight loss or issues with patients and recommending promote postoperative follow up with additional preoperative care in an effort the bariatric surgery program. to optimize outcomes.

Methods: Fifteen hundred bariatric surgery cases from 2009-2014 from a single institution were analyzed. A190

146 www.obesityweek.com Mobile Health Interventions are leading to interventions using the Trans Ineffective in the Bariatric Surgery Theoretical Model (TTM). They were Population compared to a historical group (C) of Patricia Cherasard Garden City NY1, LSG patients without mHealth Collin Brathwaite Patchogue NY1, interventions. Data was analyzed by Alexander Barkan 1, Keneth descriptive statistics. Multiple linear Hall Garden city NY1, Barbara regression analysis was used to Brathwaite Mineola NY1, Melissa compare outcomes. The primary Fazzari Mineola NY1, Donald outcome variable was BMI. Brand Mineola NY1, Borivoje-Boris Djokic Fort Lauderdale FL2, Mary Results: Baseline BMI: group A Granoff 2, Jeff Ritter 2, Mary (n=20) 43.0±4.6 kg/m2; group B (n=20) Schaefer Garden City NY1, Omodolapo 46.0±9.0 kg/m2; group C (n=40) Familusi Garden City NY1, Karen 43.7±5.1 kg/m2. Final BMI values were Norowski Mineola NY1, Gerald 34.9±4.6 kg/m2, 36.6±7.5 kg/m2, and Dessart Smithtown NY3 35.5±4.7 kg/m2 in groups A, B and C NYU Winthrop Hospital1 Keiser respectively after 4.1±0.86, 4.2±0.82, University2 RevAscent3 and 4.4±0.71 months. BMI change was 8.2 kg/m2 (2.4 kg/m2/month) in group Background: Telehealth interventions A, 9.5 kg/m2 (2.3 kg/m2/month) in have been found to be efficacious in group B and 8.1 kg/m2 (2.3 managing chronic diseases. Prior kg/m2/month) in group C. Change was teleconferencing research of our insignificant between Groups A and B postoperative bariatric patients was (p=0.07). equivocal. We hypothesized that Conclusion: mHealth monitoring with utilizing mobile health (mHealth) wearable devices does not appear to wearable devices with a Clinical influence weight-loss after bariatric Decision Support (CDS) system would surgery. Results highlight the need for enhance weight-loss outcomes. further research and development of targeted interventions.Further study is Methods: A seven-month prospective warranted. randomized clinical pilot study was conducted at our MBSAQIP Center of Excellence. Forty patients received A191 mHealth devices after Laparoscopic Revisiting COI: A Comparison of Sleeve Gastrectomy (LSG), and were Public Open Payments Data and randomized into two groups: Financial Disclosures for Obesity intervention (A) and control Week 2016 (B). Patients were monitored monthly Tara McGraw Wilkes-Barre PA1, Ryan for 16 to 20 weeks. The CDS system Horsley Scranton PA1, Jai provided weekly updates on Group A, Prasad Danville PA1, Jacob

147 Petrosky Danvillle PA1, James published. This study reveals a Dove Danville PA1, Marcus significant potential for COI at Fluck Danville PA1, Anthony OW2016, particularly in consensus Petrick Danville PA1 panels and peer-reviewed talks and Geisinger1 videos. The study suggests ASMBS should consider redesigning the Introduction: The disclosure process for scientific website openpaymentsdata.cms.gov wa meetings. There is an opportunity to s established by the Affordable Care better educate speakers and inform Act. It has made payments from attendees about potential COI. industry to physicians and hospitals Otherwise, it is inevitable that publicly available since 2013. The investigative use of the Open Payments purpose of our study was to compare database will lead to such efforts by speaker financial disclosures at Obesity “watch dog” groups or government Week 2016 (OW2016) to the publicly agencies. available Open Payments database.

Methods: The title of all presentations and the names of all moderators, A192 speakers and discussants at ASMBS or Men and women differ in body joint ASMBS Speaker sessions were composition: using bioelectric obtained from the OW2016 conference impedance technology to challenge schedule. Disclosure forms for all the status quo why Fat-Mass-Index speakers were then compared to Open should replace Body-Mass-Index Payments data for 2016. Taxable Erika La Vella Corvallis OR1, Michael income was considered as potential for Saleh Portland OR2, Kirsti conflict of interest (COI) but not food Troyer Corvallis OR1, Olivia and travel reimbursements. Pipitone Corvallis OR1, Donald Yarbrough Corvallis OR2 Results: A total of 370 speakers were Samaritan Health Services1 Western identified (45% Potential COI; University-COMPNW2 Disclosed 22%, Undisclosed 23%) who were associated with 721 presentations Background: BMI does not (72% Potential COI; Disclosed 33%, differentiate lean mass from fat mass Undisclosed 39%). (Table 1). A total of and is confounded by age, race, 109 companies made payments to morphology, and sex. Bioelectric speakers totaling $3,000,000. (Table 2) impedance analysis (BIA) distinguishes lean from fat mass in convenient Conclusions: Open Payments data has clinical settings. been available to the public for 3 years Objective: Establish body composition with 2016 being the most recent year norms before and after bariatric surgery

148 www.obesityweek.com Methods: 561 persons with obesity When should endoscopy and 24h pH- ages 18-72 presented between May test be done before bariatric 2015 and December 2017. BIA was surgery? performed with the SECA mBCA Guilherme Mazzini Richmond 1, Daniel preoperatively and several time points Navarini Passo Fundo NM2, Guilherme postoperatively. BMI, FFMI (fat-free Campos Richmond VA1, Jad mass/height squared) and FMI (fat- Khoraki Richmond VA1, Fabio mass/height squared) were calculated. Barão Passo Fundo 2, Carlos Percentage of excess FMI loss and Madalosso Passo Fundo - RS percentage of excess FFMI loss were BRAZIL 2, Richard Gurski Porto calculated and compared. Alegre 3 Results: There were significant Virginia Commonwealth differences across gender for both FMI University1 Gastrobese2 Federal (p<0.001) and FFMI (p<0.001). Men University of Rio Grande do Sul3 had lower estimated FMI and higher estimated FFMI compared to women. Background: The presence of No significant difference in the rate of gastroesophageal reflux disease weight loss by BMI, FMI, and FFMI (GERD) has an impact on the choice decrease between men and and outcomes of bariatric women. Women had an average loss of surgery. However, GERD diagnosis excess fat mass index 61.2% and based solely on clinical evaluation has 73.1% at 6 months and 1 year been proven to yield poor results in respectively and an average loss of fat individuals with and without obesity. free mass index 41.8% and 77.1% at 6 We studied the factors associated with months and 1 year respectively. Men abnormal 24h pH-test and the impact had an average loss of fat mass index on diagnostic approach in patients with 62.1% at 6 months and an average loss severe obesity. of fat free mass index 58.4% at 6 Methods: 93 consecutive patients months. Data for men beyond 6 months (BMI>35) were prospectively assessed not available. for GERD symptoms in addition to Conclusions: Body composition body composition, upper between men and women is different gastrointestinal endoscopy, esophageal but the trajectory of weight loss is manometry and 24h pH-test. similar. BIA is convenient technology Results: 50 patients (54%) had GERD for office use. Fat Mass Index has symptoms, and 33 (34.5%) had an potential to replace BMI having abnormal 24h pH-test.There were no qualification for surgery implications. significant differences between patients with abnormal or normal 24h pH-test in BMI, body composition, the presence of a hiatal hernia, and the proportion of A193 grade A esophagitis (Table 1).

149 Abnormal 24h pH-test group had and fellows are trained. The challenge higher proportion of defective lower is to assure patient safety during esophageal sphincter (60% vs 36.7%, training. Our study compares the p=0.03) and grade B esophagitis impact of first assistants on patient (33.3% vs 8.3%, p=0.004). Relevant to outcomes following Roux-en-Y gastric diagnostic approach, grade C/D bypass (RYGB) and sleeve gastrectomy esophagitis was only present in the (SG). abnormal 24h pH-test group, and the absence of both symptoms and Methods: esophagitis was a significant predictor of normal 24h pH-test (likelihood ratio A retrospective review of elective SG 5.12, p<0.001). and RYGB procedures performed in Conclusions: Bariatric patients should 2015 and 2016 from the MBSAQIP have a thorough evaluation for GERD participant user files was performed. before surgery. The initial approach Patient cohorts were categorized by the may rely at least on symptoms and level of training of the surgical first upper endoscopy, but patients with assistant(FA). Multivariate regression GERD symptoms or grade A models were developed to determine esophagitis should have a 24h pH-test, the impact of the FA level on patient especially if deciding between sleeve outcomes, adjusting for patient gastrectomy and gastric bypass. demographics and comorbid Prospective studies may define the best conditions. approach to predict GERD outcomes after surgery. Results: A194 First Assistant Impact on Early Compared to an attending weight loss Morbidity and Mortality in Bariatric surgeon as FA, minimally invasive Surgery surgery(MIS) fellows and general Mark Mahan Wilkes Barre PA1, Marcus surgery residents were more likely to Fluck Danville PA1, David have an unplanned admission to the Parker Danville PA1, Jon ICU within 30 days (OR1.422 95%CI Gabrielsen Danville PA1, Anthony 1.196,1.691; OR1.206 95%CI Petrick Danville PA2, Ryan 1.034,1.406, respectively, p <0.0001) Horsley Scranton PA1 and were more likely to have a 30-day Geisinger1 Geisinger.edu2 readmission (OR1.143 95%CI 1.056,1.236; OR1.127 95%CI Background: 1.055,1.204, respectively, p<0.0001). Compared to having a The future of bariatric surgery depends weight loss surgeon as FA, operative largely upon how effectively residents duration was significantly longer for all

150 www.obesityweek.com other assistant levels, or no assistant. patients undergo pre-operative (p<0.0001) endoscopy (EGD) with biopsies, we questioned the utility of sending all Conclusion: specimens to pathology if we additionally examined specimens on The training level of the FA does not the backtable post-LSG. We impact early patient mortality or hypothesized a similar incidence of reoperation rates following SG or microscopic findings between RYGB. However, unplanned ICU endoscopic and surgical specimens, and admissions and readmissions within 30 gross findings between specimens days were significantly associated with examined by surgeons and pathologists. surgical resident or MIS fellow FAs. Further analysis is needed to Methods: A retrospective review was understand the cause/effect, but this conducted on patients who underwent data provides direction as we redesign LSG from 05/2017–03/2018 at a single residency and fellowship training. academic institution. Included patients underwent screening endoscopy with biopsies, post-operative gross evaluation of the remnant, and post- operative pathologic evaluation. Data on demographics, upper endoscopy and endoscopic/surgical pathology were collected.

A195 Results: 116 patients met the inclusion An Evaluation of the Utility of criteria, and were characterized as 84% Routine Pathological Examination of female, 75% Caucasian, with an the Gastric Remnant Post-Sleeve average BMI=46.90 + 7.27 kg/m2. Gastrectomy. Post-EGD and post-LSG biopsies Kejal Shah Columbus OH1, Emily demonstrated pathology in 86% and Benham Columbus OH2, Munyaradzi 88% of patients, respectively. Treatable Chimukangara Columbus OH2, Bradley findings included H.pylori (5.2% vs Needleman Columbus OH2, Sabrena 2.6%), and active gastritis (8.6% vs Noria Columbus OH2 4.3%). Gross examination of the The Ohio State University1 OSU specimen by surgeons and pathologists Wexner Medical Center2 demonstrated pathology in 12.9% and 8.6%, respectively, and included Background: Post-laparoscopic sleeve benign polyps (12.1% vs 7.8%), and a gastrectomy (LSG) resected specimens serosal mass diagnosed as a 0.6cm are routinely sent for pathologic GIST at pathology. evaluation. In our program where

151 Conclusion: Our study demonstrates instrument based on a 5-point Likert similar pathologic diagnoses post-EGD scale (5=“master surgeon” and and post-LSG. Differences in treatable 1=“surgeon-in-training”). Perceived pathology were likely related to difficulty of case was also rated treatment effect after diagnosis post- (1=”low difficulty” vs 5=”high EGD. Additionally, gross backtable difficulty”). Risk-adjusted 30-day evaluation yielded comparable results complication rates were compared to that of pathology, suggesting between surgeons in the top and bottom backtable examination may be used to quartiles according to self- vs peer- identify specimens that need further rating based on data from 16,886 cases. examination, obviating the need to send Results: Overall mean self-rating of all specimens to pathology. surgical skill varied from 2.5 to 5 and mean self-rating of case difficulty varied from 1 to 4. There was no correlation between self-rating of skill A196 vs peer rating of skill (Pearson 0.10, Analysis of Self vs Peer Ratings of p=0.672). Surgeons in the top quartile Surgical Skill with Bariatric Surgery for self-rating of skill had significantly Oliver Varban Ann Arbor MI1, Jyothi higher rates of leak (0.37% vs 0.06%, Thumma Ann Arbor MI2, Arthur p=0.05) when compared to surgeons in Carlin Detroit MI3, Jonathan Finks Ann the bottom quartile, however there were Arbor MI2, Amir Ghaferi Ann Arbor no differences in outcomes when MI2, Justin Dimick Ann Arbor MI2 comparing self vs peer ratings. University of Michigan Health Surgeons who perceived cases to be System1 University of Michigan2 Henry more difficult than their peers had Ford Health System3 higher rates of leak (0.33% vs 0.21%, p=0.025) as well as infection (1.73% vs Background: Prior studies have 1.01%, p=0.48). demonstrated a correlation between Conclusions: Self-assessment of peer-reviewed ratings of surgical skill surgical skill varied widely. Surgeons and complications after bariatric with high self-ratings or who perceived surgery. However, the association cases to be harder than their peers had between self-assessment of surgical higher complication rates. Identifying skill and postoperative outcomes is perception gaps in skill may have an unknown. impact on surgical outcomes. Methods: Bariatric surgeons (n=23) participating in a statewide quality improvement collaborative submitted a A197 representative video of a sleeve Non-Alcoholic Steatohepatitis - The gastrectomy. Videos were self-rated Hidden Comorbidity: No Referral and peer-rated using a validated for Bariatric Surgery

152 www.obesityweek.com Tripurari Mishra 1, Leroy Trombetta 2, reduction; however, referrals to weight Kara Kallies La Crosse WI1, Shanu management occurred in five patients Kothari La Crosse WI2 (Table). Three patients had liver Gundersen Medical biopsies performed at the time of Foundation1 Gundersen Health System2 bariatric surgery; two of whom were self-referred for surgery. One patient Background: Non-alcoholic fatty liver was referred to bariatric surgery after disease (NAFLD), including liver biopsy but lacked insurance nonalcoholic steatohepatitis (NASH), coverage. Fourteen (10%) patients had has the potential to develop into cirrhosis identified on biopsy. cirrhosis and subsequent liver Conclusions: Comprehensive weight failure. NASH is quickly becoming the management is under-utilized in most common indication for liver patients with NAFLD and NASH. transplantation. Important risk factors Referring providers need more in the development of NAFLD include education about the positive impact of obesity, insulin resistance, type 2 metabolic bariatric surgery on diabetes, and dyslipidemia. The NAFLD. objective of this study was to determine the frequency of referral to weight management in patients with biopsy- A198 proven NAFLD. State Variation in Obesity, Bariatric Methods: A retrospective review of the Surgery, and Economic Ranks: A medical records of patients with Tale of Two Americas biopsy-proven NAFLD or NASH from Eric DeMaria Richmond VA1, Wayne 2004-2014 was completed from two English Nashville TN2, Samer community hospitals. Patients without Mattar Seattle WA3, Stacy weight documentation or biopsy Brethauer Cleveland OH4, Matthew results, and those with negative Hutter Boston MA5, John biopsies were excluded. Referrals to Morton Stanford CA6 weight management providers, Bon Secours St Mary's including nutrition therapy or bariatric Hospital1 Vanderbilt surgical services, were documented. University2 Swedish3 Cleveland Results: Overall, 147 patients were Clinic4 Harvard Unviersity5 Stanford included; 62% were women. The mean University6 age was 50.5±13.3 years. Over a mean follow-up duration of 2.5±1.5 years Introduction. Bariatric surgery from biopsy to last documented weight, (BariSurg) is the most effective the mean weight decreased by 2.6±19.4 treatment strategy for extreme kg and BMI decreased 0.8±6.2 obesity. BariSurg coverage varies by kg/m2. Twenty (14%) patients’ state. The study aim is to determine if providers recommended weight either obesity rates or economic rank

153 were correlated to penetrance of greatest need. BariSurg by state. Methods. Data from MBSAQIP, Behavioral Risk Factor Surveillance System, and US News and World A199 Report were utilized to determine Multimodal pain management with BariSurg, obesity, and economic ranks liposomal bupivicaine and by state. BariSurg case volumes per intravenous acetaminophen in a post- capita were compared to the reported operative bariatric population prevalence of obesity and the Richard Ing Bryn Mawr PA1, Michele comparative economic ranking of each Radaszewski Bryn Mawr PA2, state in order to determine if surgical Stephanie Rozick Bryn Mawr PA2 treatment resources were attainable and Main Line Health Bryn Mawr appropriately applied across the U.S. Hospital1 Main Line Health2 Economic rank is a marker for BariSurg coverage. In addition, each Multi-modal pain management has state’s Essential Health Benefit (EHB) become an integral part of early was analyzed to determine BariSurg recovery after surgery (ERAS) coverage. protocols. We performed a prospective Results. Top and bottom 5 ranking double blinded study of 150 patients states in terms of obesity prevalence are undergoing laparoscopic vertical sleeve in Table. States highest in obesity gastrectomy (83) and laparoscopic prevalence demonstrate low economic roux-en-Y gastric bypass (62). Patients ranking, low penetrance of BariSurg were randomized into 3 groups: control and 4 of the 5 states did not have group 1 (CG) receiving intravenous BariSurg as an EHB. In contrast, narcotics only, group 2 receiving lowest obesity states were of much liposomal bupivicaine (ExparelTM) higher economic status, demonstrated only (Ex) and group 3 receiving higher penetration of BariSurg and liposomal bupivicaine (ExparelTM) were more likely to have an EHB for and intravenous acetaminophen BariSurg coverage. (Ex/Ac). Discussion. These data demonstrate that there are two Americas: most Early pain scores, first recorded pain affluent / low obesity vs. least affluent / and pain at 1 hour, were significantly high obesity. Without systematic reduced for both treatment groups. coverage for obesity treatment, less Early pain scores were equivalent for affluent /high obesity states will have groups 2 and 3. Pain scores for Group little opportunity to improve those 2 (Ex) at 2 hours remained significantly circumstances. BariSurg continues to reduced as compared to controls. Pain be poorly applied across the U.S. with scores for all 3 groups were equivalent low application in the states with the by 48 hours. Group 2 (Ex) had fewer

154 www.obesityweek.com patient controlled analgesia (PCA) and may facilitate ease of operation. It attempts than the control group. There is estimated that 75 to 100% of obese were no differences in length of stay, individuals undergoing bariatric complications, pain scores at 1 or 2 surgery have non-alcoholic fatty liver weeks or amount or length of time of disease (NAFLD). We aimed to nausea or vomiting. investigate how a LCD affects liver histology in the setting of NAFLD. Both analgesia regimens produced statistically significant reductions in Methods: Forty intraoperative liver early pain as compared to PCA narcotic specimens were analyzed medication. There was no additional histologically: twenty without and 20 benefit to parenteral acetaminophen with a two-week, 1200kcal/day LCD. and by 48 hours there were no Body weight was measured pre-diet differences from control. Benefits of and at surgery. NAFLD activity score multimodal pain management occur in (NAS) was used to grade liver the early post-operative period. histology. The NAS scores steatosis, lobular inflammation, hepatocellular Statistical analysis done by ANOVA ballooning and fibrosis, defining and Tukey HSD multiple comparison nonalcoholic steatohepatitis (NASH) test. when NAS >5.

Results: Sixteen females and 4 males (age 37.9 ± 9y) with initial weight at surgery of 135.3 ± 23.7kg comprised A200 the non-LCD group. Nineteen females Impact of a low calorie diet before and 1 male (age 45 ± 11y) with initial bariatric surgery on reducing the weight 131.1 ± 24.4kg comprised the histologic appearance of liver LCD group. Average pre-surgical steatosis weight loss was 2.44kg (range 0.3- 1 Risa Wolf Baltimore MD , Kiyoko 11.7kg) in the LCD group. 5% of the 2 Oshima , Kimberley Steele Baltimore LCD group had NASH on liver 3 MD histology, compared to 25% in the non- The Johns Hopkins University SOM LCD group (p=0.001). The LCD group 1 (Endocrinology) Johns Hopkins had significantly less steatosis 2 University SOM (Pathology) Johns (p=0.01), fewer foci of lobular 3 Hopkins University SOM (Surgery) inflammation (P=0.008), and less hepatocellular ballooning (p=0.01) Background: The value of a low compared to the non-LCD group; there calorie diet (LCD) prior to bariatric was no noticeable difference in degree surgery is uncertain. Studies have of fibrosis. shown that a LCD reduces liver volume

155 Conclusions: A two-week LCD prior association between weight loss and to bariatric surgery significantly QOL scores and having decision improves steatosis, inflammation and regret (score >50). hepatocellular ballooning in NAFLD. Future research should Results: Of 205 RYGB patients, only investigate the metabolic correlates of 2.2% (year 1) to 5.1% (year 4) reported these histologic changes. regret scores>50 over 4 years; 2.0-4.5% did not think they made the right decision; 2.0-4.5% would not undergo WLS again. In contrast, of 188 gastric A201 banding patients, 8.2-20.3% had regret Decision Regret up to Four Years scores >50; 5.9-19.5% did not think after Gastric Bypass and Gastric they made the right decision; 7.1- Banding 19.5% would not undergo WLS again. Christina Wee Boston MA1, Aaron Weight loss and QOL scores were Fleishman Boston MA1, Ashley significant correlates of decision regret McCarthy Boston MA2, Donald after banding although weight loss was Hess Boston MA2, Caroline Apovian 2, a stronger correlate with higher model Daniel Jones Boston MA1 quasi-likelihood under the Beth Israel Deaconess Medical independence model criterion score. Center1 Boston Medical Center2 Four years after banding, mean weight loss for patients with regret Background: Weight loss surgery scores>50 was 7.4% vs. 21.1% for (WLS) is neither risk-free nor those with scores <50; the AOR for universally effective. Few studies have regret score>50 was 0.90 (95% CI examined what proportion of patients 0.87-0.94) for every 1% greater weight regret having undergone WLS. loss. Poor sexual function, but not weight loss or other QOL factors, was Methods: We interviewed patients at 2 significantly correlated with decision WLS centers before and after WLS regret after RYGB. about weight loss, quality of life/QOL (Impact of Weight on QOL-lite), and Conclusion: Few patients regret decision regret (modified Brehaut undergoing RYGB but 1 in 5 regret Regret scale; scores of 0-100, higher undergoing gastric banding with weight =greater regret). We conducted loss being a major driver. separate multivariable logistic regression models to examine the

 
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A264 body mass index (BMI), 25- CORRELATION OF 25- hidroxyvitamin D, insulin, GLU, HIDROXYVITAMIN D LEVELS HOMA-IR, HbA1c, HDL, LDL and WITH NON-ALCOHOLIC FATTY CHOL, reactive C-RCP and FER. LIVER DISEASE AND LEVELS OF Patients who reported use of alcoholic INFLAMMATORY AND beverages or who had hepatitis were BIOCHEMICAL MARKERS OF excluded. Statistical analysis were done METABOLIC SYNDROME IN using Student's t-test, Mann Whitney, PRE-OPERATIVE PATIENTS FOR Pearson and Spearman correlation BARIATRIC SURGERY coefficient; p-value <0.05 as statistical Carolina Ribeiro Rio de Janeiro 1, significance. Loraine Ferraz Rio de Janeiro 1, RESULTS: 164 patients (141F / 23M) Andressa Gaudencio Rio de Janeiro 1, were studied: 72 with NAFLD and 92 Guilherme Pinheiro Rio de Janeiro 1, without NAFLD. There was a Gisele Noronha Rio de Janeiro , Paula statistically significant difference on Perricelli 1 the 25-hidroxyvitamin D levels Hospital Federal do Andaraí1 between the two groups (24.9 ± 9.1 in the non-NAFLD group and 21.3 ± 7.6 OBJECTIVES: To investigate the with the NAFLD, p= 0.02) and correlation of 25-hydroxyvitamin D between vitamin D and insulin (r= - with age, gender, body mass index 0.159, p = 0.043), HOMA-IR (r= - (BMI), inflammatory markers, like 0.162, p= 0.039) and FER (r= -0.162, p reactive C-protein (RCP) and ferritin = 0.042). (FER), and biochemical markers of CONCLUSION: The NAFLD group in metabolic syndrome, like total this study had lower levels of 25- cholesterol (CHOL) and fractions (LDL hidroxyvitamin D. A significant and HDL), triglycerides (TG), insulin, correlation was also found comparing glycated hemoglobin (HbA1c), insulin vitamin D levels with insulin, HOMA- resistance index (HOMA-IR), glucose IR and FER. (GLU), as well as to compare their levels in two patient groups: with and without nonalcoholic fatty liver disease A265 (NAFLD). Brazilian National Bariatric Surgery METHODOLOGY: Retrospective Registry – Pilot Study study with patient charts in preparation Lyz Silva Recife 1, Luiz Gustavo de for bariatric surgery. NAFLD was Quadros Sao Jose do Rio Preto Sao diagnosed by an abdominal Paulo, CAETANO ultrasonography and confirmed by liver MARCHESINI CURITIBA , Victor biopsy performed during the batriatric Cabral da Costa Recife , Gabriel surgery. Variables analyzed: age, sex, Simplicio Recife 1, Eduardo

157 Godoy Recife , Manoel Galvao present moment, the Registry accounts Neto Doral FL, Almino Ramos Sao approximately six hundred patient Paulo FL, JOSEMBERG records. Conclusions: The BNBSR Campos Recife 2 will allow the SBCBM and the world to Federal University of have a detailed report on the Bariatric Pernambuco1 Hospital Santa Joana2 Surgery’s situation in Brazil. It is expected that in the following years the Introduction: Brazil is estimated to be registry will be expanded to more the second place in the number of centers, eventually reaching all the bariatric surgeries worldwide, although surgeons associated to the SBCBM. the country doesn't have a national registry yet. Hence, the creation of a registry is imperative, for we need to verify and supervise the quality of the A266 assistance for the candidates to bariatric Safety of early discharge in 605 surgery. Objective: The Brazilian patients submitted to bariatric National Bariatric Surgery Registry surgery in a SRC Bariatric Center (BNBSR) aims to provide a precise Thomaz MONCLARO São Paulo 1, overview of the patients’ profile, Carlos Pizani São Paulo 1, Ana surgeries’ financing and of the number Caroline Fontinele São Paulo 1, Dirceu and results of the procedures Santos São Paulo 1, Marcelo performed, leading to better healthcare CARNEIRO Sao Paulo 1, Eduardo planning. Moreover, it will be a Sticca São Paulo 1, Sansiro de database for research about each Brito São Paulo 1, Carlos De Souza kind of procedure’s participation, their Filho São Paulo 1, PAULO success rate, and SALLET SAO PAULO SP1, Afonso complications. Methodology: Data on Sallet São Paulo 1 preoperative and postoperative periods Instituto de Medicina Sallet1 and the surgical technique details will be uploaded on an online software There are still in the world several already validated in other countries. surgeons who have doubts about the The pilot study will be developed in safety of early discharge. After eight reference centers in the surgical establishing protocols such as ERAS, treatment of obesity, selected by the recent scientific evidence shows that Brazilian Society of Bariatric and early discharge can be performed safely Metabolic Surgery (SBCBM) based on without compromising the patient. We their surgery number and commitment analyze our discharge protocol and his with the data upload and aiming to safety in relation to the hospital have data from all the country's readmission rate in 30 days in 605 regions. Results: The pilot project patients submitted to Laparoscopic started officially in July/2017. Until the RYGB and SG in a SRC credited

158 www.obesityweek.com center in 2017. We evaluate discharge Thomaz MONCLARO São Paulo 2, day, cause of not-early discharge, Afonso Sallet São Paulo 2, PAULO complications and 30-day readmission SALLET SAO PAULO SP rate. Our early discharge rate was Obesimed1 Instituto de Medicina Sallet2 96.5%. Of the remaining 3,5%, 21 patients, 17 were discharged on the 2nd Introduction: Total energetic day, 1 on the 3rd, 2 on the 4th and 1 on expenditure decreases after bariatric the 10th postoperative day. The reasons surgery due to a for non-early discharge were: 6 (29%) reduction in the resting metabolic rate patients with bleeding, 5 (24%) with caused by the loss of lean and fat difficulty accepting diet or PONV, 4 masses. (19%) due to technical difficulty of Objective: To analyze the impact of surgery, 4 (19%) who needed ICU lean mass loss in resting metabolic rate admission and 2 (9%) due to 30 days respiratory diseases. Of the 4 patients after gastric bypass surgery. (0.7%) who needed ICU, 2 were due to Method: The research constituted a sleep apnea and 2 with cardiological sample size of 11 patients between 25 reasons. and 50 With the exception of patients who year, all meeting the inclusion criteria were not discharged solely for established by the Brazilian Society of observation (need for ICU or technical Bariatric difficulties of surgery), the others were and Metabolic Surgery. To analyse the classified through Clavien-Dindo grade level of physical fitness we performed (CD): 9 (1,5%) had CD I, 2 (0,3%) CD evaluations using the International II and 2 (0,3%) CD IVA. 30-day Physical Activity Questionnaire readmissions was 3,5% and there was (IPAQ). To assess no mortality. Early discharge is feasible the body composition we used the and safe keeping hospital readmission bioimpedance test (InBody) in the same rates low compared to literature. two encounters. The differences in physical fitness and body composition were compared A267 and analysed. IMPACT OF LOSS OF LEAN Results: The results show significant MASS IN THE RESTING loss of adipose tissue (8.2 +/- 2.9k) and METABOLIC RATE IN OBESES reduction in resting metabolic rate (7%) UNDERGOING GASTRIC BYPASS after surgery when compared to pre- SURGERY – a pilot study surgery. Marcos de Oliveira São Paulo 1, Ana Despite losing a small amount of lean Beatriz Guiesser São Paulo 1, mass (3.6 +/- 1.1kg) it was enough to Margaretth Arruda São Paulo 2, promote

159 a reduction in the basic metabolic rate These findings bring to light the fact (115.6 +/- 42k cal/day). that patients with a lower percentage of Conclusion: The present study lean demonstrated the impact of reduction mass will face a reduction in the rate of of lean mass weight loss and will be more in the resting metabolic rates in patients susceptible to shortly after undergoing bariatric regaining weight. surgery.






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A261 syndrome. CAN CHILDREN WITH GENETIC Methods Data were analyzed from SYNDROME BE OFFERED children with genetic syndrome BARIATRIC SURGERY? retrospectively from one surgeon at a MAHENDRA single private institution. Six children; NARWARIA ahmedabad each with Prader-Willi syndrome or ASIAN BARIATRICS HOSPITAL Down syndrome or leptin receptor mutation underwent LSG Background Obesity-related from 2011 through 2017 and were complication is one of the leading followed-up for one to four years. causes of mortality in children with Results Six children with identified genetic syndrome. Most syndromic for the analysis. The mean age and forms of obesity are associated with body mass index percentile(BMI) were mild to severe cognitive deficits and 7.8 ± 1year (range, 3- 12 years) and unusual behaviors. While many other 95th - 98th percentile(51.2 ± 6 kg/m2 ), syndromes affecting cognition such as respectively. The preoperative co- Down syndrome are also associated existing conditions include obstructive with a higher incidence of obesity. sleeve apnea (66.6%), dyslipidemia Objective To assess the effects of (0%), and diabetes mellitus (DM) laparoscopic sleeve gastrectomy (LSG) (16.6%). Postoperatively, at 1.5 to for treating obesity and co-existing 2 years, the patients achieved conditions in children with genetic 85%EWL. Similarly DM remission

160 www.obesityweek.com rates 100%, respectively. Also, the concerning patient selection, procedure, OSA and DM improvement rates were efficacy, and safety. 75% and 100%, respectively. The Methods: Search of the PubMed health-related QOF improved database was performed for original dramatically in early follow-ups. studies using IGBs as a weight loss Conclusion LSG is a safe procedure option in adolescents from 1998- for children with genetic syndrome. present. Relevant studies were analyzed The patients achieved significant for level of evidence, outcomes, and weight loss and remission of co- complications. existing conditions along with Results: 5 studies consisting of 91 improvement in the health-related QOF patients under the age of 18 and BMI > following LSG.Long term results are. 30 kg/m2 were identified and reviewed. needed for the final conclusion Studies included non-randomized retrospective and prospective analyses with follow-up time between 3 and 62.6 months. Patients were evaluated A262 for mean body weight loss (5.74– Intra-Gastric balloon surgery as an 12.2kg), decrease in BMI (2.25– alternative to surgery in adolescents 10kg/m2), excess weight loss (20.1– Derman Ozdemir HOLBROOK NY1, 68%) and successful improvement of Robert Dabek Boston MA2 co-morbidities. Complication rate Saba University School of ranged from 5.6% to 91.6%. Medicine1 Division of Plastic and Discussion: The use of IGBs have been Reconstructive Surgery, Massachusetts well documented in adults and review General Hospital and Harvard Medical of the literature has demonstrated their School2 safety and effectiveness in treatment of obesity. IGBs may fill the therapeutic Background: As the eating habits of gap between pharmacotherapy and kids and adolescents trend negatively, surgery, allowing adolescent obesity has become a significant populations with obesity to achieve problem which has not shown any good weight loss, better control of co- indication of a decrease in prevalence. morbidities, and better quality of life The question of whether bariatric compared to baseline. surgery is the method of choice for adolescents still remains unanswered. The less invasive intra-gastric balloon A263 (IGB) could be a safe and effective The Prevalence of Co-Morbidities in method of weight loss for appropriately Adults and Adolescents Seeking selected adolescents. The expanding Sleeve Gastrectomy Julie Liu BS1, volume of literature needs to be Mireya Montalvan-Panzer MS1, reviewed to evaluate evidence Ilene Fennoy MD MPH1, Jennifer

161 Woo Baidal MD MPH1, Lori Lynch Square Test with a significant p-Value CPNP1, Elizabeth Ranish RD1, of .05, we compared the prevalence co- Robyn Sysko PHD2, Jeffrey L. morbidities of hypertension, diabetes Zitsman MD1 1Center for mellitus, dyslipidemia, obstructed sleep Adolescent Bariatric Surgery apnea, and gastroesophageal reflux Columbia University Medical Center disease between the two groups. New York, New York 2Eating and Weight Disorders Program Icahn Results: Adults seeking weight loss School of Medicine at Mt. Sinai New surgery had a significantly higher York, New York prevalence of 5 common obesity- Julie Liu New York NY1, Mireya related co-morbid conditions compared Montalvan-Panzer , Ilene Fennoy New to adolescents of similar BMI. The York NY, Jennifer Woo Baidal New differences in the prevalence of these York NY, Lori Lynch New York NY, obesity-related co-morbid conditions Elizabeth Ranish New York NJ, Robyn between adults and adolescents were Sysko New York NY, Jeffrey statistically significant (Table 1). Zitsman New York NY Columbia University1 Conclusion: Adults seeking weight loss surgery had a significantly higher Background: Individuals with morbid prevalence of all examined obesity- obesity may undergo surgical related co-morbid conditions compared treatments such as sleeve gastrectomy to adolescents of similar BMI. Earlier for effective and sustainable weight intervention with weight loss surgery loss. Little is known about the may preclude these serious conditions prevalence of obesity-related co- from developing. morbidities among populations of adolescents and adults seeking weight loss surgery. A521 Slipped capital femoral epiphysis Methods: A retrospective cohort study (SCFE) and Blount’s disease as matched 100 adolescents (ages 12-18 indicators for early metabolic years) from the Center for Adolescent surgery Bariatric Surgery database and 100 Cornelia Griggs Boston MA1, Numa adults (mean age 42.7 years) from the Perez Boston MA2, Janey Pratt Stanford Metabolic and Bariatric Surgery CA3 Accreditation and Quality Massachusetts General Improvement Program database Hospital1 MGH2 Stanford, MGH3 (January 2010 to December 2017 for each). BACKGROUND: Prior literature has Subjects were matched for gender and shown the benefit of weight/BMI body mass index (BMI). Using Chi reduction to prevent disease

162 www.obesityweek.com progression in patients with SCFE and overall difference between the rate of Blount’s but has also shown that SCFE/Blount’s in obese vs non-obese traditional weight loss programs are children is over 25 fold: 1.05% vs ineffective. SCFE and Blount’s 0.04% (p<0.001). The mean age of diagnoses have become indications for children with SCFE/Blount’s disease referral to bariatric surgery programs was 12.31 ± 0.04 whereas the mean age per 2018 guidelines. This study of obese children with SCFE/Blount’s examines national trends in patients who underwent MBS was 16.69 ± 0.55 with SCFE and Blount’s disease as part (p<0.001). of a case series following pediatric CONCLUSION: Orthopedic patients post MBS. complications remain a persistent METHODS: The Kids’ Inpatient problem in the pediatric population Database (KID) and the National with a diagnosis of obesity, yet no Inpatient Sample (NIS) were used to literature has shown an effective identify pediatric patients (<20 years intervention for weight loss. Despite old) with SCFE and/or Blount’s disease being diagnosed at a young age, from 2005-2014. Patients were patient’s with SCFE/Blount’s undergo identified using ICD-9-CM diagnosis MBS in their later teenage years, codes with a confirmatory diagnosis potentially leading to unnecessary code for obesity. disease progression. Therefore, SCFE RESULTS: The national prevalence of and Blount’s disease should be SCFE/Blount’s among all children  20 considered indications for early MBS years old is 0.05% (33,875 pts). The surgery in pediatric patients.

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A148 veteran population and treatment is Early Indicators of Long Term difficult. Early clinical indicators for Weight Regain After Gastric Bypass weight regain after roux-en-Y gastric in a Veteran Population bypass (RYGB) have not been defined Andrew Taitano Bay Pines FL1, Candis for this population. Cornell Saint Petersburg FL2, Lynne Methods Olson Bay Pines FL2 138 veterans underwent RYGB at our CW Bill Young VA Medical Cer1 CW institution between 1999-2016 and had Bill Young VA Medical Center2 suitable follow-up. Demographics, medical history, and body mass index Background (BMI) at multiple time points were Morbid obesity is prevalent in the extrapolated from electronic patient

163 records. Predictors of weight regain Ylva Lagerros Stockholm 1, Lena were investigated. Brandt STOCKHOLM , Jakob Results Hedberg Uppsala , Magnus Sundbom , Median age was 54 years, median BMI Robert Bodén Uppsala was 47.3, and 24% were women. Mean Karolinska University Hospital1 weight loss (WL) was 32.4% at 2 years, 29.5% at 5 years, and 28.8% at 10 Gastric bypass surgery (GBP) is years. Mean weight regain was 8.6% at considered a safe method with few 5 years, and 8.3% at 10 years. Patients complications. Nonetheless, few with a weight loss velocity (WLV) <1 studies have focused on the risk of pound/week between month 3 and 6 post-surgery complications in patients after surgery (14.7%) had significantly with pre-surgery psychiatric diagnoses, lower mean WL at all follow up times compared to those without. This is a (p<0.01). Patients who experienced nationwide cohort study encompassing their post-surgical nadir weight earlier 22,539 patients undergoing GBP in than 1 year (19.6%) had significantly Sweden, 2008-2012. They were lower mean WL at 2 years, 5 years, and identified through the National Patient at last follow up (p<0.01). As a Register and/or the Prescribed Drug screening test to predict weight loss Register. GBP patients with a prior failure, “low WLV” had sensitivity 33- diagnosis of schizophrenia (n=40), 100% and specificity 87-96%. bipolar disorder (n=335), depression Similarly, “early weight nadir” had (n=2100), attention deficit sensitivity 23-67% and specificity 83- hyperactivity disorder (n=314), 92%. substance use disorder (n=971), mental Conclusions retardation (n=54), eating After RYGB, veterans with low WLV disorder(n=285), personality disorder during month 3-6 are at risk for initial (n=551) or self-harm (n=1169), since and long-term WL failure. Veterans 1997, or a prescription of who reach a nadir weight prior to 1 antidepressants (n=5,345) since 2005, year are at risk for long-term increased were not at a higher risk of reoperation weight regain. Patients with these before discharge, than patients without weight-loss patterns should be targeted these diagnoses (odds ratio 1.75, for intervention to improve WL confidence interval 0.73-4.20 adjusted outcomes. for age, gender and calendar year). Neither did we find an increased risk for reoperation within the first 30 days A149 among patients with any of these Gastric bypass surgery in patients diagnoses prior to GBP vs patients with psychiatric diagnoses – risk of without these diagnoses; 0,1% (n=18) reoperation and length of hospital were admitted to psychiatric inpatient stay care post-surgery, while 5.6%

164 www.obesityweek.com (n=1,259) were readmitted to surgery bariatric surgery between February inpatient care. Of those, 121 went 2017 to February 2018. Patients were through reoperation due to bleeding, divided by whether they had their 142 due to infection and 259 due to procedure before or after the anastomosis insufficiency. Length of implementation of TAP blocks (intent- hospital stay did not differ between to-treat analysis). Factors analyzed patients with previous psychiatric included length of stay (LOS), diagnoses compared to those without. morphine milligram equivalents In summary, in patients selected (MME) received 72 hours post- suitable for and having undergone operatively, nausea complaints, and GBP, prior psychiatric diagnoses were post-operative diet adherence. not associated with increased risk for reoperation or longer hospital stay post Results: There were 243 patients that GBP, compared to patients without met inclusion criteria with 84 patients previous psychiatric diagnoses. who were in the pre-intended group and 159 patients in the post-intended group. The mean BMI of the two groups were A150 47.37 and 46.7 respectively (p = .259) Transversus abdominis plane (TAP) and the mean number of co-morbidities block significantly improves opioid were 5.96 and 5.04 (p =.056). The use and length of stay in bariatric median LOS for the pre-intended group surgery patients was 2 days compared to 1 day (p = Laurel Mulder Chicago IL1, Emily 0.008) for the post-intended group. The Ramirez Chicago IL2, Jennifer median MME for the pre-intended Poirier Chicago IL1, Alfonso group was 24 mg and 0 mg for the Torquati 1, Philip Omotosho Chicago post-intended group (p < 0.001). In IL1 addition, patients had significantly less Rush University Medical Center1 Rush nausea complaints and a higher diet University Medical Cent4er2 adherence after the protocol change (p < 0.001). Background: The TAP block is a well- Conclusion: known method for administering perioperative analgesia for abdominal The implementation of TAP blocks at surgeries. Pre-operative TAP blocks our institution has led to a significant were integrated into the enhanced decrease in length of stay, post- recovery after surgery (ERAS) protocol operative opioid usage and an increase at our institution for patients in diet adherence emphasizing the undergoing bariatric surgery. effectiveness of TAP blocks as a pre- operative analgesic method in Methods: A retrospective chart review improving post-operative outcomes. was performed on patients undergoing

165 determine which factors had a greater influence on procedure choice. A151 Who really decides? Surgeon Results: Among 142 surgeons who preference trumps patient factors in performed >5 bariatric cases/year, 32 predicting whether patients receive a (22.5%) performed LSG in 95% or sleeve or bypass. more of their bariatric cases in year Brooks Udelsman Boston MA1, Ginger 2014. In logistic regression, a diagnosis Jin Boston MA2, David Chang Boston of diabetes (OR 1.45; p<0.001) or MA1, Matthew Hutter Boston MA1, Elan gastroesophageal reflux disease (OR Witkowski Boston MA1 1.36; p<0.001) were associated with Massachusetts General Hospital, receiving LRYGB. However, the most Department of Surgery1 Brigham and predictive factor was whether the Women's Hospital, Department of surgeon performed mostly LRYGB in Surgery2 the preceding year (OR 33.8; p<0.001). In pseudo-R2analysis 83% of the Background: Laparoscopic sleeve predictive power of the regression gastrectomy (LSG) has replaced gastric could be explained by surgeon-factors bypass (LRYGB) as the most common alone. bariatric operation. Both offer similar weight loss, but confer different Conclusions: While the percentage of benefits and risks. While many factors LRYGB vs. LSG in this cohort mirrors determine the choice of procedure, we the national average, there is wide hypothesized that the primary driver is variation at the surgeon level. While the surgeon’s preference and surgeons may offer several procedures, experience rather than patient-related in practice many perform a single factors. procedure--a trend which is increasing. Surgeon choice is the predominant factor in determining which procedure patients receive. Methods: Retrospective cohort study using the Public Discharge Data file (2004-2014) of the Statewide Planning A152 and Research Cooperative System Google Trends as a Resource for (SPARCS) for New York State. We Bariatric Education: What do identified surgeons performing bariatric Patients Want to know? operations. Logistic regression was Cristian Milla Matute Davie FL1, Maria performed to determine impact of Fonseca Mora Weston FL1, Camila surgeon, patient, and hospital factors on Ortiz Gomez Weston 1, David Gutierrez receiving LRYGB. We used logistic Blanco Weston FL1, Emanuele regression and pseudo-R2analysis to Menzo Weston FL1, Samuel

166 www.obesityweek.com Szomstein North Miami Beach FL1, complications of BS, financial costs of Raul Rosenthal miami FL2 BS, and what insurance companies Cleveland Clinic Florida1 Cleveland cover BS. Of all these interests, Clinic of FL2 traditional websites, like ASMBS, only address a few. BACKGROUND Bariatric Surgery(BS) is an effective CONCLUSIONS treatment for the morbidly obese GT could supplement understanding patient and it is one of the most about interest in bariatric surgery. frequently performed surgical Utilizing these trends can help educate procedures in the United States(US). It patients more effectively, and tailor is difficult to determine BS levels of specific official websites to the general interest through traditional approaches. interest The aim of this study is to use Google Trends(GT) as a tool to analyze the US general population interest in BS. METHODS A154 Google Trends was used to access data The Impact of Revision Bariatric for the searched term “Bariatric Surgery on Comorbidities Surgery”. Information was gathered Varun Krishnan New York NY1, from 2008 to 2018, on English Andrew Godwin Oyster Bay NY, Kevin language and US location. Search Hutchings , Julio Teixeira Scarsdale frequency, time-intervals, specific NY locations, frequent topics of interest Lenox Hill Hospital1 and related searches were analyzed. GT reports search frequency on means, a INTRODUCTION value of 100 represents peak popularity Revision bariatric surgery is being for the term. Microsoft Excel Version increasingly performed for weight 15.41.0 was used to analyze data. regain, but little is known about its RESULTS impact on comorbidities. The purpose From 2008 to 2018, US leads in Google of this study was to evaluate the impact search interest on BS. Interest has of revision surgery on comorbidities. gradually increased from the year 2008 with a mean 67% interest to a 94% on METHODS the year 2017. Regarding interest by A retrospective review of patients from sub-region, Michigan State leads the 2014-2017 was performed. frequency of searches for BS, followed Demographics, type of revision, weight by Indiana, Delaware, West-Virginia, loss data, complications, and and Tennessee. Top searched terms by comorbidity data were analyzed. frequency are; Patient eligibility for BS, what is the BS, what are the RESULTS

167 67 patients between 2014-2017 was analyzed. The average age was 47.82, average BMI 42.84, and incidence of A155 DM 19.40%, HTN 34.32%, HL Bariatric surgery with Vertical 14.93%. 61.54% were noted to have Sleeve Gastrectomy (VSG) or complete remission or reduction in the Modified Duodenal Switch (MDS) dose of anti-hyperglycemic medication modified peripheral gene expression (53.8% complete remission). Average associated with coronary artery change of HbA1c was 1.34 over 1-3 disease and inflammation years. 17.39% were noted to have Sarah Sabrudin New York NY either stopped or reduced their Northwell Health antihypertensives after surgery. LDL delta 20mg/dL over 3mo to a year. Introduction: HDL increased by 9mg/dL. Average Obesity reduces life expectancy and Cholesterol/HDL ratio decreased by increases the probability of coronary 1.94. BMI change was 5.48kg/m2. artery disease (CAD).Weight loss effects on peripheral blood gene In comparing DM versus no DM, there expression that relate to ischemic heart was no difference between BMI (41.35 disease are less well described vs 41.13; p=0.928) or %EBWL Objective: (42.65% vs 19.39%; p=0.1746). In To determine the impact of bariatric comparing complete remission of DM surgery and weight loss on a previously versus no remission, there was no validated blood-based test difference in %EBWL (45.83% vs incorporating age, sex, and gene 37.57%; p=0.713). expression (ASGES) for the assessment of obstructive CAD, in a cohort of A subgroup analysis excluding gastric morbid obese individuals. banding as the original index case: Methods: 66.67% of patients had either complete Prospective study, 48 patients remission or improvement in patient’s underwent bariatric surgery with either diabetes. The mean change in HbA1c VSG (n=24) or MDS (n=24). Blood was 1.34. 14.28% stopped or reduced samples were taken at baseline as well anti-hypertensive medications. as 24-hour, 3 month,and 6-12 month post-op time points. The ASGES and CONCLUSION individual gene expression components Revisional surgery is effective in were determined in the clinical reducing comorbidities. Remission of lab.Paired T-Test was used to compare DM appears to be independent of ASGES and gene expression changes. weight loss. Recurrence of Results: comorbidities could be considered an The study had mean age of indication for revisional surgery. 49(SD=10.5),mean BMI of

168 www.obesityweek.com 47.4(SD=8.7),and 33% were female.Post-op ASGES scores showed Introduction: Venous a significant increase vs baseline(14.86 thromboembolism (VTE), including vs. 16.02, p=0.026, n=44)and a non- pulmonary embolism, is a rare but significant decrease from baseline at 3 burdensome complication of bariatric month and 6-12 month follow- surgery. We identified and analyzed all up.Evaluation of the underlying VTE occurrences in our patient ASGES gene expression components population. showed significant alterations in lymphocyte and neutrophil associated Methods: Patients 18-80 yo from a gene single surgical center, diagnosed with expression.Neutrophil/Lymphocyte VTE, meeting MBSAQIP criteria 180 (N/L) ratio is associated with days following bariatric surgery (or inflammatory conditions and poorer revision thereof) were included. cardiac outcomes: calculation of a N/L Descriptive analysis was applied to gene expression ratio showed a retrospectively gathered data. significant increase at 24 hr post-op (p<0.001) and significant decrease at 6- Results: During the study time frame, 12 months follow-up periods (p=0.017, 2,719 patients were treated. VTE n=14) occurred in 19 (0.69%). The Conclusion: thromboembolus was abdominal Bariatric surgery altered the levels of (mesenteric, hepatic, portal, or splenic gene expression associated with vein) in twelve, pulmonary in four, circulating neutrophils and extremity in one, and three patients had lymphocytes, previously shown to be multiple thrombus locations. Median associated with the presence of CAD. time to discovery was 14 days (range 5- 145). All patients were readmitted. Two patients required invasive procedures, and 13/19 (68%) received A156 therapeutic heparin infusions prior to Detailed Analysis of Venous oral anticoagulation, on which all were Thromboembolism within 180 days discharged. Sixteen patients (84%) of Bariatric Surgery: A 6-Year underwent hematologic testing. Five Retrospective Single Center Review were diagnosed with a hypercoagulable Beata Lobel Farmington CT1, Andrea disorders (3=homozygous Factor V Stone Glastonbury CT1, Richard Leiden; 1=alpha thalassemia trait; Seip Glastonbury CT1, Ilene 1=multiple mutations). On admission Staff Hartford CT1, Darren for initial surgery, mean Caprini score Tishler Glastonbury CT1, Pavlos was 4.6. Five patients (26%) Papasavas Hartford CT1 experienced an interruption in routine Hartford Hospital1 chemical VTE prophylaxis

169 administration, defined as missed Y-gastric bypass (RYGB) for older preoperative dose, skipped patients. postoperative dose, or delay >4 hours Methods: The MBSAQIP 2015 in administration. VTE distribution by database was used to identify non- gender, procedure, anatomic location, revisional laparoscopic RYGB and SG and association with specific risk procedures. Comparisons were made factors is displayed in Table 1. based on patients' age. Clinical outcomes included post-operative Conclusion: Detailed analysis of events and mortality. occurrence often reveals an Results: There were 37388 and 85776 unsurprising narrative for development RYGB and SG performed in patients of VTE despite standard prophylaxis. under the age of 65, respectively, and Understanding these rare cases may 2474 and 5027 RYGB and SG help direct appropriate screening and performed in older patients, reinforce patient-appropriate respectively. In older patients, both perioperative prophylaxis with a goal RYGB and SG were associated with a of eradicating postoperative venous higher rate of post-operative events thromboembolism. (12.8% vs 10.5%, and 7.1% vs 5.1%, respectively, p<0.001). Mortality rate was higher for both procedures in older A157 patients (RYGB: 0.6% vs 0.1%: SG: Title: Safety of Bariatric Surgery in 0.3% vs 0.1%, p<0.001). The leak rate Patient Older than 65 was higher in patients over 65 Iliya Goldberg Commack NY1, Andrew undergoing RYGB compared to Bates Locust Valley NY1, Salvatore younger patients (0.9% vs 0.5%, Docimo Stony Brook NY1, Tyler p=0.026) but not for SG (0.4% vs Cohn Stony Brook NY1, Aurora 0.3%, p=0.636). After adjusting for Pryor Stony Brook NY1, Konstantinos baseline characteristics, the effect of Spaniolas Stony Brook NY1 age on leak rate following RYGB Stony Brook University Hospital1 persisted (OR 1.74, 95% CI 1.12-2.71, p=0.014). Background: With the increase in life Conclusions: Older patients expectancy together with the obesity undergoing bariatric surgery are at epidemic, there has been an increase in higher risk for overall events including older patients undergoing bariatric mortality. The effect of age on leak rate surgery. There are conflicting opinions is only seen in RYGB procedures. regarding the safety of performing Laparoscopic SG appears to have a bariatric procedures on older patients. favorable safety profile in older The purpose of this study was to patients. compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-

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A272 development five years postoperatively Conversion to Diabetes 5 Years Post were age; change in weight during the Bariatric Surgery in Individuals with first year postoperatively and elevated Obesity and Pre-Diabetes baseline FG. Neither baseline weight Rachel Golan Beer Sheva 1, Doron nor number of visits to a dietitian post- Comaneshter , Shlomo Vinker Ashdod , surgery, predicted conversion to Dror Dicker Petah-Tikva diabetes. We stratified our study Ben-Gurion University of the Negev1 population by weight-loss 1 year postoperatively (>25%;15%- Background: We assessed rates of 25%;<15% weight loss). Those who conversion to diabetes in individuals lost the most weight during the first with prediabetes 5 years after year postoperatively, where those who undergoing three types of bariatric presented the lowest rates of surgery, and examined predictors of conversion to diabetes at one diabetes development. (1.4%,p=.11), two (2.8%,p=.002) and Methods: Patients with prediabetes, five (4.7%,p<.001) years defined as fasting-glucose (FG) 100- postoperatively. Development of 125 mg% or HbA1c 5.7%-6.4% at diabetes 5 years postoperatively were baseline, who underwent bariatric 14.4%, 6.3%, and 6.5%, for GB, SG surgeries were accessed. The main and RYGB respectively (p<.001). outcome was conversion to diabetes, 5 Conversion to diabetes was observed years postoperatively. more rapidly among those who Results: Of 13,099 bariatric surgeries underwent GB compared to those who performed in the Clalit-Health-Services underwent SG or RYGB (HR=.53, during years 2002-2011, 1,756(13.4%) p>.001) were performed in patients with Conclusions: Our findings emphasis prediabetes: 819 gastric-banding (GB), the importance of 1 year weight loss 845 Sleeve-gastrectomy (SG) and 92 and baseline FG as factors in long-term roux-en-Y gastric-bypass (RYGB). prevention of diabetes development in Patients were 41.6 years old and 73.5% bariatric-surgery patients with were women. In a multiple-logistic- prediabetes. regression model, predictors of diabetes

171 operating characteristic (ROC) curves were generated for DiaRem and C- A273 peptide levels, and the curves C-peptide fails to improve the utility compared. Then, logistic regression of the DiaRem algorithm in was used to evaluate the utility of C- predicting non-remission of type II peptide as a predictor of T2D non- diabetes after bariatric surgery remission one year post surgery while Madison O'Brien South Windsor CT1, controlling for DiaRem score. Andrea Stone Glastonbury CT1, Results Aashish Samat New Britian CT1, Tara A total of 416 patients met inclusion McLaughlin Hartford CT1, Ilene criteria; pre-operative C-peptide levels Staff Hartford CT1, Richard were available for 175 (42%). Of these, Seip Glastonbury CT2, Darren 59 % experienced remission of diabetes Tishler Glastonbury CT1, Pavlos at 1yr post-surgery. Characteristics of Papasavas Hartford CT1 the sample are presented in Table Hartford Hospital1 Hartford Hospital 1. Both DiaRem and C-peptide Metabolic and Bariatric Surgery significantly predicted T2D remission Center2 with DiaRem outperforming C-peptide (Table 2). After controlling for DiaRem Introduction score, C-peptide was not a significant The DiaRem algorithm is a significant predictor of T2D non-remission at 1 predictor of type II diabetes (T2D) year after surgery (Table 2). This result remission at one year after bariatric held even when gastric band cases were surgery. We sought to determine excluded. whether the addition of fasting pre- Discussion surgery C-peptide levels would These results do not support the improve its effectiveness towards this addition of C-peptide to the DiaRem end. algorithm. Methods We conducted a retrospective chart review to identify patients who underwent primary gastric banding, sleeve gastrectomy, or Roux-en-Y gastric bypass between January 2008 and April 2017, with a diagnosis of T2D pre-surgery and at least 12 month A274 follow-up data. Remission of diabetes Factors related to morbidity after was defined as fasting glucose < 5.6 laparoscopic sleeve gastrectomy and mmol/l and HbA1c < 6.0% during the laparoscopic Roux-en-Y gastric first year post surgery, in the absence of bypass for morbid obesity at the any diabetic medication. First, receiver tertiary hospital.

172 www.obesityweek.com Sung Jin Oh Busan 1, Farah readmission, reoperation and mortality. Husain Portland OR2, In Ho Jeong 3, The percentage of excess weight loss Amy Douglas Portland OR2, Andrea (%EWL) at 6 months was lower in Stroud Portland OR2, Donn LSG (35% vs 43%, p<0.001) and Spight Portland OR2, Samer %EWL at 1 year was similar in both Mattar Seattle WA4, Bruce groups (55% vs 62%, p=0.105). Wolfe Portland OR2 postoperative morbidity was Inje University Haeundae Paik significantly associated with high Hospital1 Oregon Health & Science American society of anesthesiologists University2 Jeju National University (ASA) score, LRYGB, GERD, Hospital3 Swedish Medical Center4 pulmonary embolism, deep vein thrombosis, low hematocrit (<32%) and Backgrounds: The aim of this study limited ambulation. Multivariate was to evaluate the risk factors of analysis showed that LRYGB and postoperative complications after limited ambulation were important risk laparoscopic sleeve gastrectomy (LSG) factors involved with postoperative and laparoscopic Roux-en-Y gastric complications in laparoscopic bariatric bypass (LRYGB) for morbid obesity. surgery. Methods: A total of 994 obese patients Conclusion: Although minor underwent bariatric surgery in the complication was higher in LRYGB department of bariatric services at the compared with LSG, limited Oregon Health & Science University ambulation of obese patients was between January 2011 and December significant risk factors in LSG and 2015. Of the 994 obese patients, 699 LRYGB for morbid obesity. consecutives obese patients undergoing LSG (n=357) and LRYGB (n=342) were retrospectively reviewed from a prospectively collected database. Results: Preoperative comorbidities A275 regarding hypertension, TOTALLY INTRAVENOUS hyperlipidemia, sleep apnea and ANESTHESIA (TIVA) IN THE gastroesophageal reflux disease MINI-GASTRIC BYPASS (GERD) were more prevalent in PATIENTS: EXPERIENCE IN 3,743 LRYGB group. Statistically significant PATIENTS TREATED OVER NINE differences were found between LSG YEARS 1 and LRYGB in operative time (83 vs. Robert Rutledge La Quinta CA , KS 193 min. p< 0.001), surgical site Kular infection (1.4% vs 4.5% p=0.014), and Center for Laparoscopic Obesity 1 urinary tract infection (0.8% vs 3.2%, Surgery p=0.030). There were no differences regarding major complications,

173 Anesthesia is known to be a high risk and overall. factor in the morbidly obese. Different techniques have been suggested as a means to decrease the anesthetic risks in bariatric surgery. This retrospective A276 survey study reports on the perceived Surgeon Performed Transversus recovery profiles in morbidly obese Abdominis Plane Block in the Setting patients who received anesthesia by of Bariatric Surgery protocol for Total Intravenous Shaina Eckhouse St. Louis MO1, Anesthesia (TIVA). Jeannette Wong-Siegel Saint Louis MO2, J. Chris Eagon St. Louis MO2, Morbidly obese patients underwent Dawn Freeman Fairview Heights IL3 laparoscopic Mini-Gastric Bypass Washington University in St. Louis surgery managed by an anesthetic School of Medicine1 Washington protocol using Bispectral index (BIS) University in St. Louis2 Barnes Jewish guided TIVA. Postoperative, anesthetic Hospital3 complications and postoperative nausea and vomiting (PONV) were evaluated. Background: Multimodal pain management protocols demonstrate During a 9-year period, 3,743 patients decreased opioid consumption after underwent MGB per the TIVA bariatric surgery. However, limited protocol. Follow-up was completed in data exists regarding the efficacy of 2,310 patients (61%). There were 85% transversus abdominis plane (TAP) females with a mean preoperative age blocks as an adjunctive analgesic of 39 years (range, 12-81 years). The method. The present study aimed to preoperative weight and body mass demonstrate the efficacy of a surgeon- index were 134 kgs and 49.1 kg/m2. performed TAP block when compared The mean operative time was 37 to local infiltration of bupivacaine in minutes + 10 and the median hospital laparoscopic bariatric surgery. stay was 1 day. Patients awoke quickly and rarely showed serious hypoxemia Methods: From February 2017 to during the PACU stay (<1%). The December 2017, 148 patients incidence of PONV was low compared underwent laparoscopic gastric bypass to rates reported in patients treated with (GB) or sleeve gastrectomy (SG) and inhalational agents (4% in the PACU were assigned to either received 1) a and 27% overall.) TAP block (n=74) with 0.25% bupivacaine without epinephrine or 2) The TIVA protocol resulted in local anesthesia infiltration at each excellent, rapid and safe recovery from incision (no TAP block, n=74). Data anesthesia of the morbidly obese MGB collected included patient patients. PONV is low in the PACU demographics, other comorbidities, and

174 www.obesityweek.com complications. The primary outcome have shown positive results, however of the study measured inpatient use of there are accompanying risks opioid medications as measured by associated with each procedure. The morphine equivalent dose (MED). less invasive intra-gastric balloon (IGB) looks to be a safe and effective Results: Patients with and without TAP method of weight loss for appropriately blocks had similar MED scores (Figure selected patients. The expanding 1). Post-operative MED scores were volume of literature needs to be also not significantly different between reviewed to evaluate evidence types of bariatric procedures. When concerning patient selection, procedure, stratified by BMI less than or greater efficacy, and safety. than 50, MED scores were no different Methods: Search of the PubMed in patients with and without TAP database was performed for original blocks. studies using the Elipse, ReShape, LexBal, Orbera, Obalon, or End-Ball Conclusions: The present study further IGBs as a weight loss option from reinforces the limited effectiveness of a 2013-present. Relevant studies were TAP block alone on overall pain analyzed for level of evidence, control. Local anesthesia infiltration outcomes, and complications. remains an adequate adjunctive method Results: 24 studies consisting of in the post-operative pain management. 45,678 patients with BMI>25 kg/m2 were identified and reviewed. Studies included randomized controlled, retrospective and A277 prospective analyses with follow-up Intra-Gastric balloon surgery as a time between 3 and 76 months. Patients safe, effective, and less invasive were evaluated for mean body weight method of weight loss surgery loss (5.74–25.2kg), total body weight Derman Ozdemir HOLBROOK NY1, loss (7.6–18.9%), decrease in BMI Robert Dabek Boston MA2 (2.7–8.9kg/m2), excess weight loss Saba University School of (12.4–60.1%) and successful weight Medicine1 Division of Plastic and loss (>10%) seen in 60-85% of Reconstructive Surgery, Massachusetts patients. Complication rate ranged from General Hospital and Harvard Medical 0.2 to 86.9%. School2 Discussion: The use of IGBs are well accepted by patients and review of the Background: Obesity has become a literature has demonstrated their safety significant problem which has not and effectiveness in treatment of shown any indication of a decrease in obesity. IGBs may fill the therapeutic prevalence. There are a multitude of gap between pharmacotherapy and surgical options for weight loss which surgery allowing patients with obesity

175 to achieve good weight loss, better December 2017, 64 pts (25M/39F; control of co-morbidities, and better mean age: 45.1±10.7; mean BMI: quality of life compared to baseline. 35±4.6 Kg/m2; mean weight:101.4±19.6Kg) completed 4 months follow up. After 4 months, at A278 the time of excretion, mean BMI-Loss Expanding the Reach of Intragastric was 5.7±2.6Kg/m2, %EWL was 64±53 Balloons: First Multicenter Results and %TBL was 16±6. Mean of Elipse Balloon in Non-Core User Triglycerides and LDL decreased from Groups 158.4±84 mmol/L and 128.8±43.6 to Roberta Ienca Rome 1, Michele 121.1±41.3 and 114.3±32.4 Rosa MODICA , Corrado Selvaggio , respectively. Balloon removal for Carmen Zafra , Galen Shi , Carmen intolerance was required only in one Alfaro , Mante Aldaguer , Jose Maria patient. There were no serious adverse Alvarez events and typical early nausea and Sapienza University1 vomiting were easily managed. Conclusions: This study demonstrates Background: Surgeons and for the first time that Elipse™ endoscopists constitute the core user Intragastric Balloon administrated by groups placing Intragastric Balloons internists is safe and effective; The (IGB) for weight loss. Aim of this results from these non-core user groups study was to evaluate the safety and appear superior to most published data efficacy of Elipse™, an IGB not from core user groups; Internists’ requiring endoscopy or sedation, in 6 motivation of patients may have been a internists-lead European obesity factor. centres. Methods: Data was collected from 6 internists-lead obesity centres in Italy and Spain. Elipse™ Intragastric A279 balloons were placed, without Efficacy of intragastric ballons: A anaesthesia or endoscopy, as outpatient comparison of gas-filled versus and filled with 550 ml of fluid. Patients saline-filled balloons received the same dietary, exercise and Josiah Billing Shoreline WA1, Peter other advice usually given at these Billing Seattle WA1, Kurtis centres. Follow up was performed Stewart Shoreline WA1, Pui Lam utilizing a wireless scale with Adriana Ho Shoreline WA1, Eric smartphone app and visits every other Harris Edmonds WA1, Jedediah week until the end of the treatment; Kaufman Shoreline WA1 Elipse™ self-emptied and passed the Eviva1 GI-tract after 4 months. Results: From February 2017 to

176 www.obesityweek.com Background: Intragastric Balloons significant and similar weight loss at 6 (IGBs) are rapidly gaining interest as a months. IGBs prove to be a valuable non-surgical treatment for obesity. tool for patients that do not qualify for There are currently two types of IGBs or are not ready for a bariatric surgery. implanted in the United States (gas- filled and saline-filled). We present our experience implanting both types of IGBs in a free-standing ambulatory surgical center (ASC). A280 Methods: Data was collected Obesity in Veterans with Spinal retrospectively for all patients Cord Injury and Variation in Rates undergoing IGBs placement n=80. of Mandated Annual BMI Screening Patients were excluded from the study Dan Eisenberg Palo Alto CA1, Shalini if they were non-compliant with IGBs Gupta Menlo Park CA2, Thomas protocol or if they were currently Bowe Menlo Park CA2, Alexander participating in another research study. Harris Palo Alto CA3 After exclusion, 59 patients were Stanford-Surgical Policy Improvement included. There were 32 gas-filled and Research and Education Center, 27 saline-filled IGBs placed. IGBs Stanford School of Medicine; Palo Alto were placed according to the VA HCS1 VA Program Evaluation manufacturer’s protocols and were Resource Center; Center for Innovation removed at 6 months. to Implementation2 Stanford-Surgical Results: Average body mass index Policy Improvement Research and (BMI) for gas-filled and saline-filled Education Center, Stanford School of respectively was 36.0 and 34.6, average Medicine; VA Center for Innovation to percent total weight loss (TWL) was Implementation3 11.0% and 13.0% and weight loss was 24.4 pounds and 27.1 pounds at 6 Background: The prevalence of months. Early removals rates for obesity is high among patients of U.S. intolerance of the balloons were 3.1% Veterans Health Administration and 11.1% for gas-filled and saline- (VHA). Veterans with spinal cord filled respectively. Upon removal, 3 injury (SCI) are particularly susceptible small ulcers (9.4%) were seen in gas- to obesity and its related co-morbid filled IGBs and 1 small ulcer (3.7%) in conditions. Appropriate detection and the saline-filled IGBs. management of obesity in Veterans Conclusion: Patient tolerance of IGBs with SCI relies on consistent varies between both types; although measurement of body mass index gas-filled was better tolerated overall. (BMI). Despite a VA mandate for Ulcers were a common adverse event annual universal BMI screening, of both types but were asymptomatic. obtaining height and weight Both types of IGBs provided measurements can be challenging. The

177 goal of this study is to understand the PHARMACOLOGICAL burden of obesity in this vulnerable TREATMENT OF population and to describe system-wide CARDIOMETABOLIC DISEASE variation in BMI assessment of SCI ASOCIATED TO OBESITY patients within VHA. BEFORE AND AFTER BARIATRIC SURGERY: 5 YEAR Methods: National VHA fiscal year FOLLOW-UP 2017 data were used to identify Maximo Agustin Schiavone Martinez 1, Veterans with an SCI diagnosis. Vital Nicolas Paleari Pilar 1, Gabriel statistics data were used to assess Menaldi Pilar 1, Maria Eugenia clinical documentation of BMI or Garcia Buenos Aires 1, Virginia height and weight, within 6 months Asti Pilar, Buenos Aires 1, Marta before or after the index SCI encounter. Gomez Gottschalk Buenos Aires 1, Maria Gloria Linzoain Buenos Aires 1, Results: There were 31,700 Veterans PEDRO MARTINEZ with a diagnosis of SCI in 130 VHA DUARTEZ Buenos Aires 1 facilities, 29.3% had diabetes and Hospital Universitario Austral1 54.1% hypertension. BMI data was available in 67.5% of Veterans with Aims: SCI; of whom 70% were overweight or 1- To analyze the prevalence of obese (table 1). Among facilities, the pharmacological treatment for median rate of BMI assessment was hypertension, diabetes, dyslipidemia 65.1% (25.5%-91.9%); median rates of and depression before undergoing height and weight assessment were bariatric surgery 66.7% (25.5%-96.4%) and 89.8% 2- Compare the pre-surgical prevalence (66.7%-100%) (figure1). with the postsurgical prevalence Material and methods: Conclusion: Nearly 1/3 of Veterans A follow-up survey was conducted on with SCI had no documented annual patients operated from the year 2010 BMI screening, with large variation until 2017 inclusive. We evaluated among facilities for BMI assessment regarding the pharmacological rates. Efforts should be made to treatment that these patients are improve rates of annual BMI screening currently using. The following among SCI patients, so that obesity in variables were analyzed, prior to the this vulnerable population is adequately surgery and then at the time of the detected and treated. survey: age, weight, body mass index (BMI), treatment for high blood pressure, treatment for diabetes (including the type of treatment), A281 treatment for the dyslipidemia, treatment for depression or mood and

178 www.obesityweek.com time of follow-up. The follow-up time Single Anastomosis Duodeno-ileal was determined according to the Bypass with Sleeve Gastrectomy number of years elapsed between the (SADI-S): Safety, Preliminary date of surgery and the date of the Outcomes from a Single Institution survey. Prospective Cohort Study. Results: Philippe Bouchard Montreal 1, A total of 506 patients were Alexandre Bougie Montréal 1, included.The average follow-up time Mohammed Al Abri Montreal QC1, Zvi was 4.65±3 years.Regarding the Perry Cote Saint Luc, Quebec H4W treatment for diabetes, prior to surgery, 2E4 YT1, Sebastian 26%were under treatment. However, Demyttenaere Westmount 1, Olivier after surgery, only 3.5% persist today Court Montreal Quebec1, Amin with treatment for diabetes Andalib Westmount QC1 (p<0.0001). In antihypertensive McGill University1 treatment, 66.4% of patients used antihypertensive drugs before surgery. Background: The single anastomosis Currently, only 30.8% still use duodeno-ileal bypass with sleeve antihypertensive treatment (p<0.0001). gastrectomy (SADI-S) is a modification For dyslipidemia, 19.4% used some of the conventional biliopancreatic type of lipid-lowering medication prior diversion with duodenal switch (BPD- to surgery, 5.5% of patients are still DS) directed to simplify the procedure under treatment (p<0.0001). Finally, and reduce the risk of malnutrition. regarding treatment for depression or Safety and outcomes of SADI-S need mood, 15.8% took some treatment prior to be further evaluated. to surgery. Currently, 14.8% use treatment (p=0,72). Methods: We present short-term Conclusions: outcomes from a single institution In the 5-year follow-up of our patients, prospective cohort study of SADI-S we found a significant decrease in compared to conventional BPD-DS. farmacological treatment for Data are depicted as count(percentage) hypertension, diabetes and dyslidemia, and median(interquartile range). except for depression. Results: 39 patients were eligible for the study since June 2016. 27 were planned for SADI-S and 12 for BPD- DS. 23 underwent SADI-S (17 one- stage; 6 second-stage). 12 had BPD-DS (4 one-stage; 8 second-stage). Both groups had similar sex distributions but A282 higher age, BMI and obesity-related comorbidity trends in SADI-S group

179 [50(16) vs. 41(12) years], [48.0(5.7) vs. Surgery, Medical School, Istinye 44.5(9.4) Kg/m2] and [18(78%) vs. University2 Department of Basic 6(50%)], respectively. Procedure times Oncology, Cancer Institute, Hacettepe for both one and second-stage SADI-S University, ANKARA-TURKEY3 were significantly shorter (–39 minutes, p=0.04; –33 minutes, p=0.02), Background and Aim: Although excess respectively. There were no conversion weight loss is the targeted end-point of to laparotomy or 30-day mortality. In the successfull procedure, many SADI-S group, there were 2 patients might suffer from disturbed complications (negative laparoscopy bowel habits and vitamin deficiencies. for abdominal pain and stenosis We aimed to evaluate exocrine requiring dilation). Median follow-up pancreatic function after different time was 7.0(9.4) months [8.0(8.1) vs. procedures. 3.8(11.3) months]. For both one and Methods: 60(21M)patients aged 43(21- second-stage procedures, BMI changes 62)years who underwent bariatric were similar [–16.6(8.7) vs. –14.7(8.6); surgery (sleeve gastrectomy(SG), mini- –7.0(4.2) vs. –4.2(4.6)], respectively. gastric bypass(MGB) or single anastomosis duodenal switch(SADS)) Conclusions: These preliminary results and 20(6M)healthy controls aged indicate that SADI-S is a safe 33(22-56)y were included. Stool procedure with encouraging short-term samples were collected for fecal outcomes comparable to conventional elastase-1(FE1) levels (mg/g stool). 10 BPD-DS. SADI-S has promising patients from each group were given potential as a second-stage procedure pancreatic enzyme replacement following SG, which is the most therapy(PERT). Excess weight performed surgery worldwide. loss(EWL,%) and serum vitamin D However, long-term follow-up is levels were also measured. required to support its adoption. Results: FE1 levels in control group was found as 518,2(351,6-691)mg/g which were 642,35(566,3-711,4); A283 378,52(183,5-561,1); 458,88(252,5- Effect of Bariatric Surgery on 593,5)mg/g after SG, MGB and SADS Exocrine Pancreatic Function respectively. Although levels remained Mahir Ozmen Ankara 1, EMRE unchanged after sleeve gastrectomy, GUNDOGDU 2, Emir significant decrease were observed Güldogan Ankara 2, Fusun after malabsorbtive procedures. After 3 OZMEN Ankara 3 months of PERT, levels were Department of Surgery, Medical normalized (683.39(615,5-720) in School, Istinye University, MGB and 691.57(643,1-720) in SADS ISTANBUL-TURKEY1 Department of group. Vit D Levels(pg/ml) were found

180 www.obesityweek.com to be decreased in almost 60% of the studies have reported the use of patients which were 17.8(3-46.5), transversus abdominis plane (TAP) 19.04(9-30), 15.1(8.4-23.6) after SG, block for perioperative pain MGB and SADS respectively. EWL in management. one year were 58%, 65% and 71% Objectives:The aim of this study is to respectively. PERT did not effect the examine the efficiency of TAP block in weight loss but serum vit D levels were reducing the use of opioid analgesics significantly increased both in MGB during the perioperative period of and SADS. bariatric procedures. Material and Methods:A Conclusion: Almost every patients are retrospective chart review was suffering from malabsorbtion after performed on 174 patients who MGB or SADS whereas functions are underwent a laparoscopic bariatric kept normal after SG. PERT corrects procedure between April 1st, 2017 and the pancreatic function which results in March 31st, 2018. A total of 92 patients normal serum vit-D levels without received TAP block, while 82 patients affecting the weight loss. We conclude did not receive TAP block. that PERT should be in the treatment Results:Baseline patient characteristics algoritm especially after malabsorbtive were comparable between the two procedures. groups. The mean age was 44.0±11.0 years vs. 43.1±10.0 years, and the mean preoperative body mass index(BMI) was 45.6±8.5 kg/m2and 45.5±8.8 A284 kg/m2in TAP and non-TAP groups, Perioperative Transversus respectively. In the TAP group, 2 Abdominis Plane (TAP) Block for patients(2.2%) received Bariatric Surgery to Reduce the Use intravenous(IV) morphine while of Opioid Analgesics 2(2.4%) did in the non-TAP Rena Moon Orlando FL1, Linda group(p=0.94). In the TAP group, Lastrapes Orlando FL1, Andre 54(58.7%) received oral opioid Teixeira Orlando FL1, Muhammad analgesic while 66(78.6%) did in the Jawad Orlando FL1 non-TAP group(p=0.02). In the TAP Orlando Regional Medical Center1 group, 83(90.2%) received oral non- steroidal anti-inflammatory drugs while Introduction:Overuse of opioid 14(16.7%) did in the non-TAP analgesics is a public health in the U.S. group(p<0.001). Postoperative pain remains the most Conclusion:The use of TAP did not common challenges following inpatient affect the use of IV morphine, but and outpatient surgeries, and therefore significantly decreased the use of opioid analgesics are widely used opioid analgesics by mouth. A larger during the perioperative period. Several prospective study may be needed to

181 further validate the use of TAP block weight loss was defined as > = 50 % for perioperative pain management. excess weight loss (EWL) at 1 year.

Results: A285 Preoperative Diabetes and Early Sixty-four percent of patients achieved Postoperative Weight Loss Can successful weight loss. Younger age, Predict 1-year Weight Loss Success male gender, greater height, and lower after Sleeve Gastrectomy baseline excess weight and body mass Christopher Buchholz Hackensack NJ1, index were significantly associated Melissa Blatt Hackensack NJ1, Hans with success; while diabetes was Schmidt Paramus NJ1, Douglas significantly associated with failure. Ewing Paramus NJ1, Toghrul Among the patients that succeeded, the Talishinskiy Paramus NJ1 mean 1-month and 3-month EWL was Hackensack University Medical 20.1% and 37.2% respectively. This is Center1 higher than 16.3% EWL at 1 month and 28.4% EWL at 3 months among Introduction: patients that failed (p < 0.001). Of the 356 patients that followed up at 6 The sleeve gastrectomy is effective for months and succeeded, the mean EWL weight loss and resolution of obesity- was 52.6%, versus 36.6% among those related comorbidities. However, not all that failed (p < 0.001). patients achieve the same level of success. The purpose of this study is to Conclusion: determine if preoperative and postoperative markers predict Preoperative and postoperative markers successful weight loss. can predict a successful outcome. Knowing baseline demographics, Methods: diabetes history, and early weight loss can identify those individuals who are Of 3059 sleeve gastrectomies predicted to fail, thus enabling a more performed between 2012 and 2016, 472 rigorous treatment plan to achieve patients met inclusion criteria of post- success. operative follow-up at 1 month, 3 months, and 1 year. A retrospective chart review was conducted, involving collection of patients’ baseline A286 demographics, medical history, and Single Incision Laparoscopic Surgery postoperative markers. Wilcoxon rank- as a Safe and Effective Technique for sum and chi-square tests were used to Sleeve Gastrectomy perform statistical analyses. Successful

182 www.obesityweek.com Sherard Chiu Fairfield CT1, Shawn minutes and 32.58 minutes for the Garber Roslyn Heights NY1 SILS group. None of the SILS cases New York Bariatric Group1 required conversion to another technique. In our experience, the In the United States, approximately SILS sleeve gastrectomy is a safe and 216,000 bariatric procedures were effective operation as compared to performed in 2016 with 58.1% being the conventional laparoscopic sleeve gastrectomies. The majority of procedure and can be performed these procedures were performed using the same surgical principles. using the conventional laparoscopic (multiport) manner. Since the introduction of single incision A287 laparoscopic surgery (SILS), there MBSAQIP National Registry Study has been an increase in sleeve of Sleeve Gastrectomy Outcomes in gastrectomies performed using this Patients Age 70 and Older technique. This study aims to Richard Seip Glastonbury CT1, Andrea investigate our single surgeon’s Stone Glastonbury CT1, Tara experience with SILS versus McLaughlin Hartford CT1, Darren conventional laparoscopic sleeve Tishler Glastonbury CT1, Pavlos gastrectomy in terms of leak rate, Papasavas Hartford CT1 hernia occurrence, excess body Hartford Hospital1 weight loss, and operative time. This study includes 411 (44.3%) patients Introduction: The number of patients that underwent conventional over age 70 undergoing bariatric laparoscopic as compared to 516 surgery is increasing. We investigated (55.7%) patients that underwent whether age>70 affects the safety of SILS sleeve gastrectomy by a single sleeve gastrectomy (SG) performed as surgeon from our institution. The the primary bariatric procedure. leak rate of the conventional laparoscopic group was 0.49% (n=2) Methods: Using MBSAQIP 2015-16 verses 0.19% (n=1) in the SILS registries, we compared characteristics group. Hernia occurence in the and outcomes in 96,663 patients under conventional group was 2.68% age 70 (U70) to 961 patients age 70 and (n=11) as compared to 2.71% (n=13) older (>70). All underwent in the SILS group. An average of laparoscopic SG surgery with CPT 61% excess body weight loss after 1 43775 as principal code. Cases that year was achieved in the were converted from laparoscopic to conventional group versus 75% open were included. Excluded were excess body weight loss after SILS patients who underwent previous gastrectomy. Average surgical time abdominal surgery; whose surgery for the conventional group was 33.64 represented revision or conversion;

183 and emergent cases. Our initial Christina Poa Rolling Hills Estates analysis excluded cases with other or CA1, Collin Creange New York NY1, concurrent CPT codes; a secondary Matthew Pergamo Port washington analysis added back selected groups. NY1, Christine Ren-Fielding 1, George Fielding New York NY1, Bradley Results: Initial analysis: The 30d Schwack New York NY1 mortality rate was marginally higher New York University1 in >70 vs. U70 (0.31% vs. 0.07%, p=0.03) as was the rate of unplanned BACKGROUND: ICU admissions (1.35% vs. 0.49%, Gastroesophageal reflux disease p=0.0001). However, many 30 day (GERD) is a common condition in outcomes were unaffected adults, affecting both quality of life and (see Table). In >70 vs. U70, ASA risk of developing esophageal cancer. class was higher (p<1e-6) and the Laparoscopic sleeve gastrectomy number of comorbidities (diabetes, (LSG) has become a popular option for GERD, sleep apnea, hyperlipidemia, patients seeking operative management hypertension) per patient was greater of morbid obesity, however it is unclear (2.9±1.2 vs. 1.5±0.8, p<1e- whether it may potentially worsen 6). Secondary analysis: Incorporation GERD symptoms. of 77,206 additional patients with METHODS: simultaneous procedures 290 patients with morbid obesity (paraesophageal hernia repair, completed a pre-operative enterolysis, cholecystectomy, liver Gastroesophageal Reflux Disease- biopsy) did not alter results Health Related Quality of Life (GERD- (see Table). HQL including odynophagia/dysphagia, relation of Conclusion: Despite a greater number symptoms to position/meals, etc with a of comorbidities, patients over the age score range of 0-50) questionnaire of 70 have similar 30 day outcomes before undergoing elective LSG. 191 from SG. The risk of 30 day patients completed a post-operative perioperative mortality is higher in the GERD-HQL questionnaire (66%, with over 70 cohort, however, this risk still a mean follow-up time of 20.4 months). remains very low especially RESULTS: considering the comorbidities present. Mean weight loss, % body weight loss (BWL), and reduction in BMI were 79 pounds, 28.1%, and 12.7 respectively. Within the overall cohort there was not A288 a significant change in mean GERD- The Effect of Laparoscopic Sleeve HQL scores (pre-op 6.1, post-op 6.1, Gastrectomy on Gastroesophageal p=0.981). However in subgroup Reflux Disease analysis, patients without GERD pre-

184 www.obesityweek.com operatively demonstrated a significant method for the management of obesity worsening in mean GERD-HQL scores and its comorbidities.The effect of SG (pre-op 2.4, post-op 4.5, p=0.0020). on visceral fat has not been There was not a significant change in described. We intend to study the usage of GERD medication pre- vs. changes of visceral fat after SG. post-operatively (pre-op 37%, post-op 32%, p=0.233). The percent of patients Methods satisfied with their condition post- A retrospective review of the SG operatively was significantly increased procedures between 2010 and 2017 was in those with pre-op GERD, older age, conducted. All the patients with a hiatal hernia repair intra-operatively, preoperative and postoperative CT scan and in those with the highest BWL. were included in the study. Abdominal CONCLUSIONS: 3D volumetric computerized Our results suggest that while overall, tomography (CT) measurement of LSG does not significantly affect visceral and subcutaneous abdominal GERD symptoms, patients without fat was performed. GERD pre-operatively may be at risk for developing new or worsening Results: GERD symptoms after LSG. Of the 1700 patients reviewed, 23 (1.35%) SG met inclusion criteria. There was a preponderance of female sex (n=1183,69.6%), with a mean age A289 of 54.02 +13.04 years. Diabetes Sleeve gastrectomy improves mellitus was present in 1256(73.9%) of abdominal fat on computerized patients. The preoperative CT was done tomography after surgery. 0.17 + 0.39 years before surgery, and Marco Castillo Rodriguez Miramar the postoperative one 1.54 + 1.02 years FL1, Mauricio Sarmiento- after surgery.The mean volume of Cobos Weston 1, Elliot Wasser Weston abdominal subcutaneous fat was 18,348 FL1, Rama Rao Ganga Columbia MO1, ml preoperative and 12,287ml Emanuele Menzo Weston FL1, Samuel postoperative (p = 0.001), with a Szomstein North Miami Beach FL1, decrease of 6,060.86 ml. The mean Raul Rosenthal miami FL2 total abdominal fat was 5,844.86ml Cleveland Clinic Florida1 Cleveland preoperative and 17,826 ml Clinic of FL2 postoperative (p = 0.002). The visceral fat improved from a mean of 5,844 ml Background to 5,538ml (p = 0.752) after sleeve The visceral fat in obese population is gastrectomy. Glucose and lipid linked to insulin resistance and metabolisms improved postoperatively. metabolic syndrome. Sleeve gastrectomy (SG) is an effective

185 Conclusions: 2014 to 2017. Patients were Sleeve gastrectomy decreases total randomized using their hospital abdominal fat and subcutaneous fat identification numbers. Patients in the postoperatively.. In spite of a not intervention group received significant change in visceral fat after bioabsorable reinforcement along the sleeve gastrectomy, patients presented entire staple line. All patients improvement of cholesterol values and underwent a postoperative gastrograffin insulin resistance swallow to assess for leak. Patient notes were reviewed and any incidence of staple line leak or haemorrhage was A290 recorded. Bioabsorbable staple line Results: reinforcement in laparoscopic sleeve Of the 462 patients who underwent gastrectomy in the prevention of LSG, 204 (44%) received no post-operative haemorrhage and reinforcement whilst 258 (56%) staple line leak – Does it make a patients received bioabsorbable difference? reinforcement. Of the entire population, Sabin Warner-Smith Pimlico 9 patients experienced a staple line leak Mater Hospital (2%) and 3 suffered post-operative haemorrrhage (0.6%). Of the patients Introduction: with staple line leak, 4 received Staple line leak and haemorrhage bioabsorable staple line reinforcement remain two important complications compared with 5 who had no post laparoscopic sleeve gastrectomy reinforcement. All patients with (LSG). Currently, evidence suggests postoperative haemorrhage had no staple line reinforcement reduces the staple line reinforcement, however this incidence of postoperative was found to not be statistically haemorrahge and staple line leak. significant. However, there is no consensus to the Conclusion: best method for staple line Overall, we found no statistical reinforcement. The purpose of this difference in the incidence of study was to evaluate the effectiveness postoperative staple line leak or of bioabsorbable staple line haemorrhage in patients receiving reinforcement in preventing staple line bioabsorbable staple line reinforcement leak or haemorrhage in patients compared with no reinforcement. undergoing LSG. Method: A retrospective analysis was undertaken incorporating 462 patients A291 with a BMI>30 who underwent LSG at Comparison between endoscopic and an Australian surgical centre between laparoscopic evaluation of hiatus

186 www.obesityweek.com hernia in patients undergoing weight endoscopy and laparoscopy. Of the 406 loss surgery patients with no evidence of HH on Sabin Warner-Smith Pimlico endoscopy, 72 had a HH seen during Mater Hospital laparoscopy (specificity = 87.2%, negative predictive value 82.3%). Of Introduction: the 108 patients with HH seen on upper endoscopy, 59 had corresponding Currently, the advantages of pre- findings on laparoscopy (sensitivity operative upper endoscopy in patients 45%, positive predictive value 54.6%). undergoing weight loss surgery remains controversial. Data suggests that Conclusion: patients with obesity have a high incidence of gastro-oesophageal reflux, Overall, we found upper endoscopy to oesophagitis and hiatus hernia (HH). have a higher specificity and negative Upper endoscopy findings may play an predictive value than sensitivity and important role in operative planning. positive predictive value in the Currently, little evidence exists evaluation of hiatus hernia compared regarding the diagnostic sensitivity of with laparoscopic findings. upper endoscopy in detecting hiatus hernia.

Method: A292 The Effects of Aprepitant on A retrospective analysis was Postoperative Nausea and Vomiting undertaken incorporating 514 patients with Bariatric Surgery with a BMI>30 who underwent weight Ciara Lopez Windermere FL1, Dennis loss surgery at an Australian surgical Smith Celebration FL1, Sharon centre between 2014 to 2017. All Krzyzanowski Harmony FL1, Keith patients underwent upper Kim Celebration FL1, cynthia gastrointestinal endoscopy as part of buffington Celebration FL1 their preoperative workup. Endoscopic Florida Hospital Celebration health1 reports were reviewed and compared with laparoscopic findings for each Introduction. Postoperative nausea patient to determine the sensitivity of and vomiting (PONV) following endoscopy in detecting HH. bariatric surgeries may hinder recovery and extend the length of hospital stay Results: (LOS). In this study, we examine the effects of aprepitant on: 1) the Of the 514 patients who underwent incidence and severity of PONV and 2) weight loss surgery, 334 had no LOS and associated costs. evidence of HH on both upper Methods. The study population

187 involved 135 bariatric patients (15 DS, A293 60 RYGB, 60 LSG), half of whom An Aggressive Program for received an oral dose of aprepitant (80 Prevention of Nutrient Deficiencies mg) two hours preoperatively. All with the Duodenal Switch patients were on an antiemetic protocol Dennis Smith Celebration FL1, Ciara consisting of 10 mg IV Dexamethasone Lopez Windermere FL1, Lauren (during and 8 hours following surgery) Lapp Celebration FL1, cynthia and 4 mg ondansetron administered buffington Celebration FL1 prior to admission to the post- Florida Hospital Celebration Health1 anesthesia care unit (PACU). PONV incidence and severity were determined Introduction. The duodenal switch by the need for antiemetic rescue (DS) is a malabsorptive surgery that medications in the PACU and on the increases the risk for nutrient hospital unit. deficiencies. In this study, we examine Results. Aprepitant did not influence the effectiveness of an aggressive the incidence of PONV early program for prevention and treatment postoperatively (PACU) but did of early DS micronutrient deficiencies. improve PONV following discharge Methods. DS patients were advised to from PACU to the hospital unit. With take daily multivitamin/mineral aprepitant, fewer patients experienced (MVM) supplements at amounts  severe PONV (4 rescue medications) those recommended by ASMBS and a greater percentage had no PONV Guidelines (2016). Vitamin and (59% vs. 40% aprepitant vs. non- mineral levels were closely monitored aprepitant, 2 p0.05). The number of at 3, 6 and 12 months post-surgery and PONV rescue medications while on the supplement intakes adjusted to treat unit averaged 1.13 with aprepitant vs. low and deficient nutrients. 1.86 without. Patients’ self-reported Results. Nearly all micronutrients perceptions of PONV severity were declined early post-surgery (3, 6 also significantly (2 p=0.02) less with months) despite 96% MVM aprepitant. Along with improvement compliance at daily intakes  ASMBS in PONV, LOS declined with recommendations. With early aprepitant, i.e. 1.56 vs. 1.85 days laboratory assessment and (p=0.01), for a cost savings of supplementation adjustment, most $172.18/person. micronutrients returned to, or toward, Conclusion. Aprepitant added to an baseline values by one year antiemetic prophylactic regimen postoperatively. Deficiency rates at improves PONV and significantly one year were 0% for ferritin, iron, reduces the duration of the hospital selenium, Vitamin A, Vitamin K, stay. Vitamin B12, and only one case each for vitamins B1 and folate. In contrast, copper and zinc levels declined

188 www.obesityweek.com progressively, with deficiency rates of 25% and 35%, respectively, at 12 METHODS: All primary BS patients months. Vitamin D improved at 3 and were reviewed between 2014-2016 at a 6 months but returned to preoperative single institution (n=589). values and preoperative deficiency and Demographic, surgical, and psychiatric insufficiency rates, 9% and 41%, data (depression, anxiety and/or bipolar respectively. Serum calcium levels, diagnoses (DAB), binge eating scale although within the normal range, (BES), three factor eating questionnaire declined progressively and PTH (TFEQ), and Shipley-2) were obtained increased (30% elevated). through chart review. Readmissions Conclusions. Patient compliance to were documented within 30-days of recommended supplementation coupled discharge (30-R), prior to the first post- with MVM adjustment is effective in operative clinic visit (PC-R), and for the prevention of most, but not all, non-urgent causes early DS nutrient deficiencies. More (nausea/vomiting/pain) (NU-R). Six frequent monitoring and an even closer and 12-month weight-loss was reported surveillance of specific as %excess body weight-loss vitamin/minerals is necessary to reduce (%EBWL). the risk for nutrient complications. RESULTS: The incidence of DAB was 56% (n=326) in this cohort. Compared to controls, DAB patients had higher A294 30-R (9% vs 4%, p=0.02) and trended Psychometric Measures Associated towards increased PC-R (8% vs 4%, with Clinical Outcomes after p=0.06) and NU-R (62% vs 30%, Bariatric Surgery p=0.14). Patients at highest risk for Anahita Jalilvand Hilliard OH1, Jane binge eating (BES-2) trended towards Dewire Columbus OH2, Andrew higher 30-R (17% vs 6%, p=0.11), PC- Detty Columbus OH2, Bradley R (11% vs 5%, p=0.2), and NU-R Needleman Columbus OH2, Sabrena (100% vs 50%, p=0.2) compared to Noria Columbus OH2 lower BES scores. TFEQ and Shipley-2 The Ohio State Wexner Medical were not associated with early College1 The Ohio State Wexner readmissions. Compared to low scores, Medical Center2 BES-2 was associated with higher 6 and 12-month %EBWL for sleeve INTRODUCTION: Psychiatric gastrectomy patients (51% vs 38% p = evaluations prior to bariatric surgery 0.02; 63% vs 41%, p=0.06). TFEQ, (BS) vary by institution. This study Shipley-2, and DAB were not evaluates the association between associated with any %EBWL. psychometric factors, readmission rates, and weight-loss after BS. CONCLUSION: DAB and high BES

189 were associated with early, non-urgent was also no difference in time to readmissions after BS. While no postsurgical presentation to the ED psychometric factor was associated (15.3 vs. 13.7 days). The most common with decreasing %EBWL, patients at reason for presentation in both groups highest risk for binge eating had was “symptoms without a diagnosis,” increased weight loss. with nausea, vomiting, and/or abdominal pain. Overall, the rate of ED visits was higher in gastric bypass A295 patients (14% vs. 8%, p=0.04), those Early Postoperative Visit with underlying GERD (13% vs 6%, Intervention to Reduce ED Visits p<0.0005), history of frequent ED after Bariatric Surgery visits (53% vs. 9%, p<0.0001), and Wendy Miller Royal Oak MI1, Kerstyn those requiring outpatient IV fluids Zalesin Birmingham MI1, Montgomery following discharge (25% vs. 5%, Wendy 1, Kathryn Ziegler Royal Oak p<0.0001). MI1 Conclusion: Earlier postoperative William Beaumont Hospital1 outpatient visits did not result in a significant reduction in 30-day ED Background: In order to reduce visits. Focusing more efforts on postoperative emergency department patients with history of GERD, history (ED) visits within 30 days post- of frequent ED visits prior to surgery, bariatric surgery, we added an earlier and dehydration requiring outpatient IV visit with our Weight Control Center hydration may decrease early post- physician and dietitian. In January bariatric surgery ED visits. 2016, we included visits at postoperative day 5 (early), as opposed to the first visit at postoperative day 10 (standard). Methods: Preoperative, perioperative, A296 and postoperative data were collected Incidence and Management of prospectively from September 2014- Gastric Stenosis after Laparoscopic December 2015, and January 2016- Sleeve Gastrectomy: A Single April 2017. Patients presenting to the Institution Experience. ED in each time period were compared Maria Fonseca Mora Weston FL1, to patients not presenting to the ED. Cristian Milla Matute Davie FL1, David Results: 475 patients with standard Gutierrez Blanco Weston FL1, visits were compared with 440 patients Emanuele Menzo Weston FL1, Samuel with early visits (9.2 vs. 4.9 days, Szomstein North Miami Beach FL1, p=<0.0001). There was no difference Raul Rosenthal miami FL2 between the groups in the rate of ED Cleveland Clinic Florida1 Cleveland visits, 9.9% vs. 9.1% (p=0.7). There Clinic of FL2

190 www.obesityweek.com balloon. Among those, 33.3%(n=2) underwent RNYGB, of whom 6.7%(1) BACKGROUND: previously had myotomy. Of the 10 Gastric Stenosis (GS) has a reported patients, 80% were successfully incidence of 4% after Laparoscopic managed by EGD and 100% recovered sleeve gastrectomy (LSG). The successfully. objective of this study is to describe incidence and management of GS after CONCLUSION: LSG at our institution. METHODS: In this study, the incidence of GS after We retrospectively queried our LSG was very low. Endoscopic balloon prospectively maintained database for dilation is an effective treatment GS after LSG, between January 2005 method for GS. Non-responders benefit and March 2018. We included all from conversion to RYGB. patients requiring intervention for symptoms of GS, whereas patients who recovered without any intervention where excluded. Statistical analysis of A297 Categorical and nominal variables was A step in the right direction: trends conducted with Chi-square and over time in bariatric procedures for Independent T-test respectively. patients with GERD RESULTS: Zaina Naeem Stony Brook NY1, Jie Yang STONY BROOK NY2, Jihye A total of 1,878 patients underwent Park Stony Brook NY2, Andrew LSG. Post-operatively 10 patients Bates Locust Valley NY1, Salvatore underwent management for GS; among Docimo Stony Brook NY1, Aurora those, 6(60%) had LSG at our Pryor Stony Brook NY1, Konstantinos institution and 4(40%) at other Spaniolas Stony Brook NY1 hospitals. Our LSG GS stenosis rate Stony Brook University School of was 0.31%(n=6). The mean time of Medicine1 Stony Brook University2 diagnosis was 6.67±9.1 months, as one patient was diagnosed 24 months Introduction: While sleeve postoperatively. GS was located in the gastrectomy (SG) has increased in distal 2/3 of the sleeve in 83.3%(n=5) popularity compared to gastric bypass of patients. Among 6 patients, the (RYGB), even for the subset of patients endoscopic dilatations required was with GERD, recent literature suggests 2.17 ± 0.75, a 10 mm and 12 mm TTS that RYGB may be more effective in balloon was used in 50% of patients alleviating GERD symptoms and during first and second attempt normalizing gastroesophageal respectively, in the third attempt physiology. This study explored 2(33.3%) patients required a 12mm practice patterns over time for patients

191 with GERD undergoing bariatric reflective of recent literature. Despite surgery. this improvement, a significant discrepancy persists in hiatal hernia Methods: Data for SG and RYGB management per bariatric procedure were extracted from the Metabolic and type. Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) datasets for 2015 and A298 2016. Multivariable logistic regression Personalized medicine for outcomes analyses were performed to determine and expectations following bariatric effects of pre-existing GERD on the surgery: using bioelectric impedance choice of surgery type, as well as the technology to build prediction association between hiatal hernia repair models in the bariatric patient (HHR) and surgery type. population Erika La Vella Corvallis OR1, Kirsti Results: 130,772 patients underwent Troyer Corvallis OR1, Olivia RYGB (30.5%) or SG (69.5%) in 2015; Pipitone Corvallis OR1, Donald the number increased to 145,783 Yarbrough Corvallis OR2 patients in 2016 (72.85% SG). 37.8% Samaritan Health Services1 Western of RYGB patients had pre-existing University-COMPNW2 GERD compared to 28.4% of SG patients. Patients with pre-existing Background: The pattern and GERD were significantly more likely composition of weight loss following to undergo RYGB compared to those bariatric surgery is variable and without pre-operative GERD in 2015 patients compare themselves to others (OR=1.21, 95% CI 1.17-1.24); this in their cohort to gauge their success. likelihood strengthened in 2016 We developed an algorithm using (OR=1.31, 95% CI 1.27-1.34) bioelectric impedance (BIA) (p<0.0001). Concomitant HHR was technology to determine the less common amongst RYGB patients; composition of weight loss. this was more pronounced over time Methods: Anthropometric (OR=0.43, 95% CI 0.42-0.45 for 2015; measurements were performed on 290 OR=0.4, 95% CI 0.39-0.42 for 2016, persons with obesity (249 female and p=0.0032 for between-year 41 male) ages 18-72 between May comparison). 2015 and December 2017. BIA was performed with the SECA mBCA Discussion: Even though SG preoperatively and regular intervals predominates the bariatric surgery postoperatively. BMI, FFMI (fat-free practice nationally, patients with pre- mass/height squared) and FMI (fat- existing GERD are increasingly likely mass/height squared) were calculated. to undergo RYGB, a trend which is Linear regression models were created

192 www.obesityweek.com to predict post-operative BMI, FMI, conglomeration of risk factors and FFMI values based on baseline associated with obesity and measurements, age (<50 or 50+), sex, cardiovascular disease. Bariatric diabetes, and surgery (sleeve or gastric surgery is an effective treatment for bypass). obesity and its comorbidities. The aim Results: Adjusted R-squared values of this study is to evaluate the ranging from .60 to .64 and plots of remission rates of metabolic syndrome actual vs fitted values indicate after bariatric surgery. appropriate model fit. Model predictions were run for each possible METHODS: combination of demographic and We retrospectively studied our bariatric baseline characteristics. These population between 2005 and 2018. We predictions can now be used by analyzed patients who met the WHO providers with minimal effort within Criteria for MS and determined the patient encounters to discuss expected effects of bariatric surgery at 12 months outcomes post operatively. on MS and its individual components. Conclusion: BIA is a useful and SPSS software was used to apply t-test convenient method of measuring body for means. composition in obese persons. Regression models can provide a better RESULTS: understanding of postoperative Among the 1785 number of patients outcomes and can aid in personalizing reviewed, 1491(83.5%) met WHO weight loss expectations. criteria for MS. Predominant procedure was LSG 62.9%(N=939), RYGB 22 %(N: 331), and gastric band(LAGB) conversions 14 %(N: 221). Mean BMI A299 before surgery was 47±15.8 kg/m2. In Metabolic Syndrome Remission after post RNYGB patients, including Bariatric Surgery: A Single conversions from LAGB, mean BMI Institution Experience. preoperatively was 44.8±10kg/m2 Cristian Milla Matute Davie FL1, Maria versus postoperatively 31.5±5kg/m2 Fonseca Mora Weston FL1, David (P< 0.0001), preoperative glycemia Gutierrez Blanco Weston FL1, 152.5±49mg/dL versus postoperative Emanuele Menzo Weston FL1, Samuel 102±23(P<0.0001), preoperative Szomstein North Miami Beach FL1, triglycerides 176±66 versus Raul Rosenthal miami FL2 postoperative 102.7±33(P<0.0001), Cleveland Clinic Florida1 Cleveland preoperative HDL 37.7±11 versus Clinic of FL2 postoperative 57±12(P<0.0001) and MS remission rate at 12 months of INTRODUCTION: 29%. In the post LSG patients, Metabolic syndrome (MS) is a including conversions from LAGB,

193 mean BMI preoperative was OSA in patients with obesity. 48.2±17kg/m2 versus postoperative Method: 32.1±14kg/m2(P< 0.0001), A retrospective analysis was preoperative glycemia 149±45mg/dL undertaken incorporating 527 patients versus postoperative 101±16mg/dL with a BMI>30 who had undergone (P<0.0001), preoperative triglycerides sleeve gastrectomy or gastric banding 176±69mg/dL versus postoperative at an Australian surgical centre 105±37mg/dL(P<0.0001), preoperative between 2014 to 2017. All patients HDL 38.8±12mg/dL versus underwent a preoperative sleep study. postoperative 57±10mg/dL(

194 www.obesityweek.com A301 7.07).After ten years 17 intractable bile Potential Bile reflux ten years after reflux (1.1%) had to be converted into One Anastomosis Gastric Bypass : RYGB, mean EWL was 76.5 % ±12.3. low incidence in clinical and In the experimental study, weight loss experimental data . was significant, mean bile acid JEAN MARC CHEVALLIER PARIS 1, concentration was 4.2 times higher in Matthieu BRUZZI Paris Paris 151, the esogastric segments of OAGB rats. Tigran POGHOSYAN Paris 1, Richard qRT-PCR analysis showed no DOUARD Paris 1 differences between OAGB and sham Hopital Européen Georges Pompidou1 mRNA levels of Barrett’s esophagus or esogastric carcinogenic-specific One anastomosis Gastric Bypass genes. (OAGB) is a safe and efficient bariatric The rate of intractable bile reflux procedure but there is still a after OAGB is low and OAGB rats had controversy on the potential bile reflux not developed any pre-cancerous or risk. In our University Hospital cancerous lesions after 16 weeks. performing bariatric surgery since twenty five years we collected clinical and experimental data: patients after 10 years and experimental data on rats A302 exposed to prolonged bile reflux. Changes in HOMA-IR Index After From October 2006 to December Bariatric Surgery: Comparison of 2017, 1585 patients underwent OAGB: SADS-p and MGB-OAGB a long and narrow gastric tube Mahir Ozmen Ankara 1, Emir calibrated on a 32 Fr bougie; with a GULDOGAN Ankara 2, Emre linear stapled gastroenterostomy 150 Gündodu ankara 2 cm to 200 cm down from the Treitz Istinye University Medical Ligament. Complete follow-up was School1 Istinye University2 available in 64/106 at ten years. Diet- induced obese rats were subjected to Backround and Aim: Bariatric surgery OAGB (n=10) or sham (n=4) surgery plays a major role to ameliorate and followed up to 16 weeks metabolic abnormalities of type 2 (equivalent to 16 years in humans). diabetes. The aim of study was to Evolution of weight, glucose tolerance, evaluate the early effects of “Single Bile acid concentration measurement, Anastomosis Duodenal Switch- histological and qRT-PCR analysis proximal approach” (SADS-p) and were studied. “Mini Gastric Bypass” (MGB-OAGB) There were 999 women (63%).Mean on the “homeostasis model assessment age was 43.5 years (15.5-62.4). Mean of insulin resistance” (HOMA-IR) preoperative weight was 131.9 kg ± index levels in morbidly obese patients 23.9, mean BMI 47.03 kg/m2 (± with type 2 diabetes mellitus (T2DM).

195 Jane Cauley Rockwall TX1, Nicole Methods: 260(37M) patients with Forryan Denton TX2, sharon median (range) BMI of 48(35- hillgartner Flower Mound TX3, Jennifer 73)kg/m2 who underwent surgery for Peterson 4, Tiffany Norris Fort Worth morbid obesity were included in the TX5, Katherine Wardlaw Bedford TX6, study. All procedures were performed Toya White Dalas TX7 by same surgeon either Texas Health Presbyterian laparoscopically or robotically. Groups Rockwall1 Texas Health Presbyterian were compared by changes of HOMA- Denton2 Texas Health Presbeterian IR index levels. Patients were evaluated Flower Mound3 Texas Health before surgery and 1, 3, 9, 12 months Presbyterian Plano4 Texas Health after surgery. Harris Methodist Ft. Worth5 Texas Results: SADS-p was performed in Health Harris Methodist H.E.B.6 Texas 60(10M) patients and remaining Health Presbyterian Dallas7 200(27M) patients underwent MGB- OAGB. 46(77%) patients in SADS-p Background: Bariatric surgery group and 125 (63%) patients in MGB program leaders from a large hospital group had T2DM. Both procedures had system identified near misses/injuries effective excess weight loss in one to the post-bariatric surgery patient year(76% after SADI-s and 69% after while receiving care outside the MGB).In both groups, HOMA-IR specialty of bariatric surgery. It index levels decreased significantly became evident bedside caregivers and after surgery (p<0.05) and both providers often lacked general procedures markedly improved knowledge of specific tests or glycemic control. All patients with provisions of certain treatment T2DM have normalized HOMA-IR modalities which can cause injury or index levels latest at the 9th delay diagnosis/treatment for post- postoperative month with both bariatric surgery patients. procedures. Objective: The purpose of the project Conclusion: Both procedures are is to promote safety by identifying all promising as they offer not only post-bariatric surgery patients, effective weight loss but also excellent regardless of facility or admitting glisemic control. diagnosis, and provide basic recommendations specific to this patient population. Method: An interdisciplinary approach A303 was implemented to develop an alert Promoting safety through banner to populate in the Electronic technology: Implementation of EHR Health Record (EHR) when bariatric "Bariatric Banner" Alert surgery history is documented. Team members represented: Information

196 www.obesityweek.com Technology (IT), Pharmacy, Hackensack University Medical Radiology, Nursing, Nutrition and Center1 Medical Staff, and sponsored by facility Executive Leadership. Nationally, long-term and short-term Results: The system-wide EHR patient follow up after bariatric surgery features a clickable “Bariatric is exceedingly low. Per ASMBS Precautions” banner alerting all guidelines, routine follow-up should be caregivers/providers of the patient’s at month 1, 3, 6, 12 and yearly bariatric surgery history and approved thereafter. recommendations for pharmaceutical, We created a mathematical model of radiology, nursing, nutritional and the expected growth in office visits per general care. At the facility level, month if 100% compliance with screenable reports are generated by the ASMBS follow-up guidelines is EHR listing all current patients with a achieved. documented history of bariatric In Figure 1, we extrapolate to 6 years surgery. the increase in office visits of a Conclusion: Bedside caregivers and bariatric practice that operates on 15 providers report the alert banner has patients per month, or 180 cases per heightened awareness of safety needs year. We assume no increase in case specific to the post-bariatric surgery volume. The practice will be seeing 60 population; knowledge gaps are easier patients per month by the end of Year 1 to identify by bariatric specialists, and 135 patients per month by the end which are addressed of Year 6. expeditiously. Most importantly, the In Figure 2, the model allows for alert banner has promoted modest growth per year of 5 monthly conversation, awareness and cases. This results in a volume increase accountability of those providing of 60 additional cases each year. By the healthcare within the system, end of Year 6, the total case volume promoting safety and improving will be 480 annually and monthly outcomes. patient visits will have increased to 285. Our model shows significant increases A304 in monthly office visits to growing Mathematical Model for Predicting bariatric surgery practices as they strive the Increase in Office Visits Realized to meet 100% ASMBS follow-up after Bariatric Surgery when 100% guidelines. Our model does not factor Compliance with ASMBS Post- in the extensive pre-operative screening Operative Follow-Up Guidelines is process and often low conversion rate, Achieved which only further taxes resources and Amit Trivedi Paramus NJ1, Sarah potentially limits growth. Wong Hackensack NJ1 Alternative screening and follow-up

197 options need to be further developed. year) with BAC blood test at Shifting the pre-operative workup and 0,15,30,60,90 minutes after the post-operative follow-up to dedicated administration of a standard alcoholic teams exclusively focused on bariatric drink (red wine-14%). Standard drink care may decrease the burden on was established based on the total growing bariatric practices and increase amount of water. An urine sample was ASMBS compliance rate. also collected after the drink intake to evaluate the alcohol metabolism.Symptoms were evaluated A305 with a personal score looking at Alcohol after laparoscopic sleeve euphoria, anxiety, sweating, gastrectomy: high blood ethanol level nausea/vomiting and facial skin or fast metabolism? flushing. Angelo Iossa Latina 1, Maria Chiara Results: Post-operative BAC peak Ciccioriccio Rome 2, Anna increased faster (p<0.01) but the BAC Guida Latina 2, Gianfranco peak wasn't significant different with Silecchia Rome 2 the pre-operative levels (p=0.9). After University of Rome1 University of 90 minutes the BAC return to 0 pre and Rome "La Sapienza"2 post-operatively. Regarding the symptoms we registered an high level Background: Several questions of nausea/vomiting,skin flushing and remains unresolved about the post- sweating in the post-operative period operative impact of single bariatric (p<0.01). The urine analysis showed a procedures on alcohol metabolism and 2-fold higher level of acetaldehyde effects. While is largerly established (p<0.01) that bypass surgery causes an Conclusions: LSG change the heightened peak blood alcohol metabolism of alcohol in terms of concentration (BAC), results on the amount of volume fastest metabolized effects of LSG on alcohol by the liver (fast gastric emptying) and pharmacokinetics are conflicting. We the "drunk" symptoms are related to reports our metabolic study on alcohol alcohol toxicity. effect at 1 year after LSG. Methods:Exclusion criteria were: alcohol use disorders (AUD) or A306 teetotalers (evaluated with AUDIT Self-compassion as a protective test), decompensated type II diabetes, pathway in the link between mental chronic liver pathology, previous health symptoms and emotional gastric or intestinal resective surgery. eating in a pre-bariatric sample Twenty-five patients (18 female/7 Tosca Braun 1, Andrea male) were prospectively enrolled and Stone Glastonbury CT2, Jennifer evaluated pre- and post-operatively (1 Ferrand Hartford CT3, Amy

198 www.obesityweek.com Gorin Storrs CT1, Diane Quinn Storrs (=.27, p<.001) and depressive CT1, Rebecca Puhl Hartford CT1, Gina symptoms (=.27, p<.001) on Sensale 1, Darren Tishler Glastonbury emotional eating were significant. With CT2, Pavlos Papasavas Hartford CT2 self-compassion, the direct effect of University of Connecticut1 Hartford anxiety (=.10, p=.175) and depressive Hospital2 Hartford Hospital, Institute of symptoms (=.11, p=.120) on Living3 emotional eating became non- significant, indicating full mediation. Introduction: Attempts to regulate Bootstrapping results estimated indirect negative affect (e.g., anxiety, effects of anxiety (=.27, 95% CI [.12, depression) through emotional eating .41]) and depression (=.16, 95% CI have been implicated as risk factors for [.09, .41]) on less emotional eating post-operative weight regain. through self-compassion. Identifying protective factors that disrupt this pathway might inform Discussion: Self-compassion appears psychosocial interventions. The current to protect against the association of study tested whether self-compassion, depressive/anxiety symptoms with an affect regulation strategy linked to emotional eating in bariatric surgery psychosocial and behavioral health, candidates. Future research mediates the association between incorporating causal/longitudinal depressive/anxiety symptoms and designs should examine whether self- emotional eating. compassion is a modifiable protective factor that can disrupt the link between Method: Bariatric surgery candidates psychopathology and maladaptive (BSC) recruited from a clinic (N = 152, eating behaviors. 61.4% women, 62.8% White, 43 ±12 years, mean BMI: 49±9kg/m2) completed the Generalized Anxiety Scale-7 (GAD-7), Beck Depression A307 Inventory-2 (BDI-2), Emotional Eating Effects of increased intra-abdominal subscale of the TFEQ-R18 (EE), and and thoracic pressure in vasopressin Self-Compassion Scale (SCS) pre- release and kidney Function during surgery. PROCESS bootstrapping Laparoscopic Sleeve Gastrectomy estimates tested our hypothesis that David Romero Funes Weston FL1, depressive/anxiety symptoms -> self- David Gutierrez Blanco Weston FL1, compassion -> emotional eating after Giulio Giambartolomei Weston 1, controlling for sex, age, ethnicity, race, Lisandro Montorfano Weston Florida1, and insurance (Medicaid/Medicare vs. Emanuele Menzo Weston FL1, Samuel private) as proxy of SES. Szomstein North Miami Beach FL1, Fernando Dip Weston Florida1, Raul Results: Total effects of anxiety Rosenthal miami FL2

199 Cleveland Clinic Florida1 Cleveland remained high. Clinic of FL2 Consequently, urine output showed a considerable and sustained decrease at Background Pneumoperitoneum and at the end of There is no data describing the surgery when compared to pathophysiological changes of intra- baseline. Data are presented in Table abdominal pressure (IAP) and 1. intrathoracic pressure (ITP) on Conclusion vasopressin and kidney function. The Increase IAP and ITP demonstrate a aim of this study is to describe this significant effect on vasopressin release relationship through a controlled and urine output. Our finds suggest that elevation in IAP and ITP (PEEP) while IAP and ITP may affect the kidney concurrently assessing vasopressin and function and urinary output through its urine output during Laparoscopic effect on vasopressin. sleeve gastrectomy(LSG). Methods After IRB approval, a prospective A308 observational study involving patients Management of Gastro-Gastric undergoing elective LSG was Fistulas in Post-Reux-en-Y Gastric conducted. The Measured variables Bypass Patients were: serum and urine osmolality, Gerardo Davalos durham NC1, Alfredo serum vasopressin, and urine output. Guerron durhjam nc1, Dana All measurements were collected at Portenier Durham NC1 baseline, right after the establishment Duke health1 of pneumoperitoneum (15 mmHg), positive end-expiratory pressure(PEEP) of 10 mmHg, and at the end of the Background: Gastro-gastric fistula procedure. (GGF), a communication between the Results gastric pouch and gastric remnant, is a A total of 10 patients were enrolled at rare but important complication of the time of the analysis. Our patient Roux-en-Y gastric bypass (RYGB) that population was predominantly white can lead to weight gain and marginal females(n=7)70%, mean age of ulcers. Multiple approaches have been 44.66±12.24, pre-operative BMI of developed to manage this infrequent 40.82±4.11 kg/m2. Serum Vasopressin complication, however, few studies was 40 fold higher than baseline when provide guidelines that show what is measured during pneumoperitoneum the best way and moment to use them. and 55%(n=5) of our patients had a vasopressin level >65pg/mL when Methods: in this video compilation we measured at an elevated PEEP. At the present 3 different options to manage end of the procedure, the vasopressin gastro-gastric fistulas after Roux-en-Y

200 www.obesityweek.com bypass and how and when they are best gastrectomy over a 50 Fr bougie, 250 used. The first case describes fistula cm distal ileum alimentary channel closure endoscopically using an sutured to the gastric antrum with a 100 endosuture device. The second case cm common channel. Unlike the BPD- describes a trans-gastric approach using DS, the duodenum was not transected percutaneous ports and an endosuture to allow the food to pass through the device. The third case describes an 250 cm alimentary limb or the rest of operative technique using a stapler the small bowel. 9-month follow-up device. was available for 24 of the TBPs and 62 of the BPD-DS. Although not Conclusion: gastro-gastric fistulas are heavier BPD-DS patients had a higher an uncommon but well-recognized BMI. The main difference concerned complication following Roux-en- the side effects with 50% and 78% of Y gastric bypass. Endoscopic, trans- the TBP patients having 1 and 2 bowel gastric and operative approaches, when movements respectively. After BPD- used appropriately, help solve some of DS these figures were 10% and 32%. the challenges attached to this problem While no TBP patient had an albumin < and improve patient outcomes. 35 g/L, this occured for 12 of the 62 BPD-DS and 55% of the BPD-DS had a prealbumin below the normal value of 200 mg/L while this was observed in A309 13% of the 23 TBPs. 6 BPD-DS COMPARATIVE RESULTS OF patients had a surgical BILIOPANCREATIC DIVERSION revision/correction because of protein WITH DUODENAL SWITCH AND manutrition. In patients with BMI  50, TRANSIT BIPARTITION IN THE transit bipartition is a quicker TREATMENT OF procedure without an impact on the SUPEROBESITY complication rate. The most benefits Philippe Topart Angers 1, Guillaume appear to be on side effects and Becouarn Angers CEDEX 011 malnutrition. Clinique de l'Anjou1

Transit bipartition (TBP) was compared A310 with biliopancreatic diversion with TWO YEARS HEALTH RELATED duodenal switch (BPD-DS) it replaced QUALITY OF LIFE IN GASTRIC early 2017 for patients whose initial SLEEVE PATIENTS body mass index (BMI) was  50 Valerie Monpellier Huis ter Heide 1, kg/m2. Sixty three consecutive primary Vera Voorwinde Den Haag 1, Luella BPT were compared to the 63 most Smith Amsterdam 2, Maartje Straalen 3, recent primary BPD-DS. TBP used the Ignace Janssen heteren 4 same landmarks as BPD-DS : sleeve

201 Nederlandse Obesitas Kliniek1 Vu follow-up (p<0.001) except the University, Faculty of Science2 Vu “emotional role functioning” subscale University, Faculty of at 24 months (p=0.07). All IWQOL-lite Science,3 Nederlandse Obesitas scales significantly improvement from Kliniek, QURO4 BL to 15 and 24 month follow-up (p<0.001 in all). From 15 months to 24 Background: months follow-up RAND-36 scores The gastric sleeve (GS) is currently the decreased significantly for social most popular type of bariatric surgery. functioning, vitality, mental health and Complication-rate, weight loss and health change scale (p0.005 in all). effect on comorbidities have been IWQOL-lite scores did not significantly frequently studied and show promising change between 15 ad 24 month results. Health related quality of life follow-up. (HRQoL) is also one of the key outcomes after bariatric surgery, but Conclusion has been sparsely studied in GS HRQoL significantly improves after patients. GS. After 15 months, when weight stabilises, HRQoL also stabilizes and Objective: even decreases in some subscales. To study the change in HRQoL after HRQoL after GS should be considered GS using an obesity specific and a in surgical decision making. generic HRQoL questionnaire.

Methods Patients who underwent a GS in 2012 A311 and 2013 were selected from a Risk factors of intraoperative prospective database if? HRQoL difficulties during Laparoscopic assessment was available (n=203). Sleeve Gastrectomy HRQoL was assessed before surgery Tomasz Stefura Kraków 1, Magdalena and 15 and 24 months after surgery Pisarska Kraków 2, Michal with the RAND-36 (generic Wysocki Kraków 3, Michal questionnaire) and IWQOL-lite Pedziwiatr Kraków 3, Piotr (obesity-specific questionnaire). Malczak Kraków 3, Marcin Dembinski Krakow 2, Jakub Results Dros Krakow 1, Artur Mean BMI before surgery was 48.0, Kacprzyk Krakow 1, Katarzyna Total weight loss was 30.3% at 15 Chlopas Krakow 1, Andrzej months and 29.5% at 24 months. All Budzynski Kraków 3, Piotr RAND-36 scores significantly Major Poland 3 improved from BL to 15 months Jagiellonian University Medical (p<0.001 in all) and to 24 months College, Students’ Scientific Group at

202 www.obesityweek.com 2nd Department of General affecting intraoperative difficulties Surgery1 Jagiellonian University included BMI >45 kg/m2 (OR 2.15, Medical College, 2nd Department of 95% CI 1.05-4.39, p=0.0362), General Surgery2 1. Jagiellonian experience of operating surgeon (OR University Medical College, 2nd 9.22, 95% CI 4.31-19.72, p=0.0058), Department of General Surgery 2. incidence of diabetes (OR 2.44, 95% CI Center for Research, Training and 1.19-4.98, p=0.0146) or pulmonary Innovation in Surgery (CERTAIN disease (OR 12.22, 95% CI 1.97-75.75, Surgery)3 p<0.0001). In the multivariate logistic regression model only experience of Introduction: Laparoscopic Sleeve operating surgeon (OR 8.61, 95% CI Gastrectomy (LSG) is one of the most 3.75-19.72, p<0.0001) remained frequently performed bariatric significant factor affecting procedures worldwide. Preoperative intraoperative difficulties. knowledge concerning risk factors of Conclusions: The only significant potential intraoperative difficulties may factor contributing to the incidence of help to predict outcomes and influence intraoperative difficulties is the the operative approach. experience of the surgeon. Purpose: Our purpose was to identify potential risk factors of intraoperative difficulties during LSG. A312 Methods: The analysis included Redefining Staple Loading Pressures consecutive patients who underwent for Adequate Tissue Apposition in LSG between December 2009 and Laparoscopic Sleeve Gastrectomy April 2017. Patients with intraoperative Vikrom Dhar Cincinnati OH1, Eujin difficulties were submitted to Group 1, Yeo Cincinnati OH1, Tiffany patients without intraoperative Lee Cincinnati OH1, Jonathan difficulties to Group 2. Demographic Thompson Cincinnati OH1, Erica parameters were assessed for potential Langan Cincinnati OH, Caleb risk factors of intraoperative Hayward Blue Ash OH, Adam Dunki- difficulties. Length of stay (LOS) and Jacobs Cincinnati OH, Ben Thompson , complication rate were also analysed. Tayyab Diwan Cincinnati Ohio1 Results: Group 1 consisted of 37 University of Cincinnati1 (11.71%) and Group 2 of 279 (88.29%) patients. Besides rates of diabetes, Introduction: Stomach tissue pulmonary disease and sleep apnea, thickness (TT) and surgeon-selected which were higher in group 1, there closed staple height (CSH) are were no statistical differences between important factors in the formation of an the groups based on demographic adequate staple line during parameters. Univariate logistic laparoscopic sleeve gastrectomy (LSG). regression found that risk factors Staples need to have a CSH that is

203 appropriate for a given TT in order to used when developing new stapling avoid staple malformation that may devices. lead to leak or bleeding. Prior studies characterizing compressed stomach TT have used a loading pressure of A313 8g/mm2 to mimic stapling conditions. Where are sleeves performed? An We hypothesize that 8g/mm2 is an analysis of inpatient versus inadequate loading pressure for outpatient databases in a large state. measuring stomach TT. Benjamin Clapp El Paso TX1, Robert Jones El Paso TX2, Ellen Wicker El Methods: Excised stomach specimens paso TX2, Mallory Schenk El Paso TX2, from 39 consecutive patients Ira Swinney El Paso TX2, Elizabeth De undergoing LSG were collected. Staple La Rosa El Paso TX2, Alan Tyroch El line length, cartridge zone locations, Paso TX2 and TT at sequential compression Benjamin Clapp MD PA1 TTUHSC pressures were recorded. Median Paul Foster School of Medicine2 pressure to achieve CSH was evaluated and stomach TT maps at both Background: The sleeve gastrectomy 8g/mm2 and the median loading (SG) is the most common bariatric pressure were compared. surgery in the United States today. There is a trend towards doing Results: Median pressure to achieve SG as an outpatient procedure. This closed staple height was 15g/mm2. The can mean either in an ambulatory new tissue thickness map at setting, or as an outpatient at a larger 15g/mm2 produced mean TT of 1.9mm hospital. The designation "outpatient" at the antrum, 1.7mm at the body, and is essentially any patient without an 1.3mm at the fundus. Tissue thickness inpatient order.There remain safety at each of the 26 locations along the concerns regarding this operation in an staple line were significantly smaller at outpatient setting. Texas maintains the a pressure of 15g/mm2 when compared Texas Public Use Data File (PUDF) to at 8g/mm2. databases, both for inpatient and outpatient settings. This is a claims Conclusions: The median pressure based database with data on over required to compress stomach tissue to 700,000 patients per year. We used the obtain CSH was 15g/mm2. This was Texas Inpatient and Outpatient PUDF significantly greater than previously for 2016 to evaluate where SGs are reported data. Our results indicate that performed and what were the patient the use of smaller staple heights is characteristics. biomechanically acceptable in LSG and a higher loading pressure should be Methods: Both the Inpatient and Outpatient PUDF for 2016 were

204 www.obesityweek.com queried for patients undergoing Cedars-Sinai Medical Center1 UCLA SG. These populations were then Medical School2 examined for patient characteristics and the most common ICD-10 diagnosis Background: Gastroesophageal reflux codes. Patients under the age of 18 disease (GERD) can be exacerbated or were excluded. incited by VSG, potentially even leading to Barrett’s esophagus. There is Results: There were 16,855 SG limited data regarding the impact of performed in Texas in 2016. 5227 selective versus routine hiatal (31%) of these were performed under dissection and repair on GERD after outpatient status. The most common VSG. age range in both groups was 40-44 Methods: A retrospective, single- years. The most common ICD-10 code center analysis of patients undergoing in the inpatient group was E66.01 primary VSG for morbid obesity (morbid obesity), followed by I10 between 2015 and 2017. GERD was (essential hypertension), K21.9 evaluated by the GERD-HRQL (GERD), then E11.9 (diabetes questionnaire. mellitus). In the outpatient group the Results: We assessed 290 consecutive most common code was obesity patients (median age 43 years; 71% followed by K44.9 (diaphragmatic female). Among the 276 (95%) who hernia), then GERD and hypertension. underwent preoperative endoscopy, 39% were found to have a hiatal hernia. Conclusion: A third of SGs in Texas There were 246 (85%) who underwent are preformed under outpatient concurrent hiatal hernia repair. One status. Further study is needed to surgeon performed routine hiatal determine the safety of this practice. dissection in 97% of his cases, whereas the other three surgeons in the group performed selective dissection in 66% A314 of their cases. Baseline BMI, rate of Routine Hiatal Dissection and Repair preoperative endoscopy, and Does Not Improve Short-Term prevalence of hiatal hernia on Reflux After Vertical Sleeve endoscopy between the routine and Gastrectomy selective groups were statistically Mohan Mallipeddi Los Angeles CA1, similar. The median HRQL score for Emma Gillette Los Angeles CA2, the routine and selective groups Harveen Sekhon Brentwood CA2, preoperatively, 1 month postop, and 3 Desmond Huynh los angeles CA1, months postop were 4 vs 3, 2 vs 3, and Miguel Burch Los Angeles CA1, Scott 2 vs 2 (p=NS), respectively. At 3 Cunneen Los Angeles CA1, Edward months, 7 (4%) patients within the Phillips Los Angeles CA1, Daniel routine group and 6 (5%) in the Shouhed Los Angeles CA1 selective group had a HRQL score 

205 15. leakage of chyle into the peritoneum Conclusions: There is no difference in without obstruction of high flow reflux 3 months after VSG as measured venous and arterial vessels. by a validated questionnaire in patients undergoing routine versus selective concurrent hiatal hernia repair. A A316 properly designed randomized Intraoperative blood pressure controlled trial should be performed to lability in patients requiring blood assess the true value of hiatal transfusions after bariatric surgery interrogation during VSG. Lee Ying new haven CT1, Matthew Hubbard New Haven CT1, Saber Ghiassi Fairfield CT1, Kurt A315 Roberts New Haven CT1, Andrew Chylous Ascites Associated With Duffy New Haven CT1, Geoffrey Internal Hernia Following Roux-en-y Nadzam New Haven CT1 Gastric Bypass for Morbid Obesity Yale School of Medicine1 Ann Defnet New York NY1, Andrea Bedrosian New York NY, Marina Introduction: Postoperative hemorrhage Kurian New York NY requiring transfusion in patients with NYU Langone Health1 minimal operative blood loss is a rare, but frustrating, complication after We present a video outlining the bariatric surgery. In this retrospective interesting case of a 39 year-old female case control analysis, we determine with internal hernia at Peterson’s defect whether perioperative blood pressure after laparoscopic roux-en-y gastric lability, anticoagulantion or Ketorolac bypass for morbid obesity associated administration is associated with with the presence of chylous ascites. postoperative blood transfusion in Internal hernia is one of the most patients with minimal blood loss common complications after reported intraoperatively. laparoscopic roux-en-y gastric bypass, and its incidence has been found in the Methods: This is a retrospective case literature to be decreased with control study of patients who received antecolic/antegastric roux limb either a laparoscopic gastric bypass or positioning and closure of all sleeve gastrectomy at an academic mesenteric defects. Chylous ascites is a medical center from 2014-2017. Of very rare finding during exploration for 1,564 bariatric cases, we identified 9 internal hernia or small bowel patients who experienced a significant strangulation from any cause. Chylous postoperative hemorrhage requiring ascites is thought to be secondary to blood transfusion. Controls for each of chronic obstruction of the low flow these patients were identified based on: lymphatic channels with subsequent age, gender, ethnicity, procedure, and

206 www.obesityweek.com baseline blood pressure. Brathwaite Patchogue NY1, Barbara Brathwaite Mineola NY Results: When comparing patients who NYU Winthrop Hospital1 required transfusion postoperatively to those who did not, the transfusion Introduction: Optimal perioperative group was found to have a statistically anticoagulation and the resulting significant difference in mean arterial occurrence of postoperative bleeding or pressure (MAP) from baseline to the venous thromboembolic events (VTEs) morning of surgery. In addition, in patients with a history of VTE has patients who received transfusions not been well established. displayed a wider range in Methods: Our prospective database intraoperative blood pressure and a was retrospectively reviewed for significantly lower MAP just prior to patients with a VTE history undergoing closure. No differences were noted primary and secondary bariatric between the two groups with respect to procedures from January 2008- anticoagulation or Ketorolac December 2017. Factors assessed administration. included: demographics (age, gender, weight, body mass index [BMI], co- Conclusion: Increased intraoperative morbidities), surgical details blood pressure lability is associated (procedure, modality, presence of with postoperative hemorrhage inferior vena cava filter [IVCF], requiring blood transfusion in patients perioperative anticoagulation), and with minimal intraoperative blood loss outcomes (length of stay [LOS], 30-day during bariatric surgery. Patients who readmission, 30-day reoperation, 30- bled were relatively hypotensive during day and 90-day VTEs, mortality). a critical window of the surgery in Results: Sixty-five bariatric surgery which intraoperative inspection for patients with a history of VTEs bleeding prior to closure occurs. underwent 76 surgical procedures. Forty-six patients were female (71%); mean age 51 years (range 26-73), mean weight 284 pounds (range 110-550), A317 and mean BMI 45 (range 19-87). Co- Bariatric Surgery in Patients with a morbidities included: hypertension History of Venous (60%), gastroesophageal reflux disease Thromboembolism and Concurrent (54%), osteoarthritis (49%), obstructive Anticoagulation Therapy sleep apnea (45%), and diabetes Raelina S. Howell Mineola NY1, mellitus (37%). Operations performed: Keneth Hall Garden city NY1, 22 general surgery procedures (29%; Alexander Barkan 1, Patrizio e.g. herniorrhaphy, adhesiolysis, Petrone Mineola NY1, Collin cholecystectomy), 20 sleeve gastrectomies (26%), 12

207 revisions/conversions (16%), 12 Roux- (<0.8m/s) have a longer hospital length en-y gastric bypasses (16%), and 10 of stay and worse outcomes after gastric bands (13%). Operative bariatric surgery. modalities: 67% laparoscopic, 28% robotic, and 5% open. Twenty-two Methods: A retrospective review at a patients (34%) had a preoperative single institution was performed on IVCF with no IVCF-related bariatric surgery patients from February complications. Mean LOS was 4.4 days 2017-April 2018. Bariatric patients (range 1-31). Thirty-day complications deemed high risk(baseline included seven readmissions (9%) and comorbidities/functional status) were one reoperation (1%). No mortalities or enrolled in a prehabilition program. bleeding events occurred. Thirty-day Patients with normal GS(>0.8 m/s) and 90-day VTEs were zero and two, were compared to patients with slow respectively. GS(<0.8m/s) using univariate analysis: Conclusions: Bariatric surgery can be Wilcoxon rank sum, Chi-square, and performed safely with a low incidence Fisher’s exact tests where appropriate. of postoperative thromboembolisms or bleeding complications in patients with Results: There were 48 high-risk a history of VTE. patients enrolled in the prehabilition program. Of these, 35 patients had normal GS and 13 patients had slow A318 GS. There was no significant Preoperative Gait Speed is difference between with regards to Associated with Increased Length of patients on demographics, Stay after Bariatric Surgery comorbidities, or operation. Patients Benjamin Schneider Dallas TX1, Rui- with slow GS had a significantly Min Mao Dallas TX1, Tjasa increased length of stay(4.1d vs. Hranjec Hollywood FL2, Sara 2.3d,p=0.002). Readmission Hennessy Dallas TX1 rate(30.8% vs. 8.6%,p=0.07) and ICU UT Southwestern Medical admission rate(23% vs. 0%,p=0.02) Center1 Memorial Physician Group2 were higher in patients with slow GS.

Introduction: Gait speed (GS) has Conclusion: Slow gait speed prior to been used to predict patient's physical bariatric surgery is associated with performance, as well as morbidity and increased hospital length of stay. Gait mortality. It is infrequently used in speed is a quick and measureable bariatric surgery, but has the potential metric to identify patients at risk for to predict postoperative complications complications after bariatric surgery. as it may be used as a marker of Future studies on risk factors for frailty preoperative frailty. We hypothesized are necessary and may help determine that patients with a slow gait speed whether a prehabilition program will

208 www.obesityweek.com improve outcomes after bariatric Results: surgery. The average length of admission was shorter for those who underwent earl oral feeding, but this was not significantly different. There was a A319 statistically significant difference Early oral feeding following bariatric between complications in the early surgery does not result in improved versus late oral feeding group (8.9% vs. outcomes. 4.4%). The early feeding group also Lisa Parker Dallas TX1, Joshua had more than twice the rate of Parker Ft Hood TX, John Harris Dallas readmissions (5.5% vs. 2.2%). TX1, Daniel Davis Dallas TX1 Baylor University Medical Center1 Conclusion: Although previous studies have pointed Background: to the safety of early oral feeding, our Early oral feeding in lower GI surgery study showed higher complication and has been shown to be safe and result in readmission rates with no significant shorter hospital lengths of stay. Data decrease in length of admission. showing improved outcomes with early oral feeding has also been found for gastric resections for oncologic purposes. However, there are few A320 studies investigating early oral feeding Decreasing Program Cycle Time: A after bariatric surgeries, although early Lean Approach results have been encouraging with Kimberly Wilkes Indianapolis IN1, decreased length of stay and no William Hilgendorf Carmel IN1, significant difference in complications. Myesha Morrissette-Johnson Carmel IN1 Methods: Indiana University Health1 A group of 621 patients who underwent bariatric surgery at Baylor University As organizations continue to refine cost Medical Center from 2012 to 2017 was of care and seek to remain competitive included in this study. The patients in both quality of care and patient were divided into the early oral experience, we recognize that Bariatric feeding group, defined as post-op day Surgery is costly and the process for 0, or the late oral feeding group, the patient is long and complex. defined as post-op day 1 or later. This Resources are limited, and we are retrospective chart review looked challenged to do more with the same or at length of stay, readmission rates, fewer resources. In December of 2016, and complication rates. our team sensed a call to action with the addition of 3 surgeons over the

209 prior 18 months and no additional Ragui Sadek New Brunswick NJ1, Lora programmatic support. Melman Somerset NJ2, Andrew We set out to ameliorate our pre- Wassef New Brunswick NJ3 operative program process with three Robert Wood Johnson Barnabas improvement aims: 1) Increase value University Hospital1 Advanced add activity for patients, 2) Decrease Surgical & Bariatrics of NJ2 Rutgers overall pre-operative program cycle RWJ Medical School3 time, and 3) Promote throughput of high quality surgical candidates. Using Background: Lean tools for improvement, we With the astronomical tripled growth of evaluated our current process and gaps, obesity in just 30 years time, identified root causes and potential consideration for more invasive solutions, and began the year long treatments such as surgical journey to implement a number of management of obesity, has become changes. We tracked quarterly more readily available. As such, many throughput data along with patient surgical specialties have made surveys to evaluate our success, significant strides in operative recovery recognizing the average throughput for with the implementation of enhanced a patient requiring 6 months of recovery after surgery (ERAS) nutritional counseling was 341 days at protocols. Naturally protocols have baseline. With focused improvements, been developed for bariatric surgery we saw little to no change in patient that differ from program to program. satisfaction; however, we successfully removed 50 days from the pre- Objective: operative program cycle time at 9 The aim of the following study is to months, and at 12 months we improved evaluate patient outcomes (adverse further to 60 days, an 18% overall events, hospital stay length, and reduction. readmission rate) following the We aim to share how we used these implementation of our unique ERABS tools to refine our service to patients protocol in comparison to the and how they can be used to drive MBSAQIP national rate. improvement work in other programs. Methods: The following study is a retrospective A321 review of all patients who underwent ENHANCED RECOVERY AFTER primary bariatric procedures after BARIATRIC SURGERY (ERABS): ERABS implementation at RWJ HIGH VOLUME SINGLE SITE Barnabas bariatric center of excellence PROTOCOL from March 2016 to January 2018. Revisional and endoscopic procedures were excluded from the study. The

210 www.obesityweek.com program's adverse events, hospital A322 length of stay, and 30-day readmission Validation of the modified Frailty rates were compared to MBSAQIP Index as a predictor of outcomes national database for programs with after bariatric surgery implemented ERAS protocols. Jakub Dros Krakow 1, Tomasz Stefura Kraków 1, Artur Results: Kacprzyk Krakow 1, Katarzyna There was a total of 1,004 patients; 406 Chlopas Krakow 1, Michal (40.4%) Male, 598 (59.5%), 209 Pedziwiatr Kraków 2, Andrzej (20.8%) Roux-en-y Gastric Bypass, Budzynski Kraków 2, Piotr 795 (79.1%) Gastric Sleeve patients Major Poland 2 who received bariatric surgery with our Jagiellonian University Medical ERABS protocol. Adverse events, College, Students’ Scientific Group at hospital length of stay, and readmission 2nd Department of General Surgery1 1. rates were all trended over time. Jagiellonian University Medical Adverse events with implemented College, 2nd Department of General ERABS protocol were significantly Surgery 2. Center for Research, lower (3.2%) that the national average Training and Innovation in Surgery (4.6%). Readmission within 30 days of (CERTAIN Surgery)2 procedure significantly reduced (2.1%) as opposed to the national average Introduction: Obesity and aging are (4.3%). The average length of hospital associated with declines in organ stay for gastric sleeve and gastric functions and constitute a marker of bypass respectively are ( 22.8hr, 23hr) frailty. The modified frailty index compared to the national average (24hr, (MFI) is a tool for predicting 48hr). Narcotic use was nearly postoperative outcomes, usually eliminated (.01%), while the average assessed among geriatric patients. Its time to ambulation after surgery was usefulness in the field of bariatric 6.1hrs. surgery has not been sufficiently investigated. As the population ages, Conclusion: more elderly patients seek bariatric The implementation of our unique procedures. It is essential to evaluate ERABS protocol has shown to reduce utility of this method, which may adverse events and improve patient potentially improve the quality of the outcomes with greater efficacy, while treatment. effectively eliminating narcotic use by Purpose: To assess the usefulness of promoting early ambulation MFI as a predictor of the outcomes of postoperatively. bariatric surgery. Methods: This retrospective analysis was conducted among 731 patients who underwent laparoscopic bariatric

211 surgery. MFI was calculated using 11 Olga Garcia Ventura CA1, Helmuth variables defined in the National Billy Ventura CA2 Surgical Quality Improvement Program Community Memorial of the American College of Surgeons. Hospital1 Advanced Surgical Endpoints of the study include Associates2 perioperative parameters and long-term effects of bariatric treatment after one- Medically-supervised weight year follow-up. management (MSWM) has remained Results: Increasing MFI was not an insurance-mandated pre-requisite significantly associated with longer before approval of bariatric surgery for operative time (p=0.41 for sleeve treatment of morbid obesity. This gastrectomy, p=0.88 for Roux-and-Y imposes a deleterious effect on access gastric bypass), higher rates of to care increasing cost, frustration, and intraoperative adverse events (p=0.36), drop-out rates and delays life-altering postoperative complications (p=0.08), intervention. All published studies to reoperations (p=0.16), readmissions date have confirmed that insurance- (p=0.21) and longer hospital stay mandated MSWM programs confer no (p=0.25). Increasing MFI was additional benefit compared with negatively correlated with effects of standard evaluation and education bariatric treatment in terms of protocols. percentage of weight loss (p=0.02) and We reviewed MSWM policy and found percentage of excessive weight loss no standardized educational (p<0.01), but not percentage of curriculum, evidence-based milestones excessive body-mass index loss to be documented, and only vaguely- (p=0.09). described guidelines for lifestyle Conclusions: Estimation of MFI in changes. Instead requirements were bariatric patients should not constitute a focused on monthly weigh-ins and method for predicting intra- and notations that participation was postoperative outcomes of the surgery. ongoing. In some cases weight loss had However, high MFI may help to predict to be demonstrated for authorization; in inferior weight-loss effects of bariatric others, it was grounds for treatment. disqualification. We hypothesized that a standardized two-week liver reduction diet (LRD) A323 consisting of meal replacement shakes LIVER REDUCTION DIET AN supplemented by low-calorie clear EFFECTIVE ALTERNATIVE FOR liquids would produce weight loss INSURANCE-MANDATED results more consistently than time- MEDICALLY-SUPERVISED based insurance-mandated MSWM WEIGHT MANAGEMENT IN program with scheduled RD visits. We BARIATRIC PATIENTS performed a retrospective review of

212 www.obesityweek.com 104 patients who underwent bariatric weight loss after bariatric surgery based surgery in 2017 by one surgeon. All on 1 week or 2 weeks pre operative patients completed insurance-mandated diet. MSWM of 3-6 months duration, were METHODS approved for surgery and then We retrospectively reviewed all completed two weeks LRD. 49.4% bariatric surgeries between 2010 and experienced a net weight loss during 2016. We divided the patients into two MSWM vs. 96.5% with LRD. Mean groups, Group 1, patients that had one- weight loss during MSWL was 2.2 kg week pre operative diet and Group 2 vs. 12.4 kg with LRD. which had two weeks pre-operative Our results demonstrate that pre- diet. We selected and matched patients operative weight loss achieved with based on common demographics and efficient, reproducible, and safe two- comorbidities and measured outcomes week LRD. If pre-operative weight loss at 3, 6 and 12 months after surgery. is a significant indicator of improved RESULTS surgical outcome implementation Among 1399 bariatric patients, of LRD can be accomplished alongside 904(64.61%) patients were included. pre-operative education. We identified 302 patients in Group 1 and 602 in Group 2. In Group 1, 72.18% (N=218) were females versus 71.59%(N=431) in Group 2. The A324 %EBMIL at 3 months in Group 1 was Is there a Correlation Between 31.71±14.61%(N=302) versus Length of Preoperative Diet and 43.34±6.48% (N=601)in Group Weight loss After Bariatric Surgery? 2(p=0.0001) and at 6 months, Group 1 Mauricio Sarmiento-Cobos Weston 1, had an %EBMIL of 56.14±19.35% and David Gutierrez Blanco Weston FL1, Group 2 , 60.34±20.65%(P=0.04). David Romero Funes Weston FL1, At 12 months, follow-up was available Emanuele Menzo Weston FL1, Rama for 54 patients in Group 1 and 254 Rao Ganga Columbia MO1, Samuel patients in Group 2 with females Szomstein North Miami Beach FL1, composing 70.37%(N=38) and Raul Rosenthal miami FL2 72.44%(N=184) respectively. Patients Cleveland Clinic Florida1 Cleveland were matched separately from the Clinic of FL2 initial group(Table 1). The %EBMIL at 12 months was 56.08±21.81% in BACKGROUND Group 1 vs 66.89±24.60% in Group 2 It remains undetermined whether the (p=0.003). duration of diet before surgery influences outcomes after bariatric CONCLUSION surgery. The aim of this study is to Our results suggest that two weeks pre- determine the difference in short-term operative diet regimen is associated

213 with a significantly higher weight loss mass (FFM) preservation. up to 12 months follow-up. Further Results: Sample was 88% female and prospective studies may be needed to 81% had sleeve gastrectomy. Median better assess these findings. age was 43.5 years(IQR:35.6, 53.3) and body mass index of 48.1 kg/m2(IQR:40.9, 54.3). Weight (-20.1 kg, IQR:-18.7, -23.6), FFM(-4.0 kg, A325 IQR:-2.9, -7.0), and REE(-500 Early decline in resting energy kcal/day, IQR:-150, -652) decreased expenditure and its impact on body between visits (P<0.05). However, composition changes 3 months after patients (n=8) with a decline of REE bariatric surgery 500 kcal/day at 3 months had a higher DePrenger Molly 1, Asante baseline weight and REE (P<0.001). Brown Chicago IL1, Christy Additionally, patients with REE Tangney Chicago IL1, Jonathan declines of 500 had greater weight- Myers 1, Philip Omotosho Chicago IL1, loss(-22.3 kg, IQR: 20.4, 24.1, Alfonso Torquati 1, Sandra Gomez- P<0.001). However, there was no Perez Chicago IL1 difference between the ratio of change Rush University Medical Center1 in FFM/change in weight between group (P=0.57). Background: Weight-loss and body Conclusion: Patients with substantial composition (BC) changes post- decreases in weight at 3 months bariatric surgery (BS) influence resting ultimately showed greater declines in energy expenditure (REE); however REE. A consequence of greater weight- early changes have not been well loss may be larger declines in characterized. REE; however additional research is Objective: To describe the effect of BS necessary to describe if early drops in on REE and BC from pre-op to 3 REE impacts total achievable weight- months post-op and identify differences loss or preservation of FFM. in BC between patients above and below median decline in REE at 3 months. A326 Methods: A prospective study included Bariatric Surgery in Medicare 16 BS patients >18 years old. BC was Patients Younger than 65 is Safe and evaluated by bioelectrical impedance Effective analysis and REE by indirect Jacob Petrosky Danvillle PA1, Robert calorimetry. The sample was Cunnigham Danville PA, Jai dichotomized by median decline in Prasad Danville PA1, Jason REE(500 or <500 kcal/day) to explore Kuhn Danville PA, G. Craig if patients with considerable drops in Wood Danville PA, James REE consequentially had less fat-free Dove Danville PA, Marcus

214 www.obesityweek.com Fluck Danville PA, David were available for 2770 patients (88%). Parker Danville PA, Jon Minor complications and LOS >2 days Gabrielsen Danville PA, Christopher were significantly greater in the Still Danville PA, Anthony Medicare population. Mortality, major Petrick Danville PA complications and readmissions were Geisinger Medical Center1 not different between the groups. After adjusting for DiaRem score and Introduction: Worldwide, the safety surgery type, the odds ratio (OR) for and efficacy of bariatric surgery is well complete diabetes remission was not documented. However, there is less different between payers. information about the outcomes in Conclusions: The safety of bariatric Medicare patients in the U.S. The surgery in CMS<65 patients is similar purpose of this study was to evaluate to other payers with equivalent weight the safety and efficacy of bariatric loss and complete remission of diabetes surgery in patients younger than 65 on despite being older with a higher Medicare (CMS<65) compared to other comorbidity index. payers. Methods: A prospectively maintained database of all patients who underwent bariatric surgery between January 2007 A327 and December 2017 was utilized. 3146 The Impact of Endoscopic Bariatric patients, aged <65, who underwent Therapies on Diabetes and Weight Laparoscopic sleeve gastrectomy Loss Outcomes: a Systematic Review (LSG) or Roux-en-Y gastric bypass and Meta-analysis Comparing Small (RYGB) were evaluated. Bowel and Gastric Devices Results (Table): CMS<65 were older Violeta Popov New York NY1, with a higher Charlson co-morbidity Benjamin Noor New York NY, Amy index than bariatric patients with other Ou New York NY, Christopher payers (p<0.0001). CMS<65 also had a Thompson Boston MA significantly higher DiaRem score NYU School of Medicine1 (p=0.001). The TBWL for the entire cohort at 6- Endoscopic bariatric therapies (EBTs) months, 1-year, 2-years, and 3-years can be grouped into gastric (balloons, was 28.1% (SD=6.6), 34.1% (SD=8.5), aspiration therapy, endoscopic 34.1% (SD=10.4), and 31.8% gastroplasty) or small bowel EBTs (SD=11.0), respectively. The difference (duodenal bypass liner, jejuno-ileal in %TBWL was not significant when diversion, mucosal resurfacing). Data comparing Medicare to Medicaid suggests that small bowel EBTs may be (p=0.088) or Commercial payers more effective at improving diabetes (p=0.310). but it is unclear if this is related to Complication and readmission data weight loss or other factors.

215 Aim: To compare the effect of small A329 bowel (sbEBTS) vs. gastric (gEBTS) Changes In Gastric Emptying With on diabetes and weight loss parameters. The Spatz3 Adjustable Intragastric Methods: MEDLINE, Embase, and Balloon Are Associated With Cochrane were searched through 2018 Increased Weight Loss: A for trials of EBTs reporting diabetic Prospective Study outcomes. Primary outcomes included Eric Vargas Rochester MN1, Monika pooled mean differences(MD) in Rizk Rochester MN1, Fateh baseline-final values in fasting blood Bazerbachi Rochester MN1, Andres glucose (FBG), HGA1C, excess weight Acosta Rochester MN1, Barham Abu loss (EWL); % total weight loss Dayyeh Rochester MN1 (TWL), using subgroup analyses and Mayo Clinic1 meta-regression to assessbetweengroupsdifferences. Introduction:Intragastric balloons Results: 1222 citations, 65 studies (IGBs) promote weight loss through including 8,186 subjects were analyzed. complex changes in gastrointestinal Weight loss outcomes were similar: 39 physiology such as gastric emptying %(sbEBT) vs. 32.5 %(gEBT) for (GE). Adjustable IGBs are unique as EWL(p=0.05); 12 % vs. 11.2% for they can be volume-adjusted for TWL (p=0.7). SbEBTs led to greater intolerance or inadequate weight improvement than gEBTs for diabetic loss.Our major aim was to investigate parameters: FBG decreased by 25.8 the effects of the adjustable IGB (Spatz mg/dL with sbEBTs, and by 10.9mg/dL 3) upward volume adjustment on with gEBTs (p<0.001). SbEBTs gastric emptying and weight reduced HBA1C by 1.1%, and gEBTS, loss.Methods:Subjects receiving the by 0.3%, p<0.05. By meta- regression, Spatz3 adjustable IGB plus lifestyle weight loss did not predict differences interventions (LI) underwent GE in FBG and HGA1C. The strongest assessment using a 4-hr (mixed meal) predictor of improvement in HGA1C nuclear scintigraphy at baseline, and 3 and FBG was high baseline months and 5 months into IGB FBG(Figure 1). Heterogeneity was high therapy.The balloon's volume was but mostly due to variations in baseline upward-adjusted at 4 months and parameters. removed at 8months. Paired t-tests Conclusion: SbEBTS were more were used to compare changes in GE effective than gEBTs in improving and weight loss.Results:13 female diabetic parameters. The difference subjects with a mean age of 38.2±11.2 could be explained by higher baseline years and BMI of 34.9±2.7 kg/m2 were FBG, and sbEBT trials had included enrolled (balloon=10;control=3).The more subjects with diabetes. initial mean balloon filling volume was 515 mL ± 47mL and all balloons were upwardly-adjusted to a mean volume of

216 www.obesityweek.com 770 ml ± 103ml. T1/2 (minutes) was reviewed. The mean age at operation increasingly delayed from baseline was 34.8±10.2 years and 58.1% were through post-adjustment (115 min vs. females. Almost all patients underwent 177.8 min vs. 204 min; p<0.03). The 3 laparoscopic gastric sleeve (95.9%). LI controls had no change in GE at Diabetes and hypertension were on the baseline and 3 months. Percent total top of comorbidities (24.8% and 18.9% body weight loss (%TBWL) increased respectively). At 24 months of follow throughout 3, 5 and 8 months with IGB up there was significant reduction in therapy (6.9% vs 8.8% vs. 10.7% the mean Body Mass Index (BMI) in p<0.005). Change in T1/2 after balloon Glycosylated Hemoglobin (HbA1c). adjustment was significantly associated Baseline High Density with post-adjustment %TBWL (R = Lipoprotein(HDL) (44.4mg/dl), non- 0.60; p=0.009). Conclusion:The ability HDL cholesterol (147.1 mg/dl) and to volume-adjust IGBs has physiologic Triglyceride (TAG)(123.6 mg/dl) also and clinical implications that can showed significant improvement to minimize balloon intolerance reach 52.3 mg/dl, 137.7 mg/dl and 78.5 maximizing weight loss by managing mg/dl respectively at 12 months of weight loss plateaus that are commonly post-operative follow up (p<0.001 for observed with non-adjustable IGBs. all parameters). Seventy one (18.8%) patients had complete remission and 21 (5.6%) had partial remission from A330 diabetes at last follow up. The Effect of Bariatric Surgery on predicted 10-years risk of Cardiovascular Risk Factors: Single Cardiovascular disease (CVD) Institution Retrospective Study decreased significantly from 7.4% to Ali Al Montashery Montreal QC 5.5% (p<0.001). KING ABDULLAH MEDICAL CITY Conclusion:Bariatric surgeries were significantly effective for controlling Background: The study aims to obesity related cardiovascular risk describe bariatric surgeries’ effect on factors and decreasing the 10-years cardiovascular risk factors including predicted cardiovascular disease risk glycemic control, blood pressure, lipid within a short period of follow up. profile and body weight for patients treated in a tertiary center in Makkah, Saudi Arabia. Methods: This is a retrospective cohort A331 study including all obese patients who Does systemic inflammation inhibit underwent bariatric surgery at King weight loss and diabetes remission Abdullah Medical City (KAMC) following bariatric surgery? between 2013 and February 2016. John Morton Stanford CA1, Dan Results:A total of 566 patients were Azagury Stanford CA, Luis

217 Garcia Fargo ND, Homero patients in the first and second quartiles Rivas Stanford CA (75.3 ± 24.2% and 73.3 ±21.8%, Stanford School of Medicine1 respectively, p<0.05). Patients in the third and fourth quartiles of CRP had Background: Previous studies greater average BMIs preoperatively demonstrate that inflammation worsens (p<0.0001) and 12 months insulin resistance and decreases insulin postoperatively (p<0.0001). secretion. We hypothesized that patients with greater levels of C- Conclusion: The results of this study Reactive Protein (CRP), a marker of suggest that bariatric patients with systemic inflammation, would greater systemic inflammation experience less favorable weight loss experience less favorable weight loss and metabolic changes after surgery. and greater insulin resistance.

Methods: Data were collected from patients who underwent bariatric A332 surgery. Diabetes was defined as a Does weight related abuse vary by preoperative Hemoglobin A1c  6.5%, ethnicity? and diabetes resolution was defined as Genna Hymowitz Centereach NY1, an A1c < 6.5% without medication. Yvette Karvay Oceanside NY1 CRP was classified into quartiles. Stony Brook University1 Associations between continuous measures and CRP quartiles were Weight related verbal abuse (WRVA) assessed using one-way ANOVA. is linked to negative effects in adulthood (Grilo et al., 2005; Results: Patients (n=1228) in this study Rosenberger et al., 2007; Salwen et al., had a mean preoperative body mass 2013). Individuals with obesity index (BMI) of 46.7 ±7.3 kg/m2. Before experience higher rates of weight surgery, 28% of patients were diabetic, related teasing (van den Berg et al., compared to 8% after surgery. Patients 2012). The Hispanic population has in third (7.4–13.7 mg/L) and fourth the second highest rate of obesity in (13.8–17 mg/L) quartiles of CRP had America (Flegal et al., 2012). Little is greater average measures of insulin known regarding WRVA in Hispanic than patients in first (0.1 – 3.8 mg/L) Americans. This study investigated and second (3.9–7.3 mg/L) quartiles relationships between ethnicity and (p<0.05), respectively 30.3 and 32.8 vs. WRVA in individuals with morbid 24.7 and 25.8 mIU/L. After surgery, obesity. patients in the third and fourth quartiles Methods: 106 participants were of CRP had worse percent excess recruited from a bariatric weight loss weight loss (70.5 ±22.6% and 69.4 center. Ages ranged from 18 to 72 (M = ±23.8%, respectively) relative to 41.82, SD = 13.57), BMI ranged from

218 www.obesityweek.com 33.75 to 72.34 (M = 47.57, SD = 9.18). BACKGROUND: Evidence suggests 79.7% of the sample was women and change in weight and body composition 20% of the sample identified as after bariatric surgery impacts resting Hispanic. WRVA was evaluated using energy expenditure (REE) and the Weight Related Abuse metabolic adaptation in adults. Questionnaire. Weights, and Metabolic adaptation refers to the demographics were obtained from physiological changes during weight medical records. loss that reduce REE more than REE Results: 66% of the sample endorsed determined by predictive equations. WRVA. 67.5% of the sample Little is known about REE and identifying as non-Hispanic and 61.9% metabolic adaptation among of individuals identifying as Hispanic adolescents who have undergone endorsed WRVA. The percentage of bariatric surgery. individuals endorsing WRVA did not differ by ethnicity, C2(2, N = 106) = OBJECTIVE: To examine changes in .465, p = . 792. Differences between REE and metabolic adaptation among groups with regard to frequency of adolescents at 6 (6M) and 12 months abuse, F (1,106) =.63, p =.43, or (12M) post-bariatric surgery. emotional impact of WRVA, F (1, 106) = .30, p =.59, were not statistically METHODS: Adolescents from the significant. SickKids Team Obesity Management Conclusions: These data suggest that Program (STOMP) clinic who WRVA occurs at high rates in underwent gastric bypass (bypass) or individuals with morbid obesity across sleeve gastrectomy (sleeve) surgery ethnicities. Future studies should were followed. Bioelectrical impedance evaluate the impact of WRVA in a non- analysis (BIA) and indirect calorimetry English speaking Hispanic to measure REE were completed, and population. predicted REE was calculated using the Mifflin equation pre- and post-bariatric surgery at 6M and 12M. A333 Resting energy expenditure and RESULTS: Among 17 patients (12 metabolic adaptation in adolescents females), age and BMI at time of at 6 and 12 months following surgery were 17.4+/-0.8 y and 48.3+/- bariatric surgery 4.3 kg/m2, respectively. Percent of total Lisa Chu Toronto 1, Alissa weight loss was 25.0+/-10.4% at 6M. Steinberg Toronto OH1, Carley REE decreased by 435.8 kcal/day O'Kane Toronto , Alene (p<0.001). Metabolic adaptation was - Toulany Toronto 1, Jill 102.9+/-250.6 kcal/day. When stratified Hamilton Toronto 1 by surgery type, change in REE at 6M The Hospital for Sick Children1 was not significantly different (bypass:

219 -402.1+/-200.7 kcal/day, n=8; sleeve: - significantly lower prevalence of 465.8+/-206.9 kcal/day, n=9; p=0.53). NALFD (34%, p<.01), independent of Among 11 patients with completed T2D status. The impact of the presence REE at 12M, no difference in REE at of NAFLD and race on T2D 6M and 12M was found (p=0.57). pathophysiology and remission rates after RYGB is under scrutiny. We DISCUSSION: Predicted REE was investigated the possible effect of 15% lower at 6M, whereas measured NAFLD or race on percentage of REE was 20% lower, irrespective of excess weight loss (%EWL) and T2D bariatric surgery type. Metabolic remission after RYGB. adaptation may predispose adolescents Methods: Liver biopsies from a to weight regain post-bariatric surgery racially diverse group of patients with and warrants vigilant nutritional T2D undergoing RYGB were evaluated management. for NAFLD. Patients with and without NAFLD were compared at baseline and 1-year post-operatively. Outcomes A334 included %EWL and T2D remission. Does Coexistence of Non-alcoholic Results: 66 patients (44 whites, 22 Fatty Liver Disease and Type-2 blacks) with T2D had RYGB and liver Diabetes Impact Weight Loss or biopsy, mean was BMI 46.7+6.3kg/m2. Remission of Type 2 Diabetes after Compared to whites, blacks had higher Gastric Bypass? baseline BMI (51.1vs44.5,p<.01), Jad Khoraki Richmond VA1, Guilherme lower prevalence of NAFLD Mazzini Richmond 1, Matthew (46%vs75%,p=.03), but comparable Browning Richmond VA1, Martin age, prevalence of comorbidities and Mangino Richmond VA1, Dayanjan insulin use. At 1-year, blacks had lower Wijesinghe 1, Gretchen %EWL (47.2vs64.6,p<.01) but similar Aquilina Richmond VA1, Jennifer T2D remission Salluzzo richmond VA1, Guilherme rates(70%vs76%,p=.76). Patients with Campos Richmond VA1 and without NAFLD had similar Virginia Commonwealth University1 %EWL and T2D remission in both race groups (Table). Background: Obesity and type-2 Conclusions: %EWL was lower for diabetes (T2D) are risk factors for non- patients of black race, however T2D alcoholic fatty liver disease (NAFLD), remission was independent of NAFLD and Gastric Bypass (RYGB) is an and race. Larger studies are needed to effective treatment for obesity, T2D understand the possible differences in and NAFLD. While 78% of patients of the pathophysiology of obesity, T2D, white race with obesity and T2D have interaction with NAFLD and outcomes coexisting NAFLD, individuals of of RYGB. black race have been found to have a

220 www.obesityweek.com common organism isolated 19 patients A335 (61.2%), among them 10 (32.2%) were Identification of bacterial and fungal positive for Candida species only while Pathogens in patients with post 9(29%) had mixed candida and Laparoscopic Sleeve Gastrectomy bacterial mixed culture. Pure positive leakage bacterial cultures were found in 18 Saad Althuwaini Riyadh patients (58%). king khalid university hospital Klebsiella pneumoniae was the most frequent [8 patients (44.4%)] isolated Background: bacteria. Candida albicans was the Post-laparoscopic sleeve gastrectomy most common Candida species isolated (LSG) leak leads to serious [13 patients (68.4%)]. complications, and death may occur. The infection route should be Conclusion: Post-LSG fungal established in order to plan empirical infections are common and could be antimicrobial therapy. The cultures of considered in the primary empirical post-LSG leaks were reviewed. therapy. The antibiotic choice for the Methods: leak should Microbial cultures collected from all cover Klebsiella, Streptococcus, post-sleeve leakage cases managed at and Pseudomonas until definitive King Khalid University Hospital culture results are obtained. (KKUH) from May 2011 until April 2016 were reviewed Results: A total of 42 patients with positive leak A336 post-LSG were found. Eleven cases Internal hernia after duodenal were excluded due to no culture results switch or no procedural drainage. The mean Saif Al-Tai Torsby 1, Stephan presentation time was postoperative Axer Torsby 1, Leif Hoffmann Torsby day 12. Computed tomography (CT) Sweden1 was done for all 31 patients on Torsby hospital1 presentation with CT-guided drainage the next day on average postoperative Background: day 13. The drain was kept in place, and samples from collection were sent Routine closure of mesenteric defects for culture and sensitivity. in laparoscopic gastric bypass has dramatically decreased the incidence of A total of 28 patients (90.3%) had internal hernia (IH). Duodenal switch positive culture results either for (DS) is the most effective bariatric bacteria, Candida species or operation both in terms of weight loss both. Candida species were the most and effect on comorbidity. The

221 opinions about the need to close the surgery. All those patients had mesenteric defects in DS are still split. undergone a standard DS before January 2015 with primarily open Objectives: defects.

To analyze the incidence of IH after DS Conclusion: regarding different DS-techniques: Single Anastomosis Duodeno- IH after DS is an operational challenge Ileostomy (SADI), standard DS and with high risk of conversion to open SOFY-DS (Started as Omega-loop, surgery. Mesenteric defects at DS- Finished as Roux-en-y DS - a technical operations should be closed. The modification described in SOARD Feb technical modification SOFY-DS 2016) decreases the risk for IH.

Method: A337 Review of an internal prospective Weight Loss Success with New database including DS-operations Gastric Balloon System McCoy K, performed between 2010 and 2018. Durgan D, Sekhar N, Holover S, Angstadt J, Chiao J, Sommer E Results: Kristin McCoy Stamford CT1, Diane Durgan Stamford CT, Shawn 121 DS-operations were included with Garber Roslyn Heights NY, Nikhilesh 96% follow-up (between 1 and 95 Sekhar Roslyn NY months). 9 operations were performed Stamford Hospital1 primarily open. 24% of the 112 laparoscopic DS were operated as Background: With obesity rates rising, SADI, the remaining were performed patients and physicians have an as standard DS (starting January 2015 increasing interest in non-surgical as SOFY-DS). weight-loss options. Endoscopic Defects were closed in 70 of 121 gastric balloons have shown success to operations (100% in open surgery, date and new devices are continually 100% in laparoscopic SADI-DS and developing. Of current interest is the 40% in laparoscopic standard DS). FDA-approved Obalon system, Non-resorbable clips were used as comprised of 3 nitrogen filled balloons closure material in 57%, non- swallowed in a staged fashion and resorbable suture in the remaining removed after 6 months. We aimed to cases. evaluate the safety profile and success During the follow-up, 6 patients were of this balloon system. operated for IH (5% of DS) with 83% conversion from laparoscopic to open Methods: Sixty-three patients from a

222 www.obesityweek.com multicenter bariatric practice were Accuracy of Bariatric surgery studied prospectively between January patients’ estimations of pre-operative 2017 and April 2018. Patient data weight and shape collected included age, gender, starting Andrea Stone Glastonbury CT1, Janet weight, BMI, treatment duration and Ng Corvallis OR1, Richard adverse events. Statistical analysis was Seip Glastonbury CT1, Madison performed for excess weight O'Brien South Windsor CT1, Emma loss(EWL), total body weight- Tishler Glastonbury CT1, Nick loss(TBWL), and BMI change. Dugan Farmington CT2, Pavlos Papasavas Hartford CT1, Darren Results: The cohort was predominantly Tishler Glastonbury CT1 female with an average age of Hartford Hospital1 University of 42. Average starting weight was Connecticut2 225lbs and BMI 36.1. Average weight loss was 21lbs, TBWL 9.3%, and EWL The accuracy of self-reported (SR) 34.2%. BMI decreased by 3.2. Over weights across all segments of the 65% of patients achieved >5 % population, including the bariatric TBWL. There was a significant population, is not clear. Previous difference between patients who research suggests that women and those completed the 150-day course(82.5%) with overweight/obesity are most likely versus patients who had early balloon to underreport weight. We explored the retrieval in terms of weight accuracy of SR weight as well as body reduction(p=0.022), TBWL(p =0.019), shape via pictograms in bariatric EWL(p =0.015), and surgery patients using the Weight and BMI(p=0.015). No major adverse Lifestyle Inventory (WALI) events occurred. Minor complications occurred in 22.2 % of patients: 163 pre-surgical bariatric patients gagging(9.5%), gastric ulcers(3.2%), completed the WALI, including self- nausea(3.2%), abdominal pain(3.2%), reported body weight and body shape vomiting(1.6%), dyspepsia(1.6%), and using established pictograms (scaled 1 device intolerance(1.6%). to 9, Figure 1). SR weights together with measured height were used to Conclusion: From our experience the derive SR BMI and SR obesity class (I, Obalon balloon is a safe and effective II, or III). Estimates were compared to non-surgical weight loss option. There actual measured weight, BMI, and were no serious complications and the obesity class. majority of patients experienced weight reductions. Future studies will focus on SR weight (280.6±54.3 lbs) was determining optimal treatment duration. significantly higher than actual weight (276±51 lbs), mean difference: 4±19 A338 lbs, p<0.01, and SR BMI (45.5±6

223 kg/m2) was significantly higher than General Surgery, Bariatric and measured BMI (44±6 kg/m2), mean Minimally Invasive Surgery3 difference: 0.65 ±3.03 kg/m2, p<0.01. Despite overestimating Introduction: weight, 73% of patients placed Asymptomatic bacteriuria is the themselves in the correct obesity class, isolation of bacteria from urine in 20% underestimated, and 8% people without symptoms or signs. overestimated (Figure 2a). Men and Patients with obesity are at increased women differed in their ability to self- risk for asymptomatic bacteriuria, and assess measured weight (p=0.03), but patients undergoing bariatric surgery not BMI or obesity class (p=0.70, are at increased risk for hospitalization p=0.98, respectively). Pictogram due to urinary tract infection (UTI) ratings for all patients ranged from 5-9 after surgery. Understanding the (median=8; Figure 2b), with no prevalence of asymptomatic bacteriuria significant differences between men in patients undergoing bariatric surgery and women (p<0.59). is of increasing importance.

Although patients overestimated weight Methods: by 4.2 lbs, with a slightly greater Patients undergoing bariatric surgery at overestimation among women, the Stanford from August 2017 to February difference was not large enough to alter 2018 were identified. Previously, an obesity classification. These data add to increase in UTI was noted in review of the literature on SR weight across our MBSAQIP data. To determine if different populations. these UTIs were Present on Admission, a policy of preoperative UA in holding area was begun. With IRB approval, results from preoperative urinalysis on A339 clean-catch voided urine samples were Preoperative Asymptomatic reviewed. Reflex culture was Bacteriuria in Bariatric Surgery performed according to hospital Patients criteria. Katherine Blevins Stanford CA1, Dimitri Augustin Palo Alto CA2, Dan Results: Azagury Stanford CA3, John One-hundred fifty-four patients (125 Morton Stanford CA3 women, 29 men) underwent bariatric Stanford University, Department of surgery during the study period. One- Surgery, Division of General hundred fifteen completed UA (95 Surgery1 Stanford University, women, 20 men). Twenty-one patients Department of Medicine, Division of (18.2%) had positive UAs (20 women, Nephrology2 Stanford University, 1 man), and eight (6.9%) had positive Department of Surgery, Division of cultures (all women). Two patients

224 www.obesityweek.com were treated for developed symptoms therapy secondary to obesity underwent or significant risk factors. bariatric surgery in our institution with a goal to lose weight and have heart Conclusion: transplant. Demographic information, The prevalence of asymptomatic comorbidities, operative time, weight, bacteriuria in healthy, pre-menopausal weight loss, and postop complications women is reported to be 1-6%. We are reviewed in this high-risk patient observed the prevalence in patients population. undergoing bariatric surgery was found Results: Five patients (4 men) to be 7%; 8.4% in women only. implanted with Heartmate II LVAD Positive culture resulted in <40% of had bariatric surgery (2 gastric bypass, positive UAs. These data indicate 3 sleeve gastrectomy). Mean age was preoperative UAs help determine if 46 (23-64) years, and mean operative postoperative UTI was Present on time was 128 minutes. There were no Admission or a de novo UTI, which is 30-day mortalities. Average pre- important in quality reporting and operative BMI was 45 kg/m2, BMI Post improvement. op was 40 (1 mo), 37 (3 mo), 35 (6 mo), 32 (9 mo), and 31 (12 mo). Four lost sufficient weight to be transplanted A340 about 1 year later. One patient who had Bariatric Surgery as a bridge to a transplant at another center died 12 Cardiac transplantation in patients days post-transplant due to transplant with LVAD complications, and one is currently Rana Pullatt Mt Pleasant SC1, Nina only 6-months post-op and has not lost Crowley Charleston SC2, Karl sufficient weight to be listed. Byrne Charleston SC2, Diana Conclusion: Bariatric surgery is an Axiotis Charleston SC2 important treatment option for patients Medical University of South with heart failure currently with LVAD Carolina1 MUSC Charleston, SC2 as a bridge to transplant. Demographics, surgical and weight loss Background: People with advanced outcomes are similar to other high-risk heart failure who have BMI>35 are patient popu considered unacceptable candidates for heart transplant due to increased operative risk and technical challenges. A341 Some of these patients who get an Safety of Bariatric Surgery in LVAD have a poor chance of getting a Patients with Congestive Heart heart transplant. Bariatric surgery is a Failure viable option for these patients. Barbara Brathwaite Mineola NY1, Methods: Patients with end stage heart Raelina S. Howell Mineola NY2, failure with LVAD as destination Keneth Hall Garden city NY2,

225 Alexander Barkan 2, Patrizio mellitus (54%). Surgical procedures Petrone Mineola NY3, Collin included: 16 sleeve gastrectomies Brathwaite Patchogue NY2 (41%), 12 Roux-en-y gastric bypasses Stony Brook University School of (31%), and 11 gastric bands (28%), All Nursing, NYU Winthrop cases were performed minimally- Hospital1 NYU Winthrop invasively (74% laparoscopic, 26% Hospital2 NYU Winthrop3 robotic). Mean LOS was 2.6 days (range 1-13). Thirty-day complications Introduction: Congestive heart failure included two readmissions (5%; one (CHF) is a known risk factor for small bowel obstruction and one increased postoperative morbidity. subcutaneous abscess/pulmonary However, the safety of bariatric surgery edema) and one reoperation (3%; for in patients with CHF has not been well small bowel obstruction). There was established. one mortality (3%) on postoperative Methods: Our prospective database day 29 of unclear etiology unrelated to was retrospectively reviewed for the surgery. patients with known CHF undergoing Conclusions: Bariatric surgery can be primary bariatric procedures at our safely performed minimally-invasively center over a 10-year period ending in in patients with known CHF. December 2017. We assessed patient Laparoscopy should not be restricted in demographics (age, gender, weight, these patients. body mass index [BMI], co- morbidities), surgical details (procedure, modality), and outcomes (length of stay [LOS], 30-day A342 readmissions, 30-day re-operations, Reciprocal responses of plasma complications, mortality). Non-bariatric cystatin C and cathepsin S among and revision bariatric procedures were diabetic subjects after bariatric excluded. surgery Results: Over the 10-year period, Chih-Yen Chen Taipei 3,948 total bariatric surgeries were Taipei Veterans General Hospital performed, of which 39 (1%) patients had known CHF and were included in Background and aims: Cathepsin S the analysis. Twenty-one patients were deletion was shown to induce a robust male (54%) with a mean age of 55.4 reduction in blood sugar in knockout years (range 33-71) and mean BMI of mice, whereas cystatin C is the most 52 (range 38-80). Co-morbidities abundant and potent endogenous included: hypertension (90%), inhibitor of cathepsin S. We explored obstructive sleep apnea (82%), the roles of cystatin C and cathepsin S osteoarthritis (61%), gastroesophageal in patients with type 2 diabetes mellitus reflux disease (56%), and diabetes (T2DM) receiving either gastric bypass

226 www.obesityweek.com (GB) or sleeve gastrectomy (SG). A343 Methods: T2DM patients undergone Laparoscopic conversion of sleeve laparoscopic GB or SG were enrolled Gastrectomy to mini gastric bypass into this prospective study. Remission one-anastomosis gastric bypass of T2DM was defined as fasting Maud Neuberg Lyon 1, Marie-Cécile glucose 125 mg/dL with HbA1c value Blanchet LYON <6.5% in the absence of Clinique de la Sauvegarde1 pharmacotherapy (remitters). Plasma concentrations of cystatin C and The aim of this study is confirm the cathepsin S were measured before and efficacy, safety and side effects of mini after surgery. gastric bypass-one anastomosis gastric Results: GB and SG significantly bypass (MGB-OAGB) as a revisional lowered fasting blood sugar and surgery for Sleeve Gastrectomy (SG) induced weight loss one year after patients with weight loss failure or surgery. Significant increase in cystatin complications. C levels and decrease in cathepsin S concentrations were found among We reviewed the files of 38 patients diabetics after GB, but not SG. Pre- who underwent conversion from SG to operative levels of cathepsin S MGB-OAGB from October 2013 to positively correlated with those of October 2017. cystatin C in the GB group but not in Mean age was 38 years (range 23-59). the SG group. One year after GB, post- Mean pre-operatively BMI was 37,7 operative concentrations of cathepsin S kg/m (range 26,6-52,3 Kg/m). positively correlated with those of Vast majority of patients underwent cystatin C, while post-operative conversion surgery due to weight loss cathepsin S and cystatin C levels failure (n=34). Four patients underwent correlated with post-operative HbA1c. a revision due to sleeve gastrectomy Moreover, in the GB group, the complications (a stenosis for 3 patients remitters exhibited significantly lower and recurent heartburn for 1 patient) levels of cathepsin S than the non- The mean time interval from SG remitters one year after surgery. surgery was 43 months (range 1-108 Conclusion: GB, rather than SG, months). demonstrated reciprocal responses of Residual gastric volume was measured plasma cystatin C and cathepsin S preoperatively and at 1-month post among Asian patients with T2DM after surgery. surgery. Cystatin C and cathepsin S play roles in diabetes remission. After a mean follow-up of 26 months (range 1-48), the mean BMI was 31 Kg/m2 (range 21,5-43,4) SD 5,9. Mean Excess Body Weight loss was 59,9%. The mean length of hospital stay was

227 1,2 days (range 1-4). surgery and to demonstrate the The mean gastric volume was 299mL incidence of arrhythmia. (range 130-950) before conversion and Methods: A retrospective chart review failed to 87mL (10-200) at one month. of all patients who underwent bariatric Mean size of gastrojejunal anastomosis surgery at King Abdullah Medical City was 16,4mm (range 10-26). Early (KAMC) to evaluate changes in complications were encountered in 3 echocardiographs and ECG. Myocardia patients (7%), including perforated performance index (MPI), ejection ulcer and hemorrhage, all requiring fraction (EF), automated EF, end surgery. diastolic volume (EDV), end systolic Conversion to Roux-en-Y gastric volume (ESV), automated global bypass for biliary reflux occurred in 2 longitudinal strain (GLS), and patients (5%) at 6 and 9 months. pericardial fat, heart rate, PR, QRS, QT, QTc, BMI, total cholesterol, LDL, MGB-OAG as a revisional procedure HDL, triglycerides and glycated of failed SG is feasible and safe. hemoglobin (Hg) were compared before and after at least one year postoperatively. Results: 800 consecutive patients were A344 identified, 99 had ECG and Echo pre FUNCTIONAL AND ELICTRICAL and post operatively. (Table I) CARDIAC CHANGES AFTER Conclusion: BARIATRIC SURGERY There is significant improvement in Ali Al Montashery Montreal QC cardiac structure, function and ECG. KING ABDULLAH MEDICAL CITY These findings underscore the role of bariatric surgery heart health. Background:Bariatric surgery is an effective way for long-term weight loss success. Recent studies have found that A345 weight loss is significantly associated Mechanisms of Developmental with improved metabolic parameters in Obesogen Exposure as Possible addition to overall decrease in Drivers of Persistent Obesity cardiovascular morbidity and mortality. Phenotypes in Adults. Conversely, some studies have Demetri Spyropoulos Charleston SC observed the development of Medical University of South Carolina unexplained sinus bradycardia after significant weight loss. Studies increasingly implicate chemical We conducted a retrospective study to 'obesogens' as drivers of adiposity, evaluate the electrical and functional hunger and reduced metabolism, and cardiac changes on morbidly obese thereby contribute to the obesity patients who underwent bariatric epidemic. Dioctyl sodium

228 www.obesityweek.com sulfosuccinate (DOSS; CAS #577-11- A346 7) is a widely used lipid emulsifier in Reversing Fate: NLR and the role of processed foods and drinks, stool Bariatric Surgery to Prevent softeners and personal care Morbidity products/cosmetics. To test a Sarah Pearlstein New York NY1, Ali developmental origins of adult obesity Shayesteh New York NY, Deborah model in a previous study, we Allis Mount Kisco NY, Mitch administered DOSS to pregnant Roslin New York NY C57BL/6 mice in timing and dosage Lenox Hill Hospital Northwell Health1 relevant to stool softener use during human pregnancy. In that study we Introduction: In addition to increased observed that adult offspring of DOSS risk of death from cardiovascular treated dams showed significant disease, obesity is a risk factor for increases in adiposity, body mass, and many cancers and decreases tumor inguinal/epididymal fat masses. These related survival. As a result, aggressive adult offspring also showed a bariatric treatment may become an significant decrease in plasma important cancer therapy adjunct. The adiponectin and increases in leptin and neutrophil to lymphocyte ratio (NLR) IL-6, dyslipidemia akin to long-term is as a marker of poor prognosis for high fat diet induced obesity in heart disease and cancer. The purpose C57BL/6 mice, glucose intolerance and of our study is investigate the impact of hyperinsulinemia. These results were bariatric surgery on NLR in a bariatric striking because the phenotypes surgery cohort. persisted well into adulthood while the Method: We retrospectively analyzed a offspring were maintained on a regular cohort of patients undergoing chow diet. In the current study, we seek laparoscopic sleeve gastrectomy and to better elucidate the molecular compared pre-op and post-op WBC and mechanism(s) driving these persistent NLR values using paired t-tests for adult changes. Data will be presented analysis. comparing nongenomic, metagenomic Results: 34 patients were analyzed. At and epigenomic mechanisms of DOSS 3 months, 26 patients had a mean pre- exposure that might contribute to op NLR of 2.81 reduced to 2.35, not persistent obesity. Collectively, these statistically significant (p=.052), studies suggest that DOSS exposure however WBC decreased from 8.235 to during pregnancy might be a 6.36 (p<.01). 6-12 months postop, 14 contributor to long-term obesity, patients had NLR decreased from 2.39 metabolic and inflammatory health pre op to 1.78 postop (p= .04), and concerns. WBC decreased from 7.31 to 5.84 (p <.01). Conclusions: From our study, we found that after 6 months postop, patients had

229 a decreased NLR and WBC. mindfulness intervention (MI; n = 40), Discussion Although the association of beginning 5- 8 months after SG. The obesity and certain deadly diseases mindfulness approach, originally such as cancer have become clearer, developed to help prevent substance whether outcomes of patients with abuse relapse, was designed to address malignancies can be improved with challenges in weight maintenance.Six bariatric surgery is unknown. To best validated self-report instruments determine, a marker of risk and (Tables 1, 2) were assessed at study subsequent improvement would be baseline and 6 weeks later (end of the helpful. NLR may be a potential intervention). Percent total weight loss target. Further investigation will target (%TWL) was calculated at study high risk patients with obesity, active baseline and 6- and 18-month follow- disease, and elevated NLR and up (12 and 24 months post-op). No correlate the NLR to eventual clinical significant group differences were results. found for %TWL at 12 months (mean %TWL for MI = 21.69%, SD=8.04; for TAU = 21.05%, SD=9.70, t (71) =.307, p =.76) or for weight regain at 6-month A347 follow up. Several significant Pilot testing a mindfulness-based correlations were noted between weight loss maintenance intervention mindfulness measures and %TWL at to enhance outcomes after bariatric various time points (Tables 1 and 2), surgery including a relationship between Janet Ng Corvallis OR1, Andrea baseline craving levels and %TWL. Stone Glastonbury CT1, Pavlos Despite adequate power, we failed to Papasavas Hartford CT1, Darren observe a group effect on weight Tishler Glastonbury CT1, Godfrey regain. A limitation of the study is that Pearlson Hartford CT2, Ilene half of the MI participants missed half Staff Hartford CT1, Tara of the sessions and only 8/40 McLaughlin Hartford CT1, Jennifer participants attended all six MI Ferrand Hartford CT2, Sally sessions. Participant feedback was Strange Hartford CT1 overwhelmingly positive. We feel that Hartford Hospital1 Hartford Hospital, further interventions post bariatric Institute of Living2 surgery should focus on food cravings and emotional regulation, possibly Weight regain is a problem for many targeting a more narrowly defined patients after bariatric surgery. We group of patients struggling with randomly assigned 79 patients weight regain at an earlier time point undergoing sleeve gastrectomy (SG) to after surgery. either treatment as usual (TAU; n = 39) or to six weekly sessions of a

230 www.obesityweek.com A348 waste, use of the gastric clamp resulted Reducing Excess Staple Cartridge in significantly fewer cartridges wasted Use During Sleeve Gastrectomy compared to traditional bougie (1 vs. 2, Vikrom Dhar Cincinnati OH1, Tiffany p<0.01). With respect to expert Lee Cincinnati OH1, Jonathan assessment of intraoperative sleeve Thompson Cincinnati OH1, Tayyab appearance, ratings were significantly Diwan Cincinnati Ohio1 higher for the clamp group regarding University of Cincinnati1 optimal shape and volume, avoidance of retained fundus, appropriate distance Background: Variability in staple line from anatomic landmarks, and lack of creation during laparoscopic sleeve kinks, spirals, or twists in the staple gastrectomy (LSG) may be associated line (all p<0.05). with complications including leak, bleeding, and reflux. The objective of Conclusion: Use of a gastric clamp this study was to assess the impact of during LSG resulted in fewer staple using a gastric clamp on stapling cartridges wasted and improved expert efficiency and pouch quality. rating of intraoperative sleeve appearance. Standardizing operative Methods: Thirty-nine patients technique using a gastric clamp may undergoing LSG were enrolled in a result in improved outcomes for prospective, single-center, randomized patients undergoing LSG. controlled study. Patients were randomized to LSG performed with a gastric clamp (n=21) versus traditional A349 bougie (n=18). Outcomes included Sleeve Gastrectomy in Low BMI excess staple cartridge use and expert Diabetic patients rating of intraoperative sleeve Nandakishore Dukkipati Hyderabad 1, appearance. Number of wasted staple DEEPTI THAKKAR HYDERABAD 1 cartridges was determined by CONSULTANT1 subtracting the ideal number of staple cartridges required based on sleeve Bariatric/metabolic surgery is already length from the total number of staple accepted as a treatment option for type cartridges used. 2 diabetes mellitus (T2DM) in patients with body mass index Results: No significant differences (BMI) 35 kg/m2. BMI based were found between groups with regard guidelines were established and are to patient demographics or preoperative being followed since 1991. However, BMI (p>0.05). Similarly, there were no after more than 25years, we know the differences in operative time or time for inadequacy of planning surgery only sleeve creation (p>0.05). When based on BMI criteria. We now know evaluating excess staple cartridge that the risk of diabetes and/or

231 metabolic syndrome is determined patients undergoing laparoscopic more by ethnicity, waist circumference, sleeve gastrectomy (LSG) fat distribution, hepatic steatosis etc. Sabin Warner-Smith Pimlico Recently, International Diabetes Mater Hospital Federation has released its position statement which mentions that bariatric Introduction: surgery for T2DM be considered a Patients with obesity undergoing reasonable therapeutic alternative for laparoscopic sleeve gastrectomy (LSG) low BMI (<35 kg/m2) patients with have been shown to experience T2DM who do not respond to standard significant post-operative weight loss. medical therapy. In Australia, the majority of bariatric T2DM remission after metabolic surgery is performed within private surgery is based on 2 Hypotheses. hospitals as few public facilities offer According to foregut theory, nutrients bariatric services. Consequently, the directly entering distal part of the small cost of the operation can be high for bowel results in increased secretion of patients who are not privately insured. incretins such as GLP-1. Hindgut The purpose of the study was to theory states that bypassing the foregut compare excess weight loss (EWL) in decreases release of Diabetogenic insured and uninsured patients 6 factors. In addition, Insulin resistance months post undergoing LSG. decreases with Surgery induced weight Method: loss. A retrospective analysis was The regular Bariatric procedures have undertaken incorporating 276 patients also not caused a dramatic BMI with a BMI>30 who had undergone decrease in low-BMI patients. sleeve gastrectomy at an Australian However, low preoperative BMI and surgical centre between 2014 to 2017. severe T2DM also showed low long The insurance status for each patient term remission with recurrence of was reviewed. The EWL for each Diabetes after a few years. Which patient obtained at their 6-month means that the timing of intervention is postoperative visit was documented and also important. More long term, the results were then compared. randomised and prospective studies are Results: needed to determine feasibility and Of the 276 patients who underwent durability of Bariatric surgery in LSG at our facility, 58 (21%) were Diabetic patients with BMI < 35kg/m2. uninsured whilst 218 (79%) had private health insurance. The mean and median EWL was found to be 67.28% and A350 68.25% in patients with no private Money and motivation: A health insurance compared with comparison of excess weight loss 71.06% and 68.8% in patients with (EWL) in insured and uninsured private insurance.

232 www.obesityweek.com Conclusion: Results: There was no statistical Overall, we found that patients with difference in weight loss between private health insurance had both a surgeons centers or gender. There was higher mean and median EWL 6 a statistically significant difference months post LSG compared with between different age groups and uninsured patients. Reasons behind this percent weight loss. There was no difference may include both lifestyle statistically significant difference in and socioeconomic factors, however percent loss by weight class, but further research is indicated. patients with BMI up to 40 had a 94.7% chance of becoming non-obese, BMI 40-45 at 65.4%, 45-50 31.9%, and >50 BMI at 4.3%. A351 Discussion: The surgeon, center, Will I Still Be Obese Following gender or BMI class made no Sleeve Gastrectomy? difference in percentage weight loss. Sarah Pearlstein New York NY1, Ali Age had a parabolic relationship with Shayesteh New York NY, Deborah those on either end of the spectrum Allis Mount Kisco NY, Mitch losing a higher percentage. Because the Roslin New York NY percentage weight loss was comparable Lenox Hill Hospital Northwell Health1 despite BMI class, sleeve gastrectomy is not effective with super-obese Introduction: Average weight loss patients to become non-obese statistics quoted to patients undergoing Conclusion: The results of sleeve sleeve gastrectomy are around 60% of gastrectomy are consistent and excess body weight. However, this replicable however is consistently average is not geared toward specific ineffective at helping more obese patient factors. Patients desire to know patients become non-obese. if they will be non-obese following the operation. The purpose of our investigation is to elucidate factors that can indicate the probability of a patient A352 becoming non-obese following surgery; Robotic gastric bypass is getting as well as to evaluate whether various better: first results from the factors played a role on amount of Metabolic and Bariatric Surgery weight loss. Accreditation and Quality Methods: Retrospectively retrieved Improvement Program data of 447 sleeve gastrectomies Peter Lundberg Allentown PA1, performed at two related bariatric Jacqueline Seoane Bethlehem PA, centers by 4 surgeons. We looked at Samantha Wolfe Bethlehem PA, Maher differences in weight loss based on age, El Chaar Allentown PA sex, BMI class, surgeon and center. St Luke's Weight Management Center1

233 Background The use of robotic operation, or readmission between the platforms in performing laparoscopic two groups. roux-en-Y gastric bypass (LRYGB) is Conclusions Robot-assisted LRYGB is increasing, though their safety an increasingly popular alternative to compared to the conventional the conventional laparoscopic laparoscopic approach remains unclear. approach. According to the MBSAQIP Objective The objective of this study database, the early safety of these two was to evaluate peri-operative data and techniques are equal, although the 30-day outcomes of conventional and robotic approach requires more robot-assisted LRYGB using the operative time. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) A354 data registry. The effects of bariatric surgery on Setting University health network, knee outcomes in patients eligible for United States. total knee arthroplasty. Early results Methods We reviewed all conventional from the SWIFT Trial. and robot-assisted LRYGB cases Christopher Still Danville PA, Shawnee entered between January 1 and Lutcher Danville PA1, G. Craig December 31, 2016 in the MBSAQIP Wood Danville PA1, Jamie data registry. Demographic Seiler Danville PA, Christopher characteristics and 30-day outcomes Seiler Danville PA, Scott were analyzed based on separate Mann- Jamieson Danville PA, Brian Whitney rank sums tests, 2, or Fisher's Irving Baton Rouge LA, Peter Benotti exact tests as appropriate, with p < 0.05 Geisinger Health System1 denoting statistical significance with no adjustment for multiple testing. Introduction: Patients eligible for total Results Of the 39,425 patients who knee arthroplasty (TKA) with severe underwent LRYGB, 2,822 were robot- obesity (BMI40 kg/m2) are assisted. The robot-assisted approach increasingly required to lose weight required significantly more time (138 prior to TKA. The benefits of bariatric minutes versus 108 minutes, p < surgery on knee outcomes are 0.0001). Rates of organ space infection, unknown. The purpose of this study is bleeding, and other significant adverse to evaluate changes in knee outcomes events following the conventional and after bariatric surgery in patients robot-assisted approaches were 0.3% eligible for TKA. versus 0.5% (p = 0.13), 1.1% versus 0.8% (p = 0.11), and 2.3% versus 2.3% Methods: The SWIFT trial is an (p = 0.96), respectively. There were ongoing, multi-site, prospective trial also no significant differences in the that compares knee and physical rates of mortality, length of stay, re- function outcomes in patients receiving

234 www.obesityweek.com bariatric surgery prior to TKA versus Brigham and Women's Hospital1 patients that have TKA only. Knee outcomes for this analysis included Background: Transoral outlet Visual Analog Scale for knee pain, reduction (TORe) is an effective Timed Up and Go, 30-second Chair treatment for weight regain after Roux- Stand, and 40-meter fast paced walk. en-Y gastric bypass (RYGB) which Changes from baseline to 6-months may be performed via suturing or after bariatric surgery were compared plication. Restorative Obesity Surgery using paired t-tests. Endoluminal (ROSE) is a plication form of TORe. Results: Preliminary results of the ongoing SWIFT Trial included six Aim: To assess the efficacy of a novel patients that had bariatric surgery and ROSE technique combining argon completed 6-month follow-up after plasma coagulation (APC) and bariatric surgery. These patients had a plications to treat weight regain. mean age of 49.7 years (SD=5.4), 83% were female, and had a mean BMI of Methods: The gastrojejunal 45.7 kg/m2 (SD=5.7). At 6-months after anastomosis (GJA) was ablated with bariatric surgery, there were small but APC (forced, 0.8 L/min, 80W). non-significant improvements in knee Endoscopic plications were placed in pain (33 vs 31, p=0.625), Timed Up the ablated area and pouch. Part I: and Go (7.5 vs 7.0, p=0.843), Chair Technical feasibility, safety and Stand (12.5 vs 10.5, p=0.999), and 40- efficacy of ROSE were assessed. Part meter walk (22.9 vs 21.8, p=0.438). II: Patients who underwent ROSE were matched 1:2 based on age, sex, GJA Conclusion: Bariatric surgery may and pouch sizes, and follow-up time to result in modest improvements in knee those who underwent suturing. Weight outcomes in patients that are eligible loss of the two procedures were for TKA and may eventually delay or compared. negate the need for a TKA. Results: 14 RYGB patients underwent the novel ROSE procedure. Patients weighed 92.5±14.2 kg and regained A355 32.4±18.0% of maximal weight loss. Comparison of a Novel Plication Average GJA and pouch sizes were Technique to Suturing for 18±9 mm and 5±1 cm. Part I: Endoscopic Outlet Reduction for the Technical success was 100%. At 3- Treatment of Weight Regain after months, weight loss was 10.2±5.6 kg Roux-en-Y Gastric Bypass (p=0.0003), corresponding to %total Pichamol Jirapinyo Chestnut Hill MA1, weight loss (TWL) of 10.7±5.9%. Part Christopher Thompson Boston MA1 II: 14 ROSE patients were matched to

235 28 sutured reductions. The amount of patients under iv sedation, with a mean weight loss was similar between the BMI 30.1 kg/m2 (26-60). It was filled two procedures (TWL of 8.6±3.5% for with 600 ml of saline solution. suturing versus 10.7±5.9% for ROSE, Removal was done 6-7 months p=0.30). Stenosis rate was 21% for after balloon insertion, under general ROSE, all of which were amenable to anesthesia with OT intubation for endoscopic treatment, versus 0% for airway protection. Insertion and suturing (p<0.0001). removal were done ambulatory.

Conclusion: A novel ROSE technique RESULTS: combining APC with plications appears Strictly followed up by a team of to be safe and effective at treating dietitians, 360 female (85 %) and 64 weight regain after RYGB. male (15 %) underwent IGB placement, that was uneventful. Mean age 34 (14- 67). Mean time for insertion and A356 extraction was 20 minutes. 29 (6,8%) Intragastric balloon therapy for patients did not complete the 6 months, obese and overweight patients, over mainly for intolerance and vomits or last 15 years complications that required early Marcos Berry Santiago 1, Lionel removal, majority within the first 6 Urrutia , Giselle Muñoz , Daniela weeks. There was 1 gastric perforation Ghiardo Santiago de Chile Region (0.5 %), 2 days after IGB placement, in Metropolitana, Rodrigo Javier Anacona a patient with previous anti-reflux Cocio Talca - VII Región de Chile , procedure during childhood, required Karen Rojas emergency surgery, repair and Clinica Las Condes1 successful recovery. Median weight loss 11.1 kg (0.2-28.5 kg.). mean BMI BACKGROUND: loss 3,5 points. Mean EWL was 49 % Indication for intra-gastric balloon over 6 months. (IGB) is weight reduction for mild obesity. Currently this indication has CONCLUSIONS: also included overweight patients with The IGB appears to be safe and multidisciplinary approach at our effective. It is an absolute Center contraindication in patients with prior OBJECTIVES: gastric surgery. Its efficacy to reduce Evaluation of safety and efficacy of weight with a well-supervised the IGB. nutritional guidance might be a good indication for the mildly obese patient METHODS: and even for the overweight patient. From January 2002 to September 2017, IGB was placed endoscopically, in 424

236 www.obesityweek.com A357 this analysis. Demographic and A Multicenter Study of Outpatient anthropometric characteristics of the Revision of Adjustable Gastric patients can be seen in Table 1. A Banding to Sleeve Gastrectomy simultaneous hiatal hernia repair was Amit Surve Salt Lake City UT1, Hinali performed in 32% patients. The mean Zaveri Salt Lake City UT1, Daniel total operative and operating room Cottam Salt Lake City UT2, Walter times were 74.9 ± 24 mins and 96.6 ± Medlin Salt Lake City UT1, Christina 24.3 mins, respectively. One intra- Richards Salt Lake City UT1, Legrand operative complication (1.8%) Belnap Salt Lake City UT1, Austin occurred. The mean total blood loss Cottam Salt lake City UT1, Samuel was 40 ± 35.1 cc. The mean patient Cottam Salt Lake City UT1, Benjamin emergence, post-anesthesia care unit, Horsley Salt Lake City UT1, Thomas and recovery room times were 92 ± Umbach 3, Matthew Apel Las Vegas 38.8 mins, 90.5 ± 42.4 mins, and 256 ± NV3, Michael Williams Alpharetta GA4, 93.5 mins, respectively. The mean Christopher Hart Atlanta GA4, Williiam length of stay was 7 ± 2.5 hrs. None of Johnson 4, Christy Lee Johns Creek the patients required unplanned returns GA4, Ciara Lee Johns Creek GA4, John to surgery, overnight hospitalization, or DeBarros Tempe AZ5, Michael transfer from outpatient to inpatient Orris Tempe AZ5 setting within the first 24 hours of Bariatric Medicine Institute1 Bariatric surgery. The 30-day follow-up rate Medical Institute2 Blossom was 98.1%. The 30-day reoperation, Bariatrics3 Atlanta General & Bariatric readmission, emergency department Surgery Cent4 East Valley Surgery visit, and mortality rates were 3.7%, Center5 0%, 0%, and 0%, respectively. The total short-term complication rate was Background Laparoscopic sleeve 7.5%. gastrectomy (LSG) is a safe and Conclusion Same-day discharge effective procedure that can be when removing the lap band and performed as an outpatient procedure. converting to LSG appears safe when Aim To determine whether outpatient performed as an outpatient procedure. LSG is safe in patients with previous adjustable gastric banding (AGB). Methods The medical records of 53 patients who underwent revision LSG A358 from previous AGB at five outpatient RETENTION AND ATTRITION IN surgery centers from September 2013 BARIATRIC SURGERY through July 2017 were retrospectively RESEARCH: A QUALITATIVE reviewed. STUDY Results Fifty-three patients (one stage: William Gourash Pittsburgh PA1, 51 and two-stage: 2) were included in Melissa Kalarchian Pittsburgh PA2,

237 Joan Such Lockhart Pgh PA2, Lenore travel time as barriers. Study Resick 2, Anita Courcoulas Pittsburgh participants perceived strategies that PA3 better enabled them to manage their Magee Womens Hopital-University of time and availability, and study Pittsburgh Medical Center1 Duquesne measure progress reports as beneficial University2 University of Pittsburgh (27). A majority (19) viewed an Medical Center3 honorarium and travel reimbursement positively (31) and supportive to their Longitudinal bariatric surgical research participation. studies often lack information on Altruism was an important motivation, retention and attrition of participants but over time usefulness to the and the strategies utilized to optimize participants’ goals increased in these. The potential for attrition with importance. These motivations, adverse effects on validity increases barriers, and facilitators to research over time. retention provide an evidence-base To explore research participants’ from which to further develop retention perceptions, motivations, and attitudes strategies. Further research should concerning participation in the focus on evaluating the effectiveness of Longitudinal Assessment of Bariatric retention strategies and developing an Surgery (LABS) study. optimal strategy selection process. A qualitative study with content analysis of individual patient interviews from a sample stratified by prior A359 research participation. Abdominal pain before and after Thirty-six interviews were completed Roux-en-Y gastric bypass. to reach analytic Monica Chahal-Kummen Oslo 1, saturation. Fifteen motivational Ingvild Blom-Høgestøl Oslo 1, Inger themes were identified. The 3 most Eribe Oslo 1, Jon Kristinsson Oslo 1, frequently cited were:Sharing one’s Tom Mala Oslo 1 own experiences to help others, study Oslo University Hospital1 participation was helpful to my own goals, and desire to support research. Introduction Motivation changed over time and did We aimed to study the prevalence and not appear related to prior participation. characteristics of chronic abdominal A majority (22) responded that they pain (CAP) before and two years after would return to annual research visits Roux-en-Y gastric bypass (RYGB). We with poor weight loss, but with also evaluated other abdominal and ambivalence. Extensive questionnaire psychological symptoms, as well as completion was perceived as a quality of life (QoL). significant barrier (23). A sizable subgroup (15) perceived distance and Method

238 www.obesityweek.com We performed a cohort study and RYGB. Careful evaluation of CAP included patients with morbid obesity before and after RYGB is planned for RYGB. Before and after recommended. RYGB, patients were presented with a set of questionnaires including Gastrointestinal Symptom Rating Scale A360 (GSRS), Hospital Anxiety And Is There a Correlation Between Depression Scale (HADS), Short-Form Comorbidities and Post 36 version 2 (SF-36v2) and a non- Laparoscopic Sleeve Gastrectomy validated abdominal pain questionnaire, Gastric Stenosis? followed by consultation with a Maria Fonseca Mora Weston FL1, physician and retrieval of medical Cristian Milla Matute Davie FL1, David history, including comorbidities. Romero Funes Weston FL1, Emanuele Menzo Weston FL1, Samuel Results Szomstein North Miami Beach FL1, 236 patients were included and 209 Raul Rosenthal miami FL2 (88.6%) attended the two year follow- Cleveland Clinic Florida1 Cleveland up. 169/236 (71.6%) were females. Clinic of FL2 Mean (SD) age and BMI at baseline were 44 (9.2) years and 43.2 (5.9) Background kg/m2. Mean BMI (SD) at follow-up Gastric Stenosis(GS) has been reported was 29.3 (4.7) kg/m2. Surgical in 4% of Laparoscopic sleeve complications were seen in 26/209 gastrectomy(LSG) cases. No studies (12.4%) patients. At baseline 28/236 have been suggested a possible (11.8 %) and at follow-up 60/209 correlation between the incidences of (28.7%) patients reported CAP post LSG stricture and preoperative (p=0.001). For the entire cohort, we comorbidities. The aim of this study is observed significant increases in all to analyze the possible association GSRS syndrome scores, in anxiety between preoperative comorbidities symptoms and in QoL domains at two and LSG stenosis in our bariatric years. As presented by Figure 1; when population. compared to those without CAP, Methods patients with CAP two years after All patients who underwent primary or RYGB had higher GSRS abdominal secondary LSG from January 2005 to pain syndrome scores, which March 2018 at our institution were negatively affected their QoL retrospectively analyzed. The patient (p<0.001). who developed GS postoperatively were matched with a controlled group Conclusion for demographics and comorbidities. We found a significant increased Categorical and nominal variables were prevalence of CAP two years after analyzed with Chi-square and

239 Independent T-test respectively. Oregon Health and Science Results University1 Oregon Health and Of the 1878 patients reviewed, Sciences University2 10(0.53%) developed GS after LSG. These patients were matched with a Introduction: control group in a 1:1 ratio. The mean As robotic bariatric surgery becomes age was 56.85±9.59 years, all females, more common, it is important to assess and predominantly white (85%). After complications as trainees become more matching, BMI was found to be not involved in these procedures. The statistically significant for GS (0.856). Metabolic and Bariatric Surgical Preoperative diagnosis of T2DM, HTN Association Quality Improvement and dyslipidemia were significant risks Program (MBSAQIP) records bariatric factors for GS, OR: 9(CI:0.809-100 and surgery-specific complications for all P=0.051), OR 13(CI: 1.19-152 and procedures at member institutions. Our P=0.019) and OR 9(CI: 0.809-100 and hypothesis was that resident P=0.051) respectively. Active smokers involvement in robotic bariatric surgery had increased risk for GS OR 5(0.655- does not increase complications. 38.15) when compared to never Methods: smokers. No statistical significance was All robotic sleeve gastrectomy (SG) found among patients with preoperative and roux-en-y gastric bypass (RYGB) diagnosis of CKD, CAD, GERD or cases reported in 2015-2016 MBSAQIP history of GI bleed, P=1.00, P= 0.305, database were included. Complications P=0.639 and P=0.136 respectively were compared across assistant types: (Table1). resident, no assistant/surgical Conclusion technician (NA), fellow, nurse Active and former smokers, T2DM, practitioner/physician assistant/nurse HTN, and dyslipidemia seems to be first assist (NP/PA/RNFA), and related to the incidence of post-LSG attending. Propensity score weights Gastric stenosis. Larger studies are were added to all analysis to account necessary to corroborate these findings. for non-random patient assignment to different assistant types. Results: A361 For SG, there was no difference in Resident involvement in robotic complications across assistant types bariatric surgery: A MBSAQIP (Figure 1). Compared to a resident, analysis NP/PA/RNFA were 3.5 times more Tarin Worrest Portland OR1, Elizabeth likely (CI 1.8-6.9) to require Dewey Portland OR2, Farah conversion to another operative Husain Portland OR2, Stephanie technique. For RYGB, NP/PA/RNFA Wood Portland OR1 were 1.29 times more likely (CI 1.02- 1.63) to have complications compared

240 www.obesityweek.com to residents. There was no difference in gain, Their impact on weight loss complications between the other groups following bariatric surgery is not well compared to residents for RYGB studied. We compared effects of the (Figure 1). Operative length for SG was selected antidepressants fluoxetine, significantly longer for residents paroxetine, and bupropion on weight compared to other assistant groups loss at 6 months and 1 year post (p=0.02). For RYGB, residents had bariatric surgery. longer operative times compared to NA Methods or NP/PA/RNFA, but shorter than We scanned pre-operative prescription fellows (Table 2). records of 4857 patients who Conclusion: underwent primary gastric banding Resident involvement in robotic (GB), sleeve gastrectomy (SG) or Roux bariatric surgery increases operative en Y gastric bypass (RYGB) at our times, but does not lead to an increased institution from 3/1/2008 through complication rate. Bariatric surgery 4/15/2018 for antidepressant may be an appropriate model to teach medications, and found 428 were residents the essentials of robotic prescribed bupropion, fluoxetine, or surgical techniques. paroxetine <1yr prior to surgery (Table 1). Post-surgery weights were compared using ANCOVA to test for A362 the effect of drug on % total weight Effect of selected antidepressant loss at 6 months (%TWL-6m) and one drugs on weight loss post-bariatric year (%TWL-1y), alone and with surgery: a single-center, adjustment for surgery type, age, pre- retrospective chart review surgery BMI, and sex (Table 2). Devika Umashanker Glastonbury CT1, Results Madison O'Brien South Windsor CT1, We excluded 9 patients taking more Tara McLaughlin Hartford CT2, than one drug. The unadjusted mean Andrea Stone Glastonbury CT1, %TWL (±sem) for fluoxetine, Mirjana Domakonda Hartford CT3, paroxetine, and bupropion were, at Richard Seip Glastonbury CT2, Darren 6m: 17.1±1.4, 19.3±1.0, and 19.9±0.7, Tishler Glastonbury CT1, Pavlos respectively (p=0.25, NS), and at Papasavas Hartford CT1 1yr: 20.0±2.0, 22.9±1.5, and 24.8±1.0 Hartford Hospital - Metabolic and (p=0.16, NS). Means (±sem) adjusted Bariat1 Hartford Hospital2 Hartford for surgery type using ANCOVA were, Hospital Institute of Living3 at 6m: 18.1±1.1, 18.3±0.7, and 20.2±0.5 (F=2.64, p=0.064, NS), Introduction respectively, and at 1yr: 22.3±2.1, Anxiety and depression are common in 21.9±1.3, and 24.8±0.9 (F=1.91, obesity. Antidepressants, as a first line p=0.152, NS). treatment, may cause weight Conclusion

241 Weight loss following surgery, after (20%) with glycemic improvement adjustment, tended to be greater in post-LSG. The mean time of diabetes patients taking bupropion compared to remission was 2.91 months post-LSG. fluoxetine or paroxetine. More The BMI mean ± SD dropped from research will better elucidate 45.48 ± 8.84 kg/m2to 33.06 ± 6.63 psychotropic drug effects on bariatric kg/m2 post-LSG (P<0.0001). Of 80 weight loss. patients, 72 (90%) patients are on a healthy diet and discontinued diabetes treatment post-LSG due to remission of diabetes or significant glycemic A363 improvement. Laparoscopic Sleeve Gastrectomy According to our results, duration of Impact on Remission of Type 2 diabetes pre-LSG and lower pre-op Diabetes HbA1c and FBG associated with higher Saad Althuwaini Riyadh remission rate with a significant p- king khalid university hospital value (0.0019, 0.0004, <0.0001). Pre- op BMI does not predict remission of Background: Obesity is a major risk diabetes post-op. factor for type II diabetes. Mal- Conclusion: Type II diabetes remission absorptive procedures believed to have post LSG is significant with a mean better outcome. Relatively newer time of 2.9 months post-op. LSG could restrictive procedures like laparoscopic be considered as a choice of treatment sleeve gastrectomy (LSG) is being for patients with obesity and type II performed more often to these type of DM. patients. Objective: To determine the achievement rate of diabetes remission and glycemic improvement post (LSG) A364 in type 2 diabetes. Assessment of acid exposure in the Material and Methods: This was a stomach in gastric bypass patients retrospective cohort study conducted on with anastomotic ulcer: insights into 80 patients with type 2 diabetes who pathologic acid exposure underwent LSG from 2009-2016. Pei-Wen Lim Worcester MA1, Richard Diabetes remission was considered if Perugini Worcester MA1 FBS (<7mmol/L), HbA1c (<6.5%) with University of Massachusetts Medical cessation of all diabetic medications. School1 Glycemia was considered to improve if HbA1c decreased by 1% and FBS by Introduction: Anastomotic ulcer 1 mmol/l. following Roux-en-Y gastric bypass Result: 64 (80%) patients achieved affects 16% of patients. Risk factors complete remission of diabetes, and 16 such as cigarette smoking and

242 www.obesityweek.com NSAIDs/steroids use do not fully the stomach is risk factor for account for all cases. We postulate anastomotic ulcer in bypass patients. excessive acid exposure to be a culprit. Acid exposure is worsened in the We studied the acid exposure of gastric supine position. pouch in patients presenting with recurrent ulcer disease following gastric bypass. A365 Preoperative Weight Loss Method: A 24 hour ambulatory pH Medication Use and Postoperative monitoring was performed in three Outcomes patients with recurrent ulcer disease Tripurari Mishra 1, Laura without cigarettes or NSAIDSs/steroids Marchiando Onalaska WI2, Andrew use. We utilized a dual pH probe Borgert La Crosse WI1, Kara Kallies La (Medtronic), with one channel Crosse WI1, Shanu Kothari La Crosse positioned in the lower esophagus, and WI2 the other in the stomach, off acid Gundersen Medical suppression therapy. As a control, we Foundation1 Gundersen Health System2 used a similar study performed in a patient with primary esophageal Background: The impact of using dysmotility who has no evidence of weight loss medications (WLM) ulcer disease. preoperatively on postoperative outcomes is not well understood. The Results: Average age of patients were objective of this study was to evaluate 47 + 10 years and average BMI was the outcomes for patients who used 42 + 5 kg/m2. Anastomotic ulcer these medications preoperatively versus occurred at 1601 + 634 days those who did not. postoperatively.There was no Methods: The medical records of all pathologic acid exposure in the patients who underwent bariatric esophageal probe of anastomotic ulcer surgery at our medical center from patients (0.9 + 1.4%) or in the control 2001-2017 were retrospectively (0.7%). Acid was present with a much reviewed. Our integrated medical higher frequency in the stomach probe record system was used to determine of the patients with ulcer disease long-term weights and comorbidity (64.4 + 15.5%) than in the control status. Patients were grouped by (12.1%). Acid exposure was greater in whether or not they used prescription the supine position than in the upright WLM within 1 year prior to bariatric position in the symptomatic patients surgery. (79.8 + 25.6 vs 47.4 + 15.5, p = 0.15). Results: Overall, 1,876 patients underwent surgery; 333 laparoscopic sleeve gastrectomy, and 1,543 Summary: Excessive acid exposure of laparoscopic Roux-en-Y gastric

243 bypass. There were 67 patients Background: Regional body fat prescribed a WLM preoperatively. distribution is a significant predictor of Mean age, preoperative BMI, and health outcomes as cardiometabolic proportion of women for those who did disorders are associated with android vs. did not use a medication obesity, or central fat deposition. preoperatively were 43.0±10.7 vs. omparatively, gynoid obesity and 45.0±10.5 years (P=0.14), 46.8±6.7 vs. peripheral fat deposition, reportedly has 47.2±6.2 kg/m2 (P=0.67), and (76.1% a protective role against these diseases. vs. 80.1%; P=0.34). Glucose/HgbA1c Objective: The objective of this study is and cholesterol values were available to evaluate regional body composition for 874 and 984 patients, changes in patients undergoing bariatric respectively. Preoperative prevalence surgery, comparing roux-en-Y-gastric- of type 2 diabetes (14.7% vs. bypass (RYGB) with laparoscopic 16.7%; P=0.85) and dyslipidemia sleeve gastrectomy (LSG). (20.6% vs. 30.0%; P=0.24) were Methods: A prospective analysis was similar for those who did vs. did not completed on fourteen patients use a WLM. No difference in undergoing bariatric surgery, RYGB or preoperative weight changes for those LSG, between 2017 and 2018 at St who used vs. did not use WLM Vincent’s Hospital Melbourne. Body (+0.1±7.6 vs. 0.8±5.9 %TWL; P=0.09) composition was measured with dual- were observed. energy X-ray absorptiometry Conclusion: Use of WLM immediately before the procedure, and preoperatively did not significantly one-month post-operatively. impact postoperative long-term weight Results: Fourteen patients were loss or comorbidity improvement. Use recruited for this analysis (RYGB n=4, of WLM should not be used as a LSG n=10). At one month post- predictor of successful weight loss operatively; mean RYGB fat mass loss post-bariatric surgery. was 4.65 ±1.59 kg, of which 0.53 ±0.62 kg derived from android fat mass, and 0.36 ±0.67 kg from gynoid fat mass. A366 Mean LSG fat mass loss was 4.16 Differences in regional fat loss ±1.83 kg, which included 0.37 ±0.55 kg following sleeve gastrectomy and android fat and 0.92 ±0.71 kg gynoid roux en Y gastric bypass. fat. RYGB was associated with greater Jonathan Sivakumar Melbourne 1, Lynn truncal fat mass loss, mean of 2.22 Chong Fitzroy 2, Salena Ward Fitzroy 2, ±2.51 kg, compared to a mean of 1.31 Tom Sutherland Melbourne 2, Michael ±2.59 kg in the LSG group. RYGB was Hii Fitzroy 2 less associated with lower limbs fat St Vincent's Hospital Melbourne1 St mass loss, mean 1.41 ±1.57 kg, Vincent’s Hospital Melbourne2 compared with a mean of 2.4 ±2.14 kg in the LSG group.

244 www.obesityweek.com Conlusion: Both RYGB and LSG undertaken in patients with bleeding demonstrated substantial fat mass loss after LSG and matched controls. post-operatively; however, it is possible Controls were matched (1:1) with cases that RYGB is associated with a greater by age (±3 year), BMI (±4 kg/m2) loss of fat from an android distribution. gender (female versus male), staple line reinforcement (running suture versus haemostatic clips), comorbidities A367 (diabetes, hypertension and obstructive The impact of last 15 minutes of sleep apnea) and surgeon's experience surgery on the hemorrhagic (>50 or <50 LSG procedures per complications after laparoscopic year). The intraoperative blood sleeve gastrectomy. Case-control pressure was recorded in last 5th, 10th study. and 15th minutes of surgery. Michal Janik Warszawa 1, Mateusz Results Czado Warszawa , Konrad 12 patients after LSG with HC in Kosiski Warsaw , Szymon postoperative period were matched Grochans Kurów , Maciej with 12 controls. Patients who Waldziak Warsaw 1, Krzysztof experienced hemorrhagic complications Panik 1, Piotr Kowalewski Warszawa 1 after LSG had statistically significant Military Institute of Medicine1 increased mean systolic blood pressure (mmHg) in last 10th and 15th minute of Introduction surgery (87.80± 11.96 vs Laparoscopic sleeve gastrectomy 79.44±8.80mmHg, p= 0.049, and (LSG) is associated with a significant 89.20±11.67 vs 77.50±11,82 mmHg, risk of hemorrhagic complications p=0.011). The detailed analysis (HC). Last 15 minutes of laparoscopic revealed significantly higher diastolic procedure are very important in terms blood pressure measurements in 10th of hemostasis control. Therefore, blood and 15th last minutes. pressure profiles at the end of surgery Conclusion may have an influence on the risk of Compared with closely matched control HC. subjects, patients with HC after LSG Aim have incresed diastolic pressure at the The aim of the study was to assess the last 10 minutes of surgery. blood pressure profile in last 15 minutes of LSG in patients who experienced hemorrhagic complications A368 after laparoscopic sleeve gastrectomy. Safety and outcomes of laparoscopic Methods sleeve gastrectomy in patients older Medical records of 867 patients were than 60: a case-control study. reviewed. A case-control study of Katarzyna Bartosiak Warsaw 1, Maciej intraoperative blood pressure was Waldziak Warsaw 1, Piotr

245 Kowalewski Warsaw 1, Krzysztof laparoscopic sleeve gastrectomy is safe Panik 1, Micha Janik Warszawa 1 and effective in patients with age over Military Institute of Medicine1 60.

Background: The majority of older population suffers from multiple comorbid conditions including obesity. A369 Surgical interventions seem to be the Impact of bariatric surgery in anti- most promising solution for the obesity reflux medication use in patients problem. with asthma and GERD Objective: The aim of the study was to Gerardo Davalos durham NC1, Dana evaluate the safety and effectiveness of Portenier Durham NC1, Hui-Jie LSG in a cohort of patients over the Lee Durham NC1, Jennifer age of 60 years compared with matched Ingram Durham NC1, Alfredo controls under 40 years old. Guerron durhjam nc1 Methods: A retrospective review of a Duke health1 prospectively collected database was conducted of patients >60 years who Objective: to determine the effects of underwent a LSG. 23 patients aged >60 bariatric surgery in anti-reflux years were matched 1:1 with patients medication use in patients who have aged <40. obesity and both asthma and GERD. Results: The mean postoperative BMI at 12 months after surgery was Background: There is an association significantly higher in study group between asthma and GERD (36.38 kg/m3 ± 7.07 vs 33.10 kg/m3 ± (1). Although bariatric surgery has 5.65, p= 0.004). BMI was shown to reduce medication use in both significantly lower in study group at 12 comorbidities separately, there is months (13.56 ± 6.05 vs 10.3 ± 4.89, limited research done in a population p=0.008) as well as %EBMIL (50.71 ± who have both asthma and GERD. 25.94 vs 64.20 ± 23.29, p= 0.015). At 24 months the mean BMI was still Methods: Adult patients had asthma higher in elderly group but without and obesity, and at least one anti-reflux statistical significance (32.57 ± 9.45 medication before surgery were versus 30.16 ± 4.8, p=0.081). At 24 followed up at 30 days and 1 year after The difference in mean BMI and bariatric surgery. Poisson Generalized %EBMIL at 24 months after surgery Linear Mixed Models (GLMMs) with a did not reach statistical significance, log link for repeated measures were fit respectively: 14.34 ± 8.22 vs 16.51 ± to evaluate the effect of time and 5.97 (p=0.125) and 69.92 ± 45.91 vs procedure type on the number of 77.50 ± 19.41 (p=0.112). hypertension medications while Conclusions: This study suggests that adjusting for risk factors including age,

246 www.obesityweek.com gender, race, preoperative diabetes, and H Vall d'Hebron -Univ Aut de preoperative BMI. Barcelona1 H Vall d'Hebron - General Surgery Depart2 H Vall d'Hebron - Unit Results: Among 332 patients who were of Endoc surgery3 University of prescribed with at least one asthma and Rondonia and Universitat Autónoma de one GERD medication, the mean Barcelon4 Hospital Vall d'Hebron5 number of pre-operative GERD medication use was 1.12 (SD:0.37), Background: Laparoscopic Roux-en-Y which was decreased to 0.78 (SD:0.48) gastric bypass (RYGB) is one of the at 1-year post-operation. We did not most important bariatric surgical detect significant differences in a procedures performed around the world number of GERD medications between and it can produce an important lose of procedure types and thus procedure weight with reversal of metabolic type was not included in the final disorders like diabetes and model. We found that a significant dyslipidemia. Even though it has good decrease in a number of GERD results, some complications occur after medication at 1 year compared to gastric bypass. A rare complication of baseline (RR:0.72, 95% CI:0.62-0.85, RYGB is hypoglycemia which has p<0.0001), after adjusting for been estimated in 0,1% of cases but confounders. causes remain unclear. Methods: A retrospective analysis of a prospective Conclusion: all bariatric procedures database of Endocrine, bariatric and showed a decrease in anti-reflux metabolic Unit. General Surgery medication use in patients who have Department. Universitat Autònoma de obesity and both asthma and GERD Barcelona. Hospital Vall Hebron. Barcelona, Spain. Results: Between 2011 and 2018, 8 patients underwent A370 laparoscopic reversal procedure. REVERSAL GASTRIC BYPASS Preoperative Body Mass Index (BMI) TO NORMAL ANATOMY WITH mean was 31.2 Kg/m2 (range: 28 – SLEEVE GASTRECTOMY BY 39.4 Kg/m2) and 6 were women. The HYPOGLYCEMIA standard approach was laparoscopic RAMON reversal to normal anatomy with or VILALLONGA BARCELIONA 1, Jose without concomitant sleeve Manuel Fort Barcelona 2, Oscar gastrectomy (SG) and resection or not Gonzalez Barcelona 3, Jose Maria of alimentary RYGB limb. Three Balibea Barcelona 1, Enric patients presented postoperative Caubet Barcelona - Spain 3, Renato complications: gastrogastric Roriz-Silva Porto Velho 4, Gian Pier anastomosis leak (1), colitis with intra- Protti Barcelona 5, Mariona abdominal collection (conservatively Jofra Barcelona 5 managed) (1), and one case of

247 mesenteric venous thrombosis. Average (RYGB).Methods Retrospective review hospital stay was 9.8 days. No of prospective data registry from Jan mortality. All patients recovered from 2016 through Sept 2017. Eleven their initial condition, but two (25 %) patients, 10 female and 1 male had presented mild hypoglycaemia during conversion from SG to RYGB for follow-up. Two patients had weight control of reflux symptoms on high regain (25 %) and one case developed dose PPI. 11 surgeries(7 laparoscopic,4 gastroesophageal reflux disease Robotic). Mean BMI at time of RYGB (12,5%). The mean BMI in the last was 40.7 ± 11.1 kg/m2. Mean interval control was 29,8 time between SG and RYGB was 48.2 Kg/m2. Conclusions: The results of the ± 17.3 months. UGI series on laparoscopic reversal with SG after 11 patients prior to RYGB showed RYGB are acceptable, showing a significant reflux. pH testing mean clinical improvement of the DeMeester 43.3, pH < 4 mean time was hypoglycemic syndrome in all cases. 16%. High resolution esophageal manometry demonstrated varied abnormal A371 peristalsis. Results Mean operative Minimally invasive conversion of time was 173.3 ± 62.6 minutes. Mean sleeve gastrectomy to Roux-en-Y hospital stay was 2.54 ± 1.21 Gastric Bypass for Intractable days.There were no conversions to Gastroesophageal Reflux Disease: open surgery and no mortality. 7 Short Term Outcome. surgeries included a hiatal hernia Daniel Davis Dallas TX1, Lauren repair, 5 surgeries included fundectomy Kastner Dallas TX2, Steven of the retained fundus. 3 dev GJ Leeds Dallas TX2 stenosis. Mean follow up of 5.33 ± 2.89 Baylor University Medical months, all reflux symptoms resolved Center1 Baylor University Medical and off PPI, mean change in BMI 8.64 Center Dallas2 ± 7.17 kg/m2, % total weight loss13.73 ± 6.56%, and %EBMIL 40.1 ± 14.88%. Background Sleeve Mean change in BMI at follow-up was gastrectomy(SG) is considered definitiv significantly lower than initial values e surgery for weight loss due to (p=0.0006). Conversion of SG to excellent short-term results. GERD has RYGB is effective in managing been reported to have a post- intractable GERD and improving operative incidence between 3-50% and weight loss. management remains controversial. This case series demonstrates our experience with intractable GERD management after SG with conversion of SG to Roux-en-Y gastric bypass

248 www.obesityweek.com identified radiographically pre- operatively and/or intra-operatively A372 were identified. Patients with only a Internal Hernia Rates in Gastric hernia through Peterson’s defect were Bypass Using Absorbable Versus excluded. Pearson chi-square test was Nonabsorbable Suture for used to compare the relative risk of Mesenteric Closure internal hernia formation between Chris Finley Stow OH1, Adrian Dan 1, absorbable versus non-absorbable Ashley Bohon Akron OH1, Jenn Haas 1, sutures. John Zografakis Akron OH1, Mark Results: A total of 1597 total gastric Pozsgay Akron OH1 bypasses were performed between Summa Health1 2012-2017. 20 of 719 patients with absorbable sutures developed internal Background: Closure of the jejunal- hernias compared 17 of 878 jejunal mesenteric defect formed during nonabsorbable. The relative risk of a gastric bypass procedure is widely internal hernia formation with accepted as standard practice to absorbable sutures was 2.8% versus decrease the risk of internal hernia 1.9% with nonabsorbable formation. No current consensus exists (p=0.264). The overall OR of hernia regarding which suture type, formation was 1.449 (95% CI 0.753- absorbable versus nonabsorbable, is 2.788). more efficacious in prevention of post- Conclusion: Closure of the mesenteric operative internal hernia formation. defect of the jejunojejunostomy with Setting: University-affiliated, high- nonabsorbable suture carries a lower volume, accredited bariatric Center of risk for post-operative internal hernia Excellence. formation than absorbable Method: A retrospective review of sutures after laparoscopic gastric prospectively gathered data for all bypass surgery. laparoscopic gastric bypasses performed at a single high-volume center from 2012-2017 was performed. Data was utilized from the A373 facility database which tabulates all Trans-fistula Endoscopic Reduction bariatric post-operative of the Remnant Stomach: A Novel complications. Patients were Treatment Option for Weight Regain categorized into two groups based upon in Roux-en-Y Gastric Bypass the type of suture used for mesenteric Patients with Gastrogastric Fistula closure. All patients who subsequently Pichamol Jirapinyo Chestnut Hill MA1, underwent a second corrective surgery Christopher Thompson Boston MA1 for an internal hernia through the Brigham and Women's Hospital1 jejunal-jejunal defect that was

249 Introduction: Gastrogastric fistula fevers that resolved with antibiotics and (GGF) is a complication of Roux-en-Y GI bleeding that required no gastric bypass (RYGB) that is intervention. At 6 months, weight loss associated with weight was 9.8±8.3 kg (p=0.008), regain. Endoscopic closure of large corresponding to BMI reduction of GGF is ineffective and surgical 3.6±2.8 kg/m2 (p=0.005) and TWL of revision is technically challenging. 8.8±6.1%. Plication had greater TWL than suturing, although this was not Aim: To assess technical success, statistically significant (11.6% versus safety and efficacy of trans-fistula 8.0%, p=0.50). endoscopic reduction of the remnant stomach (TERRS) in the treatment of Conclusion: Endoscopic reduction of GGF. the remnant stomach via GGF appears safe and effective at treating weight Methods: This study was a regain in patients with large GGF. retrospective review of prospectively collected data. RYGB patients with large GGF (10 mm) who underwent A374 TERRS were included. Harnessing Electronic Health Record Information for Research on Procedure: The remnant stomach was Bariatric Surgery accessed via GGF and reduced using a Alicia Beeghly-Fadiel Nashville TN1, full-thickness suturing device (via Robb Flynn Nashville TN2, Robyn Endoscopic Sleeve Gastroplasty (ESG) Tamboli Nashville TN2, Shriya pattern) or a plication device (via Karam 2, Malcolm-Robert Bringhurst circumferential and longitudinal Snyder 2, Xiao Ou Shu Nashville TN2, plications of the body) (Figure Wayne English Nashville TN2, Loren 1). Outcomes: Technical success rate, Lipworth Nashville TN2 serious adverse event (SAE) rate and Vanderbilt University Medical percentage total weight loss (%TWL). Center1 VUMC2

Results: Eleven RYGB patients with Background: Bariatric surgery is the GGF were included. BMI and weight most effective approach for substantial regain were 39.3±6.1 kg/m2 and and sustained weight loss to combat 37.0±20.0% of maximal weight severe obesity, but individual response loss. GGF size was 17.8±6.2 mm. is highly variable. Few determinants Technical success rate was 100%. A have been identified, possibly due to median of 24 [19-48] stitches or 13.5 homogeneous study populations. [8-10] plications were placed per procedure. SAE occurred in 2/11 Methods: We assembled a patients (18%) including post-operative retrospective cohort of subjects who

250 www.obesityweek.com had bariatric surgery at the Vanderbilt system as well as the analysis of linked University Medical Center (VUMC) genetic data. from 2001-2017. We iteratively developed an algorithm to select individuals based on Current A375 Procedural Terminology (CPT) codes Evaluation of the feasibility of in VUMC electronic health records electronic data capture of patient- (EHR). We included patients with any report questionnaires in routine of four codes (43644, 43645, 43846, bariatric surgery patient 43847) for Roux-en-Y gastric bypass management with a rural population (RYGB) or one code (43775) for Ashleigh Pona Morgantown WV1, vertical sleeve gastrectomy (VSG), and Stephanie Cox Morgantown WV1, Nova excluded patients with any code for Szoka Morgantown WV1, Lawrence replacement, removal, or revision Tabone Charlotte NC1, Salim (43770, 43771, 43772, 43773, 43774, Abunnaja Morgantown WV1, Cassie 43842, 43843, 43848, 43886, 43887, Brode Morgantown WV1 43888). West Virginia University School of Med.1 Results: After removing patients with multiple CPT codes or age at surgery Objective: This quality improvement <18 years, our algorithm yielded 4,011 project sought to evaluate the bariatric surgery patients from VUMC feasibility of electronic data capture of EHR. The majority were Caucasian patient-report questionnaires using a (83.6%), female (77.6%), and had tablet portable personal computer RYGB (79.0%). At surgery, mean age (“tablet”) for integration in routine was 51.8 (±7.8) years and mean body bariatric surgery patient management mass index (BMI) was 48.5 (±8.6) with a rural population. kg/m2. Over time, this decreased for mean BMI, but increased for age and Methods: Participants (n=47) included proportion of non-Caucasian and VSG all bariatric surgery patients presenting patients. Non-Caucasians were for their pre-surgical psychological significantly more likely to have VSG evaluation (4/2017 to 5/2017) at an than RYGB, even after adjustment for academic medical center in West baseline BMI, age, and calendar year. Virginia. Tablets replaced the paper- and-pencil (P&P) forms routinely Conclusions: EHR information can be administered to patients at the time of harnessed to facilitate research on their psychological evaluation. A nine- bariatric surgery patients. Future item feasibility/satisfaction directions include incorporating questionnaire developed by the authors outcomes from across the VUMC EHR was administered to each patient to assess their experience of using the

251 tablet to complete clinic questionnaires. Alice Albanese Padova 1, Mirto Data analysis included descriptive Foletto Padova 2, Luca statistics (i.e., frequencies) of patient Prevedello Padua responses to the feasibility/satisfaction University of Padova1 Bariatric Unit items. Padua2 Background. Re-do surgery is still a Results: Most patients were very major concern in bariatric field. The satisfied using the tablet (77%), would best conversion treatment after weight recommend its use to other patients regain is still controversial. (87%), and preferred it over P&P Objectives. To compare early and late methods to complete clinic complications , weight loss and questionnaires (88%). The majority comorbidities resolution in mid term endorsed that the tablet was very after three different bariatric comfortable to handle (i.e., light conversional procedures: DS, OAGB, weight; 83%) and very easy to: read RYGB. (87%), use to respond to questions Methods. From January 2011 to (81%), and navigate with the touch December 2017, 21(3 M, 18 F) screen (85%). Further, 47% and 60% of patients underwent DS, 22 (22 F) patients respectively reported that use OAGB, 25 RYGB (18 F, 7 M), of the tablet encouraged them to respectively . Early and late discuss eating/mental health concerns complications, body mass index (BMI), with their provider and prompted them excess BMI loss (%EBL) were to remember symptoms that they have collected at 6, 12, 24 months follow-up experienced in the recent past. and compared. Discussion. OAGB patients showed the Conclusions: The use of tablets to best results in terms of weight loss at collect patient-report data in a rural 1st and 2nd year follow-up (%EBL = bariatric population demonstrated 65% and 63.7% vs 59% and 56.4% in excellent feasibility and satisfaction DS Group vs 41.6% and 40.9% in among patients and facilitated RYGB Group, respectively). Despite discussion about current mental health intensive vitamin supplementation in symptoms. all patients, sideropenic anemia and D hypovitaminosis affected mostly DS patients at 2nd year (76% of DS A376 patients). Weight regain after bariatric Comorbidities resolution resulted not surgery: Duodenal Switch (DS) vs statistically different in the three group: One Anastomosis Gastric By Pass Type 2 Diabetes mellitus on oral drugs (OAGB) vs Roux En Y Gastric By especially resulted controlled in the Pass (RYGB) . 60% of population about 2 years after surgery.

252 www.obesityweek.com Early comorbidity rate resulted higher underwent 1- stage and 40 underwent in the DS group : 3 duodeno-ileal 2-staged conversion. Patients who had anastomosis leak managed LAGB conversions were significantly conservatively, 1 incarcereted ventral older (p=0.0004), had a lower BMI hernia. (p<0.0001) and a higher proportion of Conclusion. OAGB efficacy on weight females (p=0.02). There were 4 pre- loss appeared higher. discharge complications (0.5%) in the primary LSG group and no complication (0%) in the LAGB A377 conversion group which were not Conversion to Laparoscopic Sleeve statistically significant (p=1.00) Gastrectomy after failed Adjustable between the 2 groups. 30-day Gastric Banding for Morbid Obesity readmission rates were not statistically Charmaine Gentles, DNP; Parth Patel, significant (p=1.00) between the 2 MD; Sarah Markham, MD, Larry groups; 16 (1.8%) in the primary LSG Gellman, MD; Dominick Gadaleta, MD group and 2 (1.7%) in the LAGB conversion group. Mean LOS was 1.16 Background
in the primary LSG group and 1.19 day Failure rates following laparoscopic in the LAGB conversion group which adjustable gastric banding (LAGB) are were not statistically significant as high as 40-50% and laparoscopic between the 2 groups (p=0.42). sleeve gastrectomy (LSG) is commonly performed as a conversion procedure. Conclusion The aim of the study is to present the Our data suggests that conversion to feasibility and safety between 1- and 2- LSG, performed as a 1 or 2-stage stage conversions compared to primary procedure after failed LAGB is safe LSG. and effective. No significant difference
in 30-day adverse outcomes when Methods performed 1 or 2-staged compared to Retrospective analysis performed on all primary LSG. LSG (n=988) including LAGB to LSG conversions, both 1- and 2-stages (n=118) from January 2012 to A378 December 2017. Primary outcome was Vertical banded Gastroplasty 30-day complication rate and secondary Revision to Gastric Bypass Helps outcomes included length of stay and Patients Lose Weight and Resolve BMI. Their Dysphagia and Reflux Symptoms Results Sara Monfared Indianapolis IN1, Don A total of 118 patients underwent Selzer Carmel IN1, Ambar LAGB conversion to LSG. 78

253 Banerjee Indianapolis IN1, Dimitrios Patients after VBG revisions stayed in Stefanidis Carmel IN1 the hospital longer, and experienced Indiana University School of Medicine1 more complications and reoperations compared with primary RYGB patients Background: Patients with vertical (table 1). Nevertheless, BMI decreased banded gastroplasty (VBG) can significantly 2 years after revision to experience failure or complications in RYGB (36.7±6.2) compared to preop the long-term and present for revisional (49.8±11.9; p<0.01) except for bariatric surgery. reversals who gained weight. Dysphagia resolved in 100% and reflux Objective: To review our experience in 95% of patients. for patient outcomes after VBG revisions and compare them to primary Conclusions: VBG revision to RYGB gastric bypass (RYGB) outcomes. leads to significant weight loss and resolution of dysphagia and reflux Methods: Data from patients who symptoms. Higher complication rates underwent VBG revisional surgery compared with primary RYGB should between 2009 and 2014 at a center of be taken into consideration, however. excellence were reviewed. Patient demographics, symptoms, co- morbidities, weight loss, complications, A379 and length of stay were analyzed and Gastric Emptying and Small Bowel compared to those of matched RYGB Transit in Poor Responders to Sleeve patients. Gastrectomy Scott Monte Buffalo NY1, Joseph Results: Forty four patients (89% Caruana Williamsville NY2, Michael female, 55±9 years old) underwent Tabone 2, Lauren Burkard- revisional surgery during the study Mandel Williamsville NY1, Mitchell period (89% RYGB, 9% VBG reversal, Pawlak Buffalo NY1 and 2% sleeve gastrectomy) and were State University of New York at compared with 1589 patients after Buffalo1 Erie County Medical Center2 primary RYGB. Patients presented 17±7 years after their VBG for weight Background: Evaluation of gain (55%), dysphagia (20%), or both gastrointestinal motility alterations to (25%); preoperative BMI for these semisolid meal in people with excess groups was 30.5±5.7, 53.0±9.2, and body weight loss (EBWL) reaching 45.7±7, respectively (p<0.05). Workup >65% after sleeve gastrectomy (SG) revealed anatomic abnormalities in showed expedited gastric emptying 68% (stricture in 23%, gastrogastric (GE) and transit to ileum with extended fistula in 29%, and pouch dilation in time in ileum versus preoperatively 16%). (Melissas 2013). The objective of this

254 www.obesityweek.com study was to characterize GE and small and expedited transit through ileum in bowel transit in people with poor comparison to established findings with response to SG and compare these EBWL >65%. These findings may same measurements to the established implicate altered gastrointestinal transit findings. as a variable in weight loss. Prospective study is underway to compare Methods: Six hour GE and small successful SG response. bowel transit scintigraphy of subjects with SG and <40% EBWL were reviewed to identify: GE 10% (TG10%) and 50% (TG50%), Intestinal Max A380 (TIntMax), Duodenal-Ileum transit (TDI- Gastric Emptying and Small Bowel transit), Ileum 10% (TIleum10%), Cecal Transit in Poor Responders to Roux- Filling Initiation (TCecalFilling) and en-Y Gastric Bypass 1 Ileocecal Valve transit (TICV-transit). Scott Monte Buffalo NY , Joseph Values are reported as median Caruana Williamsville NY2, Michael minutes(range). The standardized Tabone 2, Lauren Burkard- semisolid meal contained 350 kcal Mandel Williamsville NY1, Mitchell (50% fat, 30% carbohydrate, 20% Pawlak Buffalo NY1 protein). 29 subjects were included in State University of New York at final analyses. Buffalo1 Erie County Medical Center2

Results: Subjects were 46±11 years, Background: No reference range or 3±2 years after SG and 24% median literature exists to characterize EBWL. Scintigraphy findings were as appropriate gastric emptying and small follows: TG10%=1(1-30), TG50%=57(1- bowel transit for Roux-en-Y gastric 246), TIntMax=150(10-270), TDI- bypass (RYGB). The objective of this transit=210(5-329), TIleum10%=240(15-330), study is to characterize gastric TCecalFill=270(60-360), TICV-transit=30(30- emptying and small bowel transit in 160). Compared to established findings subjects with poor weight loss response

TG1/2 was delayed by 16%, TIntMax35%, to RYGB. Recruitment of successful TDI-transit283%, TIleum10%208%, and weight loss responders to RYGB is TCecalFilling29%. Expedited transit was underway for comparative purposes. observed for TG10% by 88% and TICV- transit76%. Methods: Six hour gastric emptying and small bowel transit scintigraphy of Conclusions: Poor responders to SG subjects with RYGB and <40% excess appear to have rapid initial transit body weight loss (EBWL) were through the pylorus, delayed gastric reviewed to identify: Gastric emptying half-time emptying, prolonged transit 10% (TG10%) and 50% (TG50%), time through duodenum and jejunum Intestinal Max (TIntMax), Duodenal-

255 Ileum transit (TDI-transit), Ileum 10% Sri Aurobindo Medical College & PG 1 (TIleum10%), Cecal Filling Initiation Institute Mohak Bariatrics and 2 (TCecalFilling) and Ileocecal Valve transit Robotics (TICV-transit). Values are reported as median minutes (range). The Introduction standardized semisolid meal contained Marginal ulcers after OAGB/MGB has 350 kcal (50% fat, 30% carbohydrate, been suggested to be a major problem. 20% protein). 39 subjects were Some recently published studies have included in the final analyses. reported the incidence of marginal ulcers after OAGB/MGB. We are a Results: Subjects were 46 ± 8 years, 9 high-volume center of bariatric surgery ± 3 years after RYGB and had median and would wish to report our results in 26% EBWL. Scintigraphy findings terms of marginal ulcers after

were as follows: TG10% = 1 (1-30), OAGB/MGB. TG50% = 29 (1-408), TIntMax = 180 (1- Upper GI endoscopy is one of the most 360), TDI-transit = 239 (89-361), TIleum10% = common modalities used to assess the 255 (90-361), TCecalFill = 300 (120-360) gastric mucosa in surveillance after and TICV-transit = 30 (30-60). bariatric surgery and we have to use the same modality to check for marginal Conclusions: Poor responders to ulcers, bile gastritis, any other lesions RYGB have immediate gastric pouch found after OAGB/MGB. emptying of 10% of the meal and rapid Material and methods emptying of 50%. The remaining 3645 OAGB/MGB surgeries have been transit through the mid-bowel to the performed at our Centre from 2011 to ileum appears delayed at over 4 hours. 2017. At 1 years of follow-up, all those Cecal filling also appears delayed at 5 patients with symptoms of upper GI hours while residence in the ileum is discomfort, GERD , belching, transient. These findings provide vomiting, solid food intolerance and important gastrointestinal transit others were investigated by upper GI benchmarks to compare with successful Endoscopy. Findings of bile gastritis, responders. esophageal lesions including ulcers and esophagitis, hiatus, Barretts and marginal ulcers were reported. A381 Results Is Marginal Ulcer really a problem 153 patients underwent upper GI after OAGB/MGB- Our experience endoscopy due to symptoms. 5 had from more than 3000 cases at a single marginal ulcers, 18 had bile gastritis, 2 center had de novo hiatus, 13 had esophagitis . Mohit Bhandari Indore 1, Winnie We had to convert one case to RYGB Mathur Indore, MP 2 due to intractable bile reflux with more than 100 % excess weight loss.

256 www.obesityweek.com Conclusion complications requiring: medical High incidence of marginal ulcers after management, hospitalization, operative OAGB/MGB proven in other studies, is intervention, and mortality. Patient not the finding in our study. The follow-up was 2 weeks and 6 weeks for incidence was less than 0.01% with the timeframe of this study. more than 100% excess weight loss. Although, problem of protein energy 1000 patients (700 LVSG, 245 LVSG + malnutrition and micronutrient HRR, 55 LVSG + GBR) were deficiencies was seen in most of these analyzed. 14 patients were treated cases. outpatient for minor complications (1 C. diff and 13 UTIs). 10 patients A382 required readmissioin for complications Bariatric surgery in the rural that did not require procedure or community hospital: a Retrospective surgical intervention. Only 3 Review from a Single Institution. readmissions were related to the Jon Harrison Jackson MS1, Wade bariatric procedure (2 mesenteric vein Christopher Jackson MS1, Terry thrombosis [10 days post-op and 20 Pinson Tupelo MS1 days post-op] and 1 leak [25 days post- University of Mississippi Medical op]). 4 patients required re-operation Center1 for complications before discharge (3 resulted in no findings and 1 post-op The purpose of this study was to bleed) and 2 patients required examine complications among bariatric readmission/re-operation (1 mesenteric surgery patients undergoing vein thrombosis [4 day post-op] and 1 laparoscopic vertical sleeve incisional hernia related to previous gastrectomy (LVSG) at a single hysterectomy incision [16 days post- comprehensive bariatric center. The op)]. There were no deaths. aim of the study was to assess safety in a community setting. LVSG is a low risk operation that can be successfully reproduced in a This is a retrospective review of community hospital setting. bariatric procedures performed by a single surgeon at a community hospital from 2014-2017. The primary A383 procedure in each case was a LVSG. Eliminating Routine Intra-operative LVSG performed as a conversion Foley Catheters May Reduce Post- procedure after gastric band removal Operative Urinary Tract Infections (GBR) was included. 24.5% of patients in Bariatric Surgery Patients also underwent hiatal hernia repair Alexis Cralley Cralley Denver CO1, (HHR) at the time of their LVSG. Rebecca Jackson Denver CO1, Fredric Outcomes of interest were Pieracci Denver CO1

257 Denver Health1 .149).

Background Conclusions Urinary tract infections (UTIs) are a While not statistically significant, common post-operative complication in Denver Health did see an elimination in bariatric surgery patients . We UTI rates after discontinuing the hypothesized that elimination of routine practice of routine intraoperative foley intra-operative Foley catheters would catheters during bariatric surgery; reduce UTI prevalence in these however, the effort to reduce UTI rates patients. may be at the expense of increased post-operative urinary Methods retention. Larger studies should be This is a retrospective study of 227 carried out comparing the risks and bariatric surgery patients who had benefits of intra-operative foley surgery from February 2012-April 2018 catheters when deciding which practice at Denver Health, a safety net hospital to follow. in Denver, Colorado. Retrospective EMR chart reviews were done to determine patients who had Foley A384 catheters placed intra-operatively. Investigating racial disparities in Subsequently, data was collected on bariatric surgery referrals. any urinary symptoms or UTI Crystal Johnson-Mann Charlottesville diagnoses during admission or follow VA1, Allison Martin Charlottesville up encounters (including scheduled VA1, Michael Williams Charlottesville bariatric follow ups, primary care visits VA1, Peter Hallowell Charlottesville or emergency room visits). VA1, Bruce Schirmer Charlottesville VA1 Results University of Virginia Health System1 227 bariatric patients were screened and 161 patients received intra- Background:Studies investigating the operative Foley catheters. Of these presence of racial, socioeconomic or patients, 3 UTIs (1.9%) were identified insurance disparities with regards to compared to 0 UTIs (0%) in the 66 access to care and outcomes in bariatric patients who did not receive an intra- surgery have been performed with operative foley catheter placed varying results. Our aim was to (Fisher’s test = .558). Of the 66 patient determine if racial disparities exist in who did not receive an intraoperative regards to referral patterns for bariatric foley, 3 required a post-operative foley surgery at a single center. (4.5%) for urinary retention compared to 2 patient (1.2%) in the intra- Methods:A single center retrospective operative foley group. (Fisher’s test = data review from January 2012 through

258 www.obesityweek.com June 2017 was performed for patients weight loss and Vitamin D levels in that met referral criteria to bariatric the bariatric population. surgery after obtaining Institutional David Romero Funes Weston FL1, Review Board approval. Data David Gutierrez Blanco Weston FL1, collection was limited to patients Maria Fonseca Mora Weston FL1, referred to our bariatric surgery clinic Rama Rao Ganga Columbia MO1, from on-site primary care clinics. Emanuele Menzo Weston FL1, Samuel Szomstein North Miami Beach FL1, Results:Bariatric eligible patients Raul Rosenthal miami FL2 totaled 4,736 patients. Population Cleveland Clinic Florida1 Cleveland demographics as follows: 63.8% Clinic of FL2 female (n=3022), 36.2% male (n=1714); 53.9% white (n=2553), INTRODUCTION 37.8% black (n=1790), and 8.3% There is evidence of an inverse Hispanic (n=393). Female patients association between obesity and more likely to be referred than male Vitamin D levels, attributed to the patients (5.5% versus 4.1%, c24.59, sequestration of Vitamin D in the p=0.032). Hispanic patients less likely adipose tissue. The objective of our to be referred compared to Black or study is to show the impact of White patients (2.0% versus perioperative BMI and rapid weight 5.3%/5.2%, c27.88, p=0.019). loss in vitamin D levels in the bariatric population. Conclusion:Hispanic patients were less METHODS likely to be referred at our institution We conducted a retrospective chart for bariatric surgery when compared to review of all patients who underwent White and Black patients. A barrier to Bariatric surgery at our institution from referral may be explained by the 2010 and 2015. The assessment of disproportionate number of Hispanic 25(OH) vitamin D levels was done pre- patients that were self-pay as our operatively and at 3,6, 12,18 and 24 institution does not accept self-pay months follow-up. patients in referral for bariatric surgery. RESULTS This underscores the need for further Of the 978 patients work with access to care for bariatric reviewed, 50.51%(n=494) had a pre- surgery. operative Vitamin-D assessment. Our population was predominantly Caucasian women 70.04%(n=346) and 75.10%(n=371) respectively and with a A385 mean age of 54.67±12.54. The most Vitamin D deficiency in the morbidly prevalent surgery was LSG obese: Unraveling the correlation 51.18%(n=256). Pre-operatively between perioperative BMI, rapid 74.89%(n=370) of our population

259 presented with Vitamin D deficiency or psychosocial benefits within the first insufficiency. Patients with underlying year post-surgery, there is less known Vitamin D deficiency showed the most about longevity of these outcomes. In significant improvement at 12 and 24 this study, we explore whether time months follow-up showing a Vitamin D since bariatric surgery attenuates improvement of 13.99ng/ml and psychological well-being in patients. 11.55ng/ml (p=0.0001 and P=0.0248) respectively. Regarding the relationship Methods: Patients at an accredited between pre-op BMI and Vitamin D bariatric program who underwent levels the results of a simple linear bariatric surgery between the years regression show an inversely 2011-2017 were surveyed to determine proportional relationship (P=<0.0001). whether changes in psychological wellbeing differ in patients less than or CONCLUSIONS greater than three years post-op. Our findings suggest that Vitamin D deficiency is an issue that should be Results: In total, 591 patients recieved addressed pre-operatively and, although surveys, of which 184 patients met rapid weight loss seems to have a inclusion criteria in responding to all positive impact on vitamin D levels, survey questions. There was no strict supplementation is still needed. difference in the age, sex, or type of bariatric surgery between groups (Table 1). Patients who recently underwent A386 surgery were more likely to report that When does the honeymoon end? they like their new body, but Changes in psychological well-being significantly less likely to report that based on time since bariatric they met their weight loss goal (Table surgery. 2). Patients farther out from surgery Lyndsey Wallace Milwaukee WI1, were more likely to report significantly Melissa Helm Milwaukee WI1, Rana greater post-operative weight regain Higgins Milwaukee WI1, Tammy [p<0.001] Kindel Milwaukee WI1, Jon Gould Fox Point WI1, Kathleen Lak Milwuakee Conclusion: In summary, while those WI1 farther out from surgery were more Medical College of Wisconsin1 likely to reach their weight loss goal they were also more likely to Introduction: Bariatric surgery offers experience post-operative weight multiple benefits above and beyond regain and decreased body satisfaction. weight loss including pain relief, There are unique challenges to improved cardiovascular health and improving quality of life in patients improved psychological well-being. with obesity and this highlights the Despite well documented health and importance of an ongoing

260 www.obesityweek.com multidisciplinary post-operative distribution and patient-directed approach to address necessary lifestyle referral. Later, referrals consisted of changes and to promote long-term literature distribution, optimization durability of weight loss and protocol and formal referral. Outcomes psychological well-being. analyzed included number of: referrals, initial bariatric consults, patients undergoing medical weight A387 management, bariatric surgeries and STANDARD REFERRAL total joint arthroplasties performed. PRACTICES FROM A SPECIALTY PRACTICE TO A Results: BARIATRIC PRACTICE DO NOT 327 referrals were made (mean INCREASE PATIENT 109/year). 72 initial bariatric consults TREATMENT FOR OBESITY were performed (22.0%). 25 patients David Voellinger Charlotte NC1, Craig received medical weight management Kolasch Matthews NC1, Ellen (7.6%), 10 received bariatric surgery Carraro Charlotte NC1, Shannon (3.1%). 12 patients underwent total McNeill Charlotte NC1, Christine joint arthroplasty (3.7%). Bolo Charlotte NC1, Bryan Springer Charlotte NC2 Conclusion: Novant Health Bariatric Standard referral practices from a Solutions1 OrthoCarolina2 specialty practice to a bariatric practice only slightly increase patients treated Background: for obesity with bariatric surgeries 24 million Americans are morbidly performed barely increasing from 0.9% obese and only 0.9% received surgical to 3.1%. Phase two of this project will treatment in 2016. A referral program consist of a formal care collaborative was initiated between a community for pre-surgical optimization with bariatric practice and a total joint improved education, resources, patient program. This specialty practice was navigation and clinical pathways. chosen due to the growing evidence of higher morbidity after total joint arthroplasty in the morbidly obese A388 patient. The aim of this study was to Is There a Learning curve in investigate referral practices and Adopting the Robotic Platform to results. Revisional Bariatric Surgery? Andrew Godwin Oyster Bay NY1, Julio Methods: Teixeira Scarsdale NY1, Dimitar A retrospective analysis was performed Ranev New York NY of referrals received from 2015-2017. Lenox Hill Hospital1 Referrals initially consisted of literature

261 Introduction Conclusion Robotic technology is gaining interest Revisional robotic surgery neutralized in bariatric surgery with advocated the effect of the learning curve in benefits in revisional surgery. Whether experienced laparoscopic surgeons there is of the learning curve of with no impact on patient outcomes. adopting this technology, has not been LAGB and previous leak were examined. Our study evaluates the significant risk factors not associated introduction of this technology and with the learning curve. impact on surgeon experience and patients outcomes. Methods Prospectively collected data on A389 revisional robotic procedures analyzed Is there a difference in patients who looking at operative times, are self referred for bariatric surgery complications rates(CR), and LOS. VS those referred by relatives? Multivariable analysis and linear Winnie Mathur Indore, MP 1, Mathias regression analysis to identify Fobi Palos Verdes Peninsula CA1, correlations between, Mohit Bhandari Indore 1, SUSMIT time,original primary index KOSTA Indore IN2 procedure(OPIP) and outcomes. MOHAK BARIATRICS AND Results ROBOTICS1 Sri Aurobindo Medical 59 patients underwent College & PG Insti2 robotic revisional procedures from 2015 to 2018: mean age 48 years, BMI Background: Patients who present for 42, 84.7 % were female, 11.7%with bariatric surgery may be referred by a BMI>50, The avg. operative time relative or self referred. We did a 145.2 minutes and avg LOS 2.93 days. retrospective study to see if there are Patients were divided into 3 groups,A any differences in self referred and 1st 20, B 2nd 20 and C 3rd 19. The relative referred patients. groups were similar by age, BMI, and gender . There was a significant Material and methods: A review of the difference, with Group B having a prospectively maintained database of higher number of LAGB as the OPIP patients who have surgery at Mohak, and a higher CR in this group(p = bariatric and Robotic Surgery Center in 0.045). Open gastric bypass as the Indore, India was carried out. Patients OPIP had a significantly longer who had surgery in 2017 were operative time but not associated with identified. Patient who stated their higher CR. LAGB was independently referral source were identified and data associated with a higher CR. Overall was collected on these patients and complications rate was 18.6% ( 45% of analysed and presented. LAGB patients) (p = 0.026).

262 www.obesityweek.com Result: 320 patients had information on depression, central muscle stiffness, their referral source. Of 48 self muscle weakness, obstructed breathing, referred patients 40 were from print negative inotropism, nausea, vomiting. media and 8 knew someone who had Demonstrate that OFA protocol is had surgery. Of the 272 who were reproducible, effective and safe causes referred by a relative, 123 relatives had less nausea, prevents postoperative had bariatric surgery. It took 1.3 years respiratory collapse and generates on the average for the patients with a adequate analgesia for patients with relative with surgery to decide to have obesity. surgery whereas the average time in the A prospective, observational and self referred group was 5.4 years. The descriptive study. Patients 20 to most feared complication in the relative 65years old. ASA II-III with BMI equal referred group was hair loss and loose or greater than 60 kg / m2 skin whereas in self referred group it undergoing bariatric laparoscopic was fear of death due to surgery. surgery. Induction: Ketamine .125 mg/kg IBW, Conclusions: A significant number of Dexmedetomidine 0.5 ug/kg IBW, the referrals to our center came from Lidocaine 1.5 mg/kg IBW. Mg Sulfate relatives and peers we operated on. The 40 mg/kg IBW, Rocuronio 0.6 mg/kg others who came mostly came by print IBW, Propofol 2.5 mg/kg media although we also utilise other IBW.Followed by inhalation anesthesia sources of marketing. Relative referral at 0.6 MAC Desfluorane. group chose the surgery the relative had Manteinance. Same doses of whereas the others choice was based on medicament. the recommendation of the surgeon. Postoperative analgesia. Paracetamol 2 gr loading 1 gr/6h, Parecoxib 40 mg/12 h. Dexmedetomidine 0,1 – 0,2 ug/kg/h the first hour. A390 RESULTS 25 patients operated from Opioid-free anesthesia (OFA) in August 2016 to December of 2017. super-obese Mexican patients With an age range of 20-60 years with undergoing bariatric surgery, with an average of 35.7 of which 14 were the protocol of Sint Jan Brugge. women and 11 men, BMI range of Lizzet Villalobos MEXICO 1, Luis 50.59 to 74.4 kg / m2 with an average Aceves CIUDAD DE MEXICO CMX2 54.33 kg / m2. CENTRO BARIATRICO 11 gastric sleeves and 14 gastrojejunal METABOLICO DALINDE1 CBMD2 bypass, with a maximum surgical time of 2:10 hours with an average of 1:50 No intraoperative systemic, hours. neuraxial opioid is administered during Generating adequate hypnosis, the anesthetic. Avoiding respiratory immobilization and perioperative

263 hemodynamic stability. Two patients weight regain (n=6), or both (n=6). The presented hypotension of 70/40 mmHg, average preoperative weight before SG was resolved with 5 mg ephedrine. was 312 lbs. (SD=76.8), compared to CONCLUSION. The OFA protocol 218 lbs. (SD=46.8, p=0.001) 1 year OFA is safe, reproducible and after SG. The average preoperative decreases the risk of VA collapse, weight before conversion to RYGB postoperativa nausea and vomitig in was 264 lbs. (SD=70.6), compared to Mexican obese patients in bariatric 207 lbs. (SD=38.1) 1 year after RYGB. surgery Prior to SG, 64%, 29%, and 36% of patients experienced comorbid hypertension, diabetes, and A393 hyperlipidemia, respectively. 1 year Weight Loss, Complications, after SG, 45%, 18%, and 36% of Readmissions, and Complications in patients still experienced comorbid Patients Undergoing Sleeve-To- hypertension, diabetes, and Bypass Conversion hyperlipidemia, respectively. Only Jaime Dutton Stanford CA, Luis 17%, 8%, and 27% of patients Garcia Fargo ND, John experienced comorbid hypertension, Morton Stanford CA1 diabetes, and hyperlipidemia, Stanford School of Medicine1 respectively, 1 year after RYGB. No complications or readmissions were Introduction: Patients may undergo observed after initial SG, whereas conversion from laparoscopic sleeve 12.5% and 4.4% of patients gastrectomy (SG) to Roux-en-Y gastric experienced a complication (leak, bypass (RYGB) due to complications stricture,arrythmia) or readmission, or weight gain. The objective of this respectively, after RYGB. GERD study was to investigate weight loss, motivated conversion in 74% of comorbidity, complication, and patients with only 13% continuing to readmission outcomes after conversion. experience GERD 1 year after RYGB.

Methods: Anthropometric and Conclusion: The results of this study comorbidity data were obtained for suggest that sleeve gastrectomy patients from a prospectively maintained undergoing conversion to database at an academic medical center. RYGB experienced resolution of The Wilcoxon Signed-Rank test was GERD and significant weight loss. used to evaluate differences between preoperative and postoperative outcomes. A394 Bile Acids Increased after RYGB in Results: Patients (n=24) underwent Chinese Patients Could be Potential conversion due to GERD (n=11),

264 www.obesityweek.com Contribution to Improved Glucose =-0.228, P=0.034; r =-0.237, P= 0.041; and Lipid Metabolism r =-0.318, P= 0.026; respectively). Pin Zhang Shanghai Conclusion:Our data suggest that Shanghai 6th People's Hospital increased bile acid levels may contribute to the improved glucose and Background:The multifactorial lipid metabolism in patients who have mechanisms promoting weight loss and had RYGB. improved metabolism following Roux- en-Y gastric bypass (RYGB) surgery A395 remain incompletely understood. Evaluating sarcopaenia in bariatric Recent rodent studies suggest that bile surgery through regional body acids can mediate energy homeostasis muscle distribution. by activating the G-protein coupled Jonathan Sivakumar Melbourne 1, Lynn receptor TGR5 and the type 2 thyroid Chong Fitzroy 2, Salena Ward Fitzroy 2, hormone deiodinase. Altered Tom Sutherland Melbourne 2, Michael gastrointestinal anatomy following Hii Fitzroy 2 RYGB could affect enterohepatic St Vincent's Hospital Melbourne1 St recirculation of bile acids. Vincent’s Hospital Melbourne2 Objective:We assessed whether circulating bile acid concentrations Background: The deterioration of lean differed postoperatively in Chinese body mass (LBM) and development of patients with different degree of obesity sarcopaenia has been reported in or HbA1c levels, which might then patients following bariatric surgery. contribute to improved glucose and Objective: To evaluate regional lean lipid metabolism. body mass changes in patients Result:The data showed that the following bariatric surgery, comparing preoperative concentration of bile acid roux-en-Y-gastric-bypass (RYGB) with is not change significantly in patients laparoscopic sleeve gastrectomy (LSG). with different degree of obesity in Methods: A prospective analysis was different HbA1c groups. Interestingly, completed on seventeen patients bile acids all increased significantly 1 undergoing either RYGB or LSG, year after surgery in different degree of between 2017 and 2018 at St Vincent’s obesity group. In the HbA1c6.5 Hospital Melbourne. Body composition group, we also observed the same was measured with dual-energy X-ray changes postoperatively (P<0.05), but absorptiometry (DXA) immediately the bile acid levels elevated moderately before the procedure, and at one-month in the HbA1c6.5 group. In addition, post-operatively. the increase of bile acid levels after Results: Fourteen patients were surgery was positively associated with recruited for this analysis (RYGB n=4, the improvement of fasting blood LSG n=10). At one month after glucose, cholesterol and triglyceride (r surgery; mean RYGB LBM loss was

265 1.07 ±3.27 kg, composed of 0.28 ±0.3 Darren Tishler Glastonbury CT2, kg from the trunk and 0.78 ±1.99 kg Pavlos Papasavas Hartford CT2 from appendicular mass. In this group, University of Connecticut1 Hartford the trunk accounted for 26.1% of LBM Hospital2 Hartford Hospital, Institute of loss, whereas the upper and lower Living3 limbs each accounted for 37.6% and 35.0%, respectively. Mean LSG LBM Introduction: Experienced weight bias loss was 4.48 ±3.42 kg, of which the (EWB) causes poor psychosocial and trunk accounted for 1.72 ±3.06 kg and behavioral health in bariatric surgery the appendicular mass accounted for patients pre- and post-operatively, yet 2.71 ±1.99 kg, respectively. In this little research has examined related group, trunk was responsible for mechanisms or risk/protective 38.4%, upper limbs 16.0%, and lower pathways. The current study tests a limbs 44.6%. mediational model positing risk paths Conclusion: This preliminary data is between EWB, internalized weight bias suggestive of a variance in outcomes (IWB), shame, and effects on mental with respect to lean body mass loss health symptoms. Self-compassion following RYGB and LSG. LSG is (SC), an affect regulation strategy associated with a greater loss of lean inversely linked to each risk factor, was body mass; however with a sparing tested as a mediating protective factor. effect of LSG on upper limb musculature. Further research is Method: Bariatric surgery candidates warranted in evaluating whether this is (BSC) recruited from a surgical clinic associated with differences in long term (N = 152, 61.4% women, 62.8% White, functional outcomes. 43 ±12 years, mean BMI: 49±9 kg) completed validated measures for EWB, IWB, shame, and SC and post- traumatic stress disorder (PTSD) and A396 depression screeners pre-operatively. Testing risk and protective pathways PROCESS bootstrapping estimates between weight bias and mental tested our hypothesized model: EWB- health symptoms in a bariatric >WB->shame->self-compassion- sample: Internalized weight bias, >mental health. shame, and self-compassion Tosca Braun 1, Diane Quinn Storrs CT1, Results: In each model, hypothesized Andrea Stone Glastonbury CT2, direct paths were significant (p<.001). Jennifer Ferrand Hartford CT3, Amy The total effects of EWB on PTSD Gorin Storrs CT1, Jessica (=.43, p<.001) and depressive Sierra Hartford CT3, Rebecca symptoms (=.38, p<.001) partially Puhl Hartford CT1, Gina Sensale 1, attenuated with mediators in each model (PTSD, =.19, p=.002, R2=.570;

266 www.obesityweek.com depression, =.18, p=.025, R2=.297). obesity. This study extends these For PTSD, significant indirect effects findings by independently comparing indicated one risk pathway from EWB BMI classes and treatment-seeking to higher symptomatology via IWB- populations. >shame and three protective paths to lower symptomatology via SC. For Methods: Patients with class II depression, significant indirect effects (BMI=35–39.99 kg/m2) and class III revealed one risk pathway from EWB obesity (BMI=40–54.99 kg/m2) from to higher symptomatology via IWB and samples seeking bariatric surgery one protective pathway to lower (N=584) and behavioral treatment with symptomatology via SC. pharmacotherapy (BT+P; N=245) completed the Weight and Lifestyle Discussion: Self-compassion appears Inventory and Beck Depression to offer partial protection against the Inventory-II. Independent effects of adverse mental health sequelae BMI class, treatment-seeking group, affiliated with EWB. Alongside and their interaction were analyzed broader systems efforts to reduce EWB, (all p<.01). SC may prove a helpful accompaniment to intrapersonal stigma Results: Across BMI classes, bariatric reduction efforts and mental healthcare surgery patients were significantly for BSC. more likely to report a history of emotional problems, current depression, and health-related stress than BT+P patients. These A397 psychosocial outcomes did not differ Differences in Psychosocial Status by BMI class. Independent of treatment and Predisposition to Obesity by group, patients with class III obesity BMI Class and Type of Treatment reported earlier onset of obesity and Jena Tronieri Philadelphia PA1, higher historic weights than those with Thomas Wadden Philadelphia PA1, class II obesity. Their parents had Rebecca Pearl Philadelphia PA1, Kelly higher BMIs. Weight and dieting Allison Philadelphia PA1, Olivia histories did not differ between Walsh Philadelphia PA1, Noel treatment groups. Independent of BMI Williams Philadelphia PA1 class, patients seeking BT+P endorsed University of Pennsylvania1 more problematic eating behaviors than those seeking surgery. Surgery patients Background: In prior studies, women had larger weight loss goals and were with class III obesity have reported more confident that they would change more psychosocial complications and a their eating/exercise habits than those stronger biological predisposition to seeking BT+P. obesity than patients with less severe

267 Conclusions: Psychosocial gastrectomy (SG) in order to achieve complications were more prevalent sufficient weight loss to be eligible for among patients seeking bariatric cardiac transplant. The patient’s surgery but did not differ by BMI class. medical record was reviewed for pre- The weight histories of patients with and postoperative body mass index class III obesity suggest a stronger (BMI), ejection fraction (EF), and New biological predisposition to obesity. York Heart Association (NYHA) Desired weight loss and problematic classification. behavioral habits may differentiate Results: Preoperatively, the patient surgery and BT+P-seeking patients. had BMI of 55.4 and suffered from non-ischemic cardiomyopathy with NYHA class 3 symptoms and EF 30%. A398 She underwent SG without Laparoscopic sleeve gastrectomy complication, reducing her BMI to 38.1 improves cardiac function for a heart at 12 months. With weight loss, her EF failure patient requiring left improved to 55% and NYHA class ventricular assist device support improved to 2 at 12 months. Given Russell Hawkins Gainesville FL1, Julie these improvements in her EF and Stortz GAINESVILLE FL1, Alexander functional status, her cardiologist is Ayzengart Gainesville FL1, Jeffrey considering weaning LVAD support to Friedman Gainesville FL1 eventual explant and not listing for University of Florida1 cardiac transplantation.

Introduction: Obesity is an epidemic Conclusions: SG is safe and effective closely associated with heart failure. for patients with morbid obesity and The definitive treatment for end-stage end-stage heart failure requiring LVAD heart failure is cardiac transplantation. support. The excess weight loss However, morbid obesity is a accomplished with bariatric surgery can contraindication for cardiac transplant lead to significant improvements in listing. Left ventricular assist devices cardiac function and may preclude the (LVADs) have emerged as a bridge to need for cardiac transplantation. transplant for heart failure patients, and bariatric surgery can be performed in patients with LVADs. The effect of weight loss on cardiac function for A399 these patients is not well known. Staple Usage Comparison Between Suction Calibration System and Methods: We reviewed the case of a Rubber Bougie in LSG patient with morbid obesity and heart Elizabeth Dovec Baltimore MD failure on LVAD support who GBMC Comprehensive Obesity underwent laparoscopic sleeve Management Pr

268 www.obesityweek.com With bariatric staple loads costing TITLE: Staple Usage Comparison upwards of over $400 per staple, this Between Suction Calibration System could mean significant savings for and Rubber Bougie in LSG institutions who implement the use of a AUTHOR: Elizabeth Dovec, MD, SCS in their LSG procedures. FACS BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) procedures are growing in popularity which makes A401 it important for institutions to be as Bariatric Surgery Complication efficient as possible. Suction Rates in a Safety Net Hospital with a calibration system (SCS) devices have large Hispanic population been shown to reduce cork-screwing Alexis Cralley Cralley Denver CO1, during the stapling process in LSG Rebecca Jackson Denver CO1, Fredric procedures which would also mean a Pieracci Denver CO1 shorter staple line. This shorter staple Denver Health1 line may translate to a decrease in staple usage. Background OBJECTIVE: To compare the staple Bariatric centers are not often found in usage between a SCS and a rubber safety net hospitals. However, as an bougie (RB). urban safety net hospital Denver Health METHODS: Surgical case records maintains a comprehensive bariatric were retrospectively examined directly center with a strong institutional focus before and after the switch from using a on providing exceptional care to our RB to a SCS to determine the number 37% Hispanic population. Previous of staples used. studies have identified Hispanic RESULTS: There were 51 patients in patients as 77% more likely to both the RB and SCS groups (n=102). experience post-operative The mean number of staples used for complications compared to non- the RB and SCS group respectively Hispanic patients undergoing bariatric were 5.40 and 5.07 (p=0.02). There procedures. We hypothesized that post- was no significant difference in mean operative complication rates in between the RB and SCS groups in age Hispanic patients would be no different (47.4, 45.0, p=0.27), female/male ratio as compared to non-Hispanic patients (0.86, 0.84, p=0.78), or BMI (41.8, at both our institution and prior reports 42.7, p=0.52). from other centers. CONCLUSION: The data suggests a savings of 0.33 staple loads per case Methods over this period due to switching to a The medical records of 227 consecutive SCS. That translates in to saving a bariatric patients undergoing surgery staple approximately every third case. from June 2012 through April 2018

269 were retrospectively Successful Weight Loss Surgery on reviewed. Records were reviewed for the Professional Voice demographic information, past medical Timothy Schaffner Carmel IN1, Noah history, surgical procedures, and Parker Carmel IN, Don Selzer Carmel standard 30 day post-operative IN1 complications rates including re- Indiana University1 admission, re-operation, surgical site infections, and UTI rates. Background: It has been previously suggested that successful weight loss Results after bariatric surgery could have an 91 of 227 patients (40%) identified effect on various qualities of voice. themselves as Hispanic, while the Anectdotally, the idea that successful national average across bariatric centers weight loss could be a detriment to is 12.5%). Despite a high rate of one or voice is a commonly held belief among more comorbidities (47.5% of patients), opera singers. However, this theory the overall 30 day post-operative hasn't been rigorously tested in this complication rate was 22.0%; the most population. We present a case study of common complication was 30 day an opera singer who lost approximately readmission for any reason at 180 pounds after gastric bypass, and 8.8%. Compared to Denver Health’s hypothesize that this weight loss will non-Hispanic bariatric patients, our have an effect on her vocal function. Hispanic population was not at an increased risk for post-operative Objective: To compare subjective and complications (OR=0.80, 95% CI: vocal parameters pre-and post-bariatric 0.39-1.60). surgery in a professional opera singer

Conclusions Methods: Voice assessment includes, In this study, Hispanic patients did not 1) quality of life measurement using the appear to have a higher likelihood of Voice-Related Quality of Life complications as compared to non- questionnaire, 2) videostroboscopy, 3) Hispanic patients. A focus on providing perceptual analysis using the culturally-sensitive care to this patient Consensus Auditory-Perceptual population specifically may partially Evaluation of Voice, and 4) acoustic explain this finding. measurements of vocal function. Each measure was obtained pre- and post- weight loss.

A402 Results: The patient's pre- and post- Toned Down: A Case Study operative voice-related quality of life, Demonstrating the Effect of endoscopic evaluation and perceptual and acoustic measurements were

270 www.obesityweek.com assessed. Comparative analysis of Methods: vocal parameters are performed to All patients who had either incidental delineate alterations in phonatory or known gut malrotation and bariatric function following baraitric surgery. surgery, from 2010 to 2017 were identified. Data collected included Conclusion: The patient demonstrated baseline demographics, co-morbidities, altered vocal function following intraoperative findings, perioperative bariatric surgery by several assessment parameters, length of stay, morbidity parameters. Bariatric surgery may have and mortality up to one-year follow-up. an effect on the phonatory tract, leading to changes in speech production that Results: can be assessed through subjective and There were 4 patients with gut objective measures. These changes may malrotations. The majority were be subtle in most patients, but have a females (n=3) with a median age of 34 more profound impact on the years.The median preoperative body professional voice. Future studies mass index (BMI) was 51 kg/m2. prospectively evaluating vocal function Preoperative comorbidities included before and after weight loss would hypertension (n=1, 25%), and sleep better define these changes. apnea (n=1, 25%). All the patients had laparoscopic bariatric procedures; sleeve A403 gastrectomy (SG, n=2) and Roux-en-Y The Outcomes of Bariatric Patients gastric bypass (RYGB, n=2). Only one with Gut Malrotation patient was known to have gut Zubaidah Nor Hanipah Cleveland OH1, malrotation from preoperative Kellen Hayes , Raul Rosenthal miami computed tomography of the abdomen, FL2, Stacy Brethauer Cleveland OH2, and she had SG. One of the RYGB Philip Schauer Cleveland OH2 patients had Ladd band released and Cleveland Clinic, University Putra appendectomy during the same setting. Malaysia1 Cleveland Clinic2 The median operative time, estimated blood loss and length of hospital stay Introduction: were 178 minutes, 20 ml and 4 days, Anatomic anomalies, such as gut respectively. There was no 30-day or 1- malrotation, although rare, may year morbidity, mortality, readmissions significantly complicate surgical or reoperations in this group. procedures and post-operative course. The aim of this study is to determine Conclusion: outcomes of patients with gut Gut malrotation is a rare condition, malrotation who underwent bariatric mostly found incidentally during time surgery. of operation. Bariatric surgery can be performed safely in these patients with

271 good outcomes. However, definitive majority reported having and regularly outcome of patients with gut using at least 1 health app on their malrotation can only be obtained with smartphone (n=203, 88%). More than larger clinical trials. half of participants reported using a healthcare tracker regularly, with the most common being a smartwatch. 2 out of 3 patients reported using social media and more than half used a search engine to get more information about weight loss surgery. More than half of A404 those found the information they Healthcare Technology Use among received from the either group of sites Bariatric Surgery Patients visited very or extremely helpful. A 1 Colleen Tewksbury Glenside AL , Leah minority of patients reported that the 1 Cassella Philadelphia PA , Louise information found through either social 1 Hesson Philadelphia PA , Kristoffel media or a search engine made them 2 Dumon Philadelphia PA , Noel feel discouraged about their progress. 2 Williams Philadelphia PA Conclusion: Bariatric surgery patients University of Pennsylvania Health are actively engaged consumers of 1 2 System University of Pennsylvania healthcare technology and are searching for information about Background: Bariatric surgery patients bariatric surgery online. Future have access to a large number of tools, research should focus on the quality of apps, and information via healthcare the information patients are receiving technology. For online content, through tools and apps and the impact previous studies have found of utilizing healthcare technologies on information available for bariatric surgical outcomes. surgery patients to be of poor quality. However, little is known about the utilization by patients and their A405 perceptions about these technologies. Remission of type 2 diabetes one year Methods: 234 patients completed a after bariatric surgery among Asian survey on their technology population use. Descriptive statistics and Bo Chuan Tan Singapore frequencies were used to analyze Khoo Teck Puat Hospital responses including demographics, tracking technologies, smartphone Background: apps, social media use, and internet Bariatric procedures are effective searches. treatment for type 2 DM with either Results: 98% of participants reported improvement of glycaemic control or owning a smartphone. Of those, the remission of DM. The aim of this study

272 www.obesityweek.com is to look at remission of DM 1 year A406 after Bariatric procedures Do Early Outcomes Improve the (Laparoscopic Roux-En-Y Gastric First Year After Completing a bypass LRYGB and Laparoscopic Bariatric Surgery Fellowship? sleeve gastrectomy LSG) among Asian Dvir Froylich Haifa 1, Eden population. Gerszman 1, Edress Khatib I`billin 1, Christopher Daigle Akron OH2, David Methods: Hazzan Haifa 1 A retrospective cohort study was Carmel Medical Center1 Akron General conducted to look at remission of DM Hospital2 among patients with at least class II obesity (BMI > 32.5) who underwent Background: Bariatric surgery training Bariatric surgery from year 2012 - has long learning curves. It has been 2016. The primary outcome was level suggested that fellowship training can of HbA1c at 6 and 12 months. improve patient outcome. There is Remission of DM is defined as HbA1c limited data comparing the outcomes < 6.5% without medication / insulin. before and after bariatric surgery training. The aim of this study was to Result: evaluate the impact of bariatric surgery There were total of 113 patients (80 fellowship during a surgeon’s early LRYGB: 33 LSG) with mean BMI of experience on perioperative outcomes 42.8kg/m2 ± 7.9 before surgery. Mean and to compare it to the results before HbA1c before surgery were measured training. at 8.5% ± 1.7. Mean HbA1c measured Methods: All patients who underwent at 6 months were 6.8% ± 1.3 (p<0.05) bariatric surgery by a single surgeon and at 12 months were 6.7% ± 1.3 with a junior assistant prior to his (p<0.05). Overall, 66 (58.6%) patients training and the 18 months following had remission of type 2 DM 1 year bariatric surgery fellowship were after surgery. Patient in RYGB group included. A 30-day outcomes has higher remission than LSG group ( comparison was conducted between 65.5% vs 42%). those two periods. Results: Prior to the fellowship Conclusion: training, there were 49 patients who This study showed that bariatric underwent sleeve procedure had significantly improved gastrectomy. Eighteen months patient’s diabetes control after surgery following fellowship training there evidence by marked HbA1c were 146 patients who underwent improvement. We plan to publish 3 and sleeve gastrectomy, Roux en-Y gastric 5 years follow-up result later bypass or mini gastric bypass (117, 29, and 5 respectively). Post-training sleeve gastrectomy patients were

273 significantly older 36.4±11.7 Introduction: vs. 42.3±14.6 years old (p=0.01), with Despite variable weight loss after higher ASA score 2.1±0.3 vs. 2.29±0.4 Sleeve gastrectomy (SG) and Roux-en- (p=0.02). Intra-operative complications Y gastric bypass (RYGB), bariatric occurred in 1 (2.0%) vs. 2 (1.7%) surgery remains the most effective, (p=n/s) during the pre-training and durable treatment for morbid obesity. post-training periods, respectively. MicroRNA (miRNA) are short non- Estimated blood loss was77.7±16.6 vs. coding RNA that regulate post- 76.0±24.7 (p=n/s). There were no transcriptional gene expression. They conversions to open surgery and no are implicated in numerous metabolic mortalities. Overall 30-day morbidity processes, possibly including weight was 5 (10.2%) vs. 4 (3.4%) (p=0.07). homeostasis. MicroRNA are readily Major complication (bleeding and detectable biomarkers that exist in a leaks) were significantly lower during variety of cell-free matrices. This pilot the post-training period; 3 (6.1%) vs. 1 study aims to investigate the utility of (1.7%) (p=0.04). miRNA biomarkers to predict weight Conclusions: Designated bariatric loss. surgery training is associated with Methods: reduced major post-operative Serum was collected from patients at complications. Surgeons should pursue the initial bariatric consultation. Data a formal bariatric surgery training was collected 6-12 months before starting their practice. postoperatively on 53 patients. Individuals experiencing the least (n=10) and the greatest (n=10) amount of percentage of excess weight A407 lost (%EWL) were included in this Pre-operative serum microRNA study. Total RNA was isolated from profiles associated with weight loss each serum sample and screened for following bariatric surgery 752 miRNA. Laura Doyon Concord MA1, Travis Results: Sullivan Burlington MA2, Sanjna The median %EWL was 51% (range Das Burlington MA2, Jingjing 23-61%) for those who lost the least Sherman Englewood NJ3, Thomas and 87% (range 80-105%) for those Schnelldorfer Burlington MA2, David who lost the most. Groups were similar Brams Burlington MA2, Kimberly in age, gender, diabetic status, and type Rieger-Christ Burlington MA2, Dmitry of surgery. In total, 119 miRNA were Nepomnayshy Burlington MA2 detected; seven were selected for Emerson Hospital1 Lahey Hospital and additional analyses Medical Center2 Englewood Hospital (FDR<0.15). Supervised hierarchical and Medical Center3 clustering analysis grouped samples by weight loss group (p=0.001); six

274 www.obesityweek.com miRNA demonstrated potential for Aim To determine if the number of discriminating between these groups follow-ups before weight-loss plateau (AUC>0.7). Bioinformatics pathway affects the weight-loss outcomes analysis identified several target following stomach intestinal pylorus- proteins. sparing (SIPS) surgery. Conclusions: Methods The medical records of 437 Several serum miRNA were detected in patients who underwent primary SIPS bariatric patients that could serve as surgery by three surgeons from June predictors of postoperative weight 2013 through January 2018 were loss. These biomarkers could help retrospectively reviewed. The facilitate an informed decision about inclusion criterion was patients that surgery. Likewise, these miRNA could were out by 18 months of surgery. play a critical role in the Follow-ups above 18 months were pathophysiology of obesity. excluded from analysis. Patients with <5 follow-ups (range 1-4) and 5 follow-ups (range 5-15) were A408 categorized into two different groups. Does the Number of Follow-Up Percentage excess body weight Following Stomach Intestinal (%EWL) and change in body mass Pylorus-Sparing Surgery Affect index (BMI) were calculated for each Weight-Loss Outcomes? group at 18 months. Amit Surve Salt Lake City UT1, Hinali Results A total of 305 patients were Zaveri Salt Lake City UT1, Daniel identified for analysis. There were 132 Cottam Salt Lake City UT2, Austin patients with <5 follow-ups and 173 Cottam Salt lake City UT1, Walter patients with 5 follow-ups until 18 Medlin Salt Lake City UT1, Christina months following surgery. There was Richards Salt Lake City UT1, Legrand no statistically significant difference Belnap Salt Lake City UT1, Samuel between the preoperative characters of Cottam Salt Lake City UT1, Benjamin both groups. The patients with <5 Horsley Salt Lake City UT1 follow-ups and 5 follow-ups achieved Bariatric Medicine Institute1 Bariatric 73.4% EWL and 69.6% EWL at 18 Medical Institute2 months, respectively. However, there was no statistically significant Background It is presumed that good difference (P: 0.819). Similarly, the postoperative programs correlate with patients with <5 follow-ups and 5 weight loss outcomes. Therefore, follow-ups lost 18.4 BMI points and surgeons design “optimal” programs to 19.9 BMI points at 18 months, maximal weight loss. However, we respectively. However, there was no wondered does compliance with statistically significant difference (P: postoperative programs result in better 0.906). weight loss? Conclusion More follow-ups do not

275 result in significantly higher weight outcomes were also compared at 3 and loss. 12 months. Results The two groups, those with surgeon A409 and PA follow up, were not found to Physician follow up is unnecessary: have statistically significant differences PAs are all we need in any preoperative demographic. They Samuel Cottam Salt Lake City UT1, also were found to have statistically Daniel Cottam Salt Lake City UT2, similar weight loss following surgery. Austin Cottam Salt lake City UT1, Amit Conclusion Surve Salt Lake City UT1, Hinali Surgical postoperative visits can be Zaveri Salt Lake City UT1, Christina very important for patients following Richards Salt Lake City UT1, Walter bariatric surgery, however, they need Medlin Salt Lake City UT1 not be done by the surgeon and can be Bariatric Medicine Institute1 Bariatric delegated to competent staff without Medical Institute2 affecting patient outcomes.

Introduction: Currently there are mixed opinions on how much the surgeon should be A410 involved with the follow up visits of Common Channel Lengthening is the patients following bariatric surgery. best way to treat chronic diarrhea Some believe that surgeons should be and hypoprotenemia following Single present for the patients throughout the Anastamosis Duodenal-Ileal Bypass weight loss journey while others with Sleeve Gastrectomy believe that this attention is not Benjamin Horsley Salt Lake City UT1, necessary and can be delegated to Daniel Cottam Salt Lake City UT1, competent office staff. In our practice Austin Cottam Salt lake City UT1, Amit we began to delegate follow up to the Surve Salt Lake City UT1, Hinali PAs in 2016 and have now decided to Zaveri Salt Lake City UT1, Walter compare weight loss outcomes to see if Medlin Salt Lake City UT1, Samuel surgeon follow up helps patients lose Cottam Salt Lake City UT1 more weight. Bariatric Medicine Institute1 Methods We retrospectively analyzed 1124 BACKGROUND: patients, 893 of whom received surgical Single Anastomosis Duodenal-Ileal follow up from a surgeon and 231 of Bypass with Sleeve Gastrectomy whom received surgical follow up from (SADI-S) is a modification of the a PA. The two groups were compared biliopancreatic diversion with duodenal in terms of pre-operative BMI, age, and switch (BPD-DS) surgery. A concern comorbidities. Patients’ weight loss with SADI-S is chronic diarrhea and

276 www.obesityweek.com hypoproteinemia. Common channel Body composition changes 1 month lengthening (CCL) is a surgical following bariatric surgery: RYGB procedure to increase absorption in the vs LSG small intestine to decrease diarrhea. Jonathan Sivakumar Melbourne 1, Lynn OBJECTIVES Chong Fitzroy 2, Salena Ward Fitzroy 2, The aim of this study was to assess the Tom Sutherland Melbourne 2, Michael occurrence and treatment of Hii Fitzroy 2 hypoproteinemia and chronic diarrhea St Vincent's Hospital Melbourne1 St with CCL following SADI-S surgery. Vincent’s Hospital Melbourne2 SETTING Private Practice in the United States Purpose: While the effects of bariatric METHODS surgery on total body weight have been The prospectively kept data bank was well-documented, the post-operative searching for patients who underwent body composition changes in these primary SADI-S from September 2013 patients is poorly understood. to March 2018 or revisions of gastric Objective: To evaluate body bypass to SADI-S and Sleeve to SADI- composition changes in patients S. We then looked through each undergoing bariatric surgery, and to patient record to find which patients compare roux-en-Y-gastric-bypass had undergone CCL procedures. (RYGB) with laparoscopic sleeve RESULTS gastrectomy (LSG). Average operating time for Methods: A prospective analysis was laparoscopic CCL is 56.5 ± 4.6 completed on patients undergoing minutes. The average bowel RYGB or LSG at St Vincent’s Hospital movements for the eight patients before Melbourne between 2017 and 2018. laparoscopic CCL was 9.1 ± 4.7 a day. Body composition was measured with After the surgery, the bowel dual-energy X-ray absorptiometry movements were reduced to 2.625 ± (DXA) immediately before surgery, 0.4 a day. This difference was found to one-month post-operatively and be statistically significantly different ongoing. (p=.002). The only patient experiencing Results: Thirteen patients were hypoproteinemia, improved protein included in this series, (RYGB n=4, levels following CCL. LSG n=9). In average, the total CONCLUSION bariatric cohort lost 7.9 kg (95% CI: With chances of complications being 5.9 – 9.9), body mass index decreased low, CCL are feasible options to treat by 2.9 kg/m2 (95% CI: 2.3 – 3.5) and symptomatic chronic or acute diarrhea excess weight loss was 22.2% (95% CI: without labs to confirm malnutrition. 15.5 – 26.9). LSG patients lost 3.8 kg more lean body mass (LBM) compared to the RYGB group. (LSG; 4.8 kg, 95% A411 CI: 2.8 – 7.1 vs. RYGB; 1.1 kg 95%

277 CI: 2.6 – 5.3) (p=0.052). Fat mass (FM) Setting loss was 4.0 kg (LSG; 95% CI: 2.6 – ASMBS members current practice 5.3) and 4.7 kg (RYGB; 95% CI: 2.5 – patterns. 6.8), respectively. No meaningful change in bone mineral density was Objective detected in the cohort. Conclusion: There was substantial To identify preoperative practice weight loss in the first month following patterns related to bariatric weight bariatric surgery. LBM is lost management and identify postoperative concurrently with FM however there is practice patterns when WR or IWL is a trend for LSG resulting in greater loss present. of LBM as compared with RYGB. Methods

A survey was emailed to the ASMBS A412 membership of 3,939 individuals. Ten Weight Regain and Insufficient questions pertained to the preoperative Weight Loss after Bariatric Surgery: timeframe, 11 to the postoperative a Survey to identify current practices timeframe, and 4 to demographics. In and attitudes amongst ASMBS order to explore common practice members. patterns, Chi-square tests were used to Saniea Majid Chatham NJ1, Anthony examine bivariate associations between Gonzalez Miami FL, Brandon selected question responses. Grover La Crosse WI, Michael Morell La Crosse WI, David Results Podkameni Gilbert AZ, Vanessa Cobarrubia Bend OR, Christopher Responses were received from 337 Still Danville PA, Raul (8.5%). There was variability related to Rosenthal miami FL, Stephen requirements for preoperative and Archer Bend OR postoperative weight loss, dietitian Weightloss and Wellness Center1 visits, use of medications, and other interventions. Correlations were found Background between requirements for preoperative weight loss and postponing surgery, Weight regain (WR) and insufficient and the frequency of preoperative and weight loss (IWL) are observed in postoperative visits with the dietitian. some post bariatric surgery patients. This has an impact on patients and Conclusions affects the perception of bariatric surgery among referring providers. There is currently variability in the care of bariatric surgery patients.

278 www.obesityweek.com Empirically developed pathways could 0.5 ug/kg IBW, Lidocaine 1.5 mg/kg standardize care and allow greater IBW. Mg Sulfate 40 mg/kg IBW, understanding of WR and IWL. Rocuronio 0.6 mg/kg IBW, Propofol Focused interventions could prevent 2.5 mg/kg IBW. at 0.6 MAC and treat these problems. Desfluorane. table position beach, tongue is retracted and placed cannula Migration endotracheal tube is advanced fiberoptic, identify epiglottis, vocal cords, advances to the carina, endotracheal tube is lowered and removed fiberscope A413 20 patients operated from August 2016 Orotracheal intubation in the super- to March 2017. With age range of 20- super obese patient with a flexible 65 years with an average of 62.4 of bronchoscope under general which 9 were women and 11 men, BMI anesthesia and deep neuromuscular range of 60.1 to 71.9 kg / m2 with an relaxation average 62.5 kg / m2. And 100% over 5 Lizzet Villalobos MEXICO 1, Luis 2 predictors of VAD and ventilation Aceves CIUDAD DE MEXICO CMX difficult, with neck circumference of CENTRO BARIATRICO 1 2 55-63 cm. a successful intubation at the METABOLICO DALINDE CBMD first attempt 19 of 20. 25’ range intubation. The approach of the airway in the Conclusions: The use of flexible patient is always a challenge for fiberoptic bronchoscopy disposable, is anesthesiologists especially when this, a good tool in the endotracheal is done under general anesthesia and intubation of super super obese patients Relaxation Neuromuscular deep with a high success rate, allowing (RND), the approach firoscopy is often increased security to addressing performed under local anesthesia or complex VA sedation, without relaxation, for the collapse of the VA that can be generated, hampering ventilation; A414 however, recent studies show that the Pregnancy after Bariatric Surgery: RNP facilitates ventilation-perfusion Current Evidence and A prospective, observational, Recommendations descriptive study. Patients 20 to 65 Leah Kim Savannah GA1, Jaine years old. ASA II-III, BMI equal or McKenzie Augusta GA1, Lisa greater than 60 kg / m2 undergoing Hilton Augusta GA1, Andrew elective laparoscopic abdominal Duffy New Haven CT2 surgery ,Inducción. Dexmedetomidine

279 Medical College of GA at Augusta successful weight loss following Univ.1 Yale University2 bariatric surgery. Management is often complex and can require a high risk Approximately 30% of reproductive obstetrician in addition to a bariatric age women in the United States are surgeon. obese. Maternal obesity is associated with an increased risk of many This manuscript discusses pregnancy complications including gestational considerations following bariatric diabetes mellitus, hypertension, surgery, including the safety of preterm delivery, and fetal pregnancy, the effect of pregnancy on macrosomia. As a result, weight post-operative weight loss, and obesity- reduction in the pre-pregnancy period related infertility. Current contraception has become imperative for both recommendations in the perioperative maternal and fetal health. The period as well as nutritional monitoring American College of Obstetrics and and supplementation in the post- Gynecology (ACOG) recognizes operative period are defined. bariatric surgery as a promising pre- pregnancy obesity treatment. A415 Nearly half of all bariatric surgeries Gut hormone changes and resolution performed in the United States are for of diabetes in Indian morbidly obese women of reproductive age. Due to patients undergoing sleeve concern for increased maternal and gastrectomy fetal risks, the current recommendation Vivek Bindal New Delhi is to delay pregnancy for 12-18 months Sir Ganga Ram Hospital after bariatric surgery. This poses an important topic of patient counseling Introduction for contraceptive use in the We propose to analyze and attempt to postoperative period. The issue is understand the gut physiology and its further amplified by increased metabolic alteration in Type 2 Diabetes postoperative fertility after weight loss Mellitus (T2DM) after Laparoscopic / along with decreased efficacy of oral Robotic Sleeve Gastrectomy (SG). contraceptives in patients who have undergone malabsorptive weight loss procedure. Objectives 1. To evaluate the gut metabolic In addition to the risks imposed on the alterations in Indian Diabesitic patients fetus as a result of early pregnancy undergoing SG following bariatric surgery, the delay in 2. To correlate with the improvement in continued weight loss during the the anthropometric, diabetic indices pregnancy is often detrimental to and co-morbid conditions leading to

280 www.obesityweek.com betterment of quality of life indices

Methods A416 This is a prospective study being History of #obsmuk : The obesity conducted in Sir Ganga Ram Hospital, and bariatric surgery social media New Delhi, India after IRB approval. group in the UK Prospectively enrolled patients having Zaher Toumi Durham BMI > 32.5 Kg/m2 with T2DM County Durham and Darlington NHS underwent Standardized SG. Baseline Foundation Trust levels of Glucose, Insulin, C-Peptide were measured in Fasting (F) and #obsmuk is a multidisciplinary group Postprandial (PP) states. HbA1C levels of doctors, AHPs and patients that was are evaluated and HOMA-IR index established in March 2017. calculated. Baseline fasting and PP levels of GHRELIN, GLP-1 & PYY #obsmuk ‘s main objective is to fight are evaluated. obesity. This is achieved by disseminating an evidence-based Results message about obesity and bariatric A total of 32 patients have been surgery and by campaigning to improve enrolled in study thus far. The prevention programmes, to improve preliminary results show a significant access to treatment and to stop weight decrease in BMI and a significant bias. (p>0.001) correlation is found between fasting blood glucose-, insulin-levels The evidence-based message is with HbA1c. Furthermore, C-peptide disseminated through: 1) establishing a decreases significantly within 1 month specific UK obesity social media but increases as expected by 1 year. hashtag: #obsmuk 2) conducting Also, as levels of Ghrelin decrease, multidisciplinary tweet chats about GLP1 was observed to increase and obesity and bariatric surgery related PYY1 was also observed to decrease topics and 3) by tweeting and over a period of 6 months. Further Gut retweeting evidence-based message hormone data analysis is under process. about obesity and bariatric surgery.

Conclusions The campaigning and advocacy are Our preliminary data shows that SG achieved through: 1) highlighting the even though traditionally believed to be poor provision of services that help in a restrictive procedure, does lead to the prevention and treatment of obesity metabolic alterations by producing and campaigning for better provision changes in the gut hormones and and access 2) drawing attention to resetting the deranged Gut- Endocrine misconceptions about obesity and Axis. bariatric surgery and about patients

281 who are affected by obesity and/or had medications known to cause weight bariatric surger 3) by accentuating the gain. As an alternative, bilateral prevalence of weight bias and its salpingectomy provides highly reliable detrimental effects on people affected contraception and has even been by obesity and by initiating and proposed as a strategy to reduce the supporting campaigns to eliminate risk of ovarian, tubal, and peritoneal weight bias. cancers. Objective: To demonstrate the safety #obsmuk has made significant and feasibility of performing bilateral achievements during its first year that salpingectomy for sterilization at the include: establishing large number of time of a bariatric operation followers and producing many tweets, Setting: A large academic medical running 9 chats, being invited to center present at BOMSS scientific meeting, Methods: Between September 2011 influencing a UK parliamentary survey and April 2018, we performed 19 cases about obesity that omitted bariatric of planned concurrent bariatric and surgery as a treatment option, signing a sterilization procedures. These cases letter to eliminate weight bias in the were retrospectively reviewed. media and establishing another obesity Results: Nineteen patients underwent social media group in the Middle East various sterilization procedures at the and North Africa region. time of minimally invasive bariatric surgery (11 RYGB, and 8 VSG), with the vast majority receiving bilateral A417 salpingectomy. No additional incisions Concurrent Bilateral Salpingectomy or instruments were required. The for Sterilization at the Time of average age body mass index was 46.3 Bariatric Surgery kg/m2, and average age 39.4 years. Brandon Williams Nashville TN Over half (10/19) of the patients had a Vanderbilt University Medical Center history of prior abdominal gynecologic surgery, predominately C-section. The Background: Women of child-bearing average additional time required for potential generally experience an bilateral salpingectomy was 8.1 increase in fertility following bariatric minutes. Only 1 sterilization procedure surgery. However, the most commonly could not be performed, due to dense performed bariatric operations, Roux- pelvic adhesions. There were no en-Y gastric bypass (RYGB) and perioperative complications. sleeve gastrectomy (VSG), may impair Conclusions: Salpingectomy at the absorption of oral contraceptives, time of bariatric surgery is safe, potentially rendering them ineffective. feasible and should be offered to Moreover, women desiring to lose women who desire permanent weight should avoid contraceptive sterilization.

282 www.obesityweek.com with another sample reliably showing excess weight loss benefits from the A418 inclusion of the patient’s goals. This The Integration of Medical, current psychological data include the Psychological, and Quality of Life Coding subtest of the Wechsler Scales, Measures in the Prediction and the Beck Depression Inventory, the Maintenance of Excess Weight Loss Obsessive Compulsive Screening, after Bariatric Surgery. anxiety screening, EATS-26, and the Vincent Escandell Alexandria LA1, Three Factor Eating Questionnaire. James Parrish Alexandria LA2, Richard Currently, the authors integrate medical Elder Alexandria LA1 data (blood pressure, sleep apnea, Louisiana State University diabetes, GERD, hours of sleep), the Alexandria1 Mid Louisiana Surgical psychological data, the Schwartz Specialist2 Outcome Scale, and the patient’s stated desired weight. The medical data plus The National Institute of Health, the the psychological data and QOL/goal American Association of Clinical allow this predictive performance at Endocrinologists, the American Society post-surgical assessment, <.05. Tables for Metabolic and Bariatric Surgery, acknowledging the regression and and the Obesity Society Guidelines for correlation data will be presented. the Clinical Management of Bariatric Surgery patients have long recommended that assessment of bariatric surgery candidates include A419 presurgical psychological evaluations Chances of Normal BMI Following as a national standard practice amongst Single-Anastomosis Duodenal Switch bariatric centers. (SDS) Escandell and Elder in a previous study Sarah Pearlstein New York NY1, Mitch showed results affirming predictive Roslin New York NY, Ali validity for cognitive, psychological, Shayesteh New York NY, Deborah and operationalized questions from Allis Mount Kisco NY categories of the Allied Health Lenox Hill Hospital Northwell Health1 Sciences Section Ad Hoc Behavioral Health Committee (AHSSAHBHC) Introduction: After SDS, patients can pre-surgical psychological assessment expect to lose around 70-80% of excess of bariatric surgery candidates. The weight with an average BMI around 50. results of this study affirmed the Although many people appreciate the predictive ability of these psychological health benefits that come with mild to tests plus the patient’s goals in moderate weight loss, the desire for determining excess weight loss. The most people having surgery for obesity authors then validated these measures is that they would no longer be obese

283 post-op. A420 The purpose of this investigation is to Utilization of Enhanced Recovery determine the probability of each After Surgery in Patients individual patient of whether they will Undergoing Revisional Bariatric be obese following SDS, as well as the Surgery probability of them being outliers; Kevin Bree Cincinnati OH1, John looking at whether various factors Mitko Cincinnati OH1, Lala affected weight loss. Hussain Cincinnati OH2, George Kerlakian Cincinnati OH1, Kevin Methods: Retrospectively retrieved Tymitz Mason OH1, Katherine data of 34 SDS performed, looking at Meister Cincinnati OH1 percent total weight loss (TWL) Good Samaritan Hospital1 2. TriHealth differences at one year between age, Hatton Research Institute2 sex and BMI class. Background: Enhanced Recovery After Results: Average TWL was 41% from Surgery (ERAS) has been adopted by pre-op. There was no statistical many surgical disciplines to improve difference in TWL between age, sex or clinical outcomes and Length of Stay BMI class. Probability of becoming (LOS). The LOS for ERAS primary non-obese was 81% for starting BMI Roux en Y gastric bypass (RYGB) was 45-50, 33% for BMI 51-55, 20% for previously found to be 2.34 days at our BMI 56-60% and 0% for BMI over 60. institution. The purpose of this study is 12% of patients lost <35% total body to investigate clinical outcomes of weight, 62% lost between 35-45%, and patients undergoing revision bariatric 26% lost over 45%. Nutritional data surgery using ERAS. showed Vitamin D deficiency in only 12% of 26 patients with measured Methods: A retrospective chart review levels, and no albumin or Vitamin was performed at a single institution to A deficiency in 24 patients reported. identify patients who underwent revisional bariatric surgery using ERAS Discussion: SDS proves effective in from January 2016 to March reducing patient’s weight to a non- 2018. ERAS pathway consisted of obese level at one year. The results of extensive preoperative patient SDS are replicable across gender, age education, regimented oral hydration and BMI class. until 3 hours preoperatively, multimodal pain management, Conclusion: The results of SDS are judicious use of perioperative consistent and replicable and patients intravenous fluids, early Foley catheter can fairly reliably expect >35%TWL. removal, ambulation, and enteral feeding. Demographic data, LOS, reoperation rates, and readmission rates

284 www.obesityweek.com were collected and calculated. staff. However despite our dedication and commitment to ongoing education, Results: Twenty-seven patients were none of our nurses are currently included. Seventeen (62.9%) certified bariatric nurses (CBN). underwent single stage band removal With nursing leadership support, we with conversion to RYGB. Median have witnessed an increase number of preoperative Body Mass Index was our nurses throughout the institution 44.01 kg/m2(range, 31.48-67.78 kg/m2) becoming certified in a variety of and median age was 54 years (range, specialties. A recent change in nursing 26-67 years). Median LOS was 1 day leadership on our bariatric surgery (range, 1-5 days). Six (22.2%) patients designated unit provided us the underwent intraoperative drain opportunity to begin the dialogue with placement. Two (7.4%) patients our nursing staff on the benefits of underwent postoperative contrast study; certification. This resulted in 20 nurses all others were started on a liquid diet expressing an interest to become the night of surgery. There were no certified bariatric nurses. mortalities, thirty-day readmissions or reoperations. A team was assembled to develop an in-house, 2 day-eight hour review Conclusion: ERAS is safe and feasible course to assist our nurses in preparing in patients undergoing revisional for the CBN examination. In addition, bariatric surgery, with no observed we use a weekly newsletter to provide mortality, thirty-day readmission or nurses with sample examination reoperations in this cohort. LOS is questions. We created a CBN board on similar to that of patients undergoing the unit with test taking tips, additional RYGB at our institution. review questions and case studies. A review Q & A is planned for late June with one of our bariatric surgeon to allow for any last minute clarifications A421 before the July-August examination. A Single-Center Experience in Supporting Certified Bariatric Nurse As per MBSAQIP Standard 2.9, we are Certification continuously seeking ways in which to Carmela Pontillo Bothell WA improve our nurses’ knowledge and Overlake Hospital Medical Center clinical expertise in bariatric surgery. Our goal is to now expand As a MBSAQIP Accredited Center, we upon Standard 2.10 and offer our are committed to the quality care we patients nursing care which has met the deliver to our metabolic and bariatric professional standards for certification surgery patients. Our facility has a in bariatric nursing. dedicated and knowledgeable nursing

285 several measures of patient frailty or fitness. Recommended techniques A422 designed to decrease complications or Leak, Bleeding and Complications in improve the outcomes of leaks, Bariatric Surgery, A Quality bleeding and other complications Improvement Opportunity included: Preoperative, intra-operative Robert Rutledge La Quinta CA1, KS and post operative strategies. Most Kular appear to have mixed or small effects Center for Laparoscopic Obesity making these areas ripe for efforts to Surgery1 improve the outcomes of bariatric surgery. Bariatric surgery results have improved over time. The purpose of this study is Conclusions to review recent studies of leaks, Publications reporting the relative bleeding and readmissions and suggest safety of the present state of bariatric this may be a Quality Improvement surgery are in the main to be correct. (QI) opportunity to further protect On the other hand taking a QI approach patients from these complications. to the devastating impact of leaks, bleeding, readmissions and other Methods complications have on the 1-5% of Recent published articles on Bariatric patients that do have these surgery complications such as leak, complications appears justified. bleeding and readmission's were reviewed. Predictive and preventative factors were also reviewed to search for QI efforts that might offer opportunities A423 for improvement. Morgagni Hernia in a patient with gastric bypass - laparoscopic repair Results with mesh Reported rates of leak, bleeding and Subhash Reddy San Antonio TX1, readmission ranged widely from less Nilesh Patel San Antonio TX1 than 1% to 6% or more. Procedures Texas Bariatric Specialists1 with long suture/staple lines appeared to have the greatest risk of major 41 years old male with history of complications. Predictive or gastric bypass in 2011 (399 lbs,BMI preventative factors for these 57.4), lost to follow up for 3years now complications included surgeon skill, comes to office with giant staple misfire, reinforcement of diaphragmatic hernia and current wt staple/anastomotic suture lines, 224 lbs (BMI 32). He went to local ER elevated blood pressure, diabetes, for shortness of breath and cough after smoking and pulmonary disease as well workup with chest xraythen CT

286 www.obesityweek.com abdomen/pelvis diagnosed with application. Sessions were recorded, diaphragmatic hernia. He underwent and themes were identified. elective laparocopic repair with Results: Major results indicated that underlay mesh. Defect was 7*8 cms bariatric surgery patients are actively and repaired with 15 cms mesh. Pateint using multiple forms of technology to was discharged home on POD1. No gain knowledge about bariatric surgery issues in recent followup (2 months). and track their health Rare type of congential diaphgramatic progress. Additionally, patients hernia, can be managed effectively by reported a strong desire for more laparoscopic approach with mesh. technology options and support from their surgical program. This included mechanisms to track progress on relevant health outcomes, share with A424 healthcare providers, and receive Qualitative Assessment of feedback. Technology Use and Development of Conclusion: Bariatric surgery patients a Smartphone App for Bariatric are consumers of healthcare technology Surgery Patients widely available. Additionally, patients Colleen Tewksbury Glenside AL1, interviewed reported being receptive to Megan Mulgrew Philadelphia PA1, program-specific technologies such as a Samantha Warner- smartphone app. Future studies are Grimsley Philadelphia PA1, Jacqueline needed to develop a viable Countess philadelphia PA1, Kristoffel technological such as an app tool to Dumon Philadelphia PA2, Noel assist bariatric surgery patients. Williams Philadelphia PA2 University of Pennsylvania Health System1 University of Pennsylvania2 A425 Background: Bariatric surgery patients Weight loss outcomes of tier 3 weight have access to thousands of heath care management service in patients apps through their smartphones. Few referred to bariatric surgery. studies have been conducted to assess Robert Winstanley Durham 1, Zaher the current use of these tools and Toumi Durham 2 overall preferences. County Durham and Darlington Methods: Nineteen bariatric surgery NHS1 County Durham and Darlington patients of a multicenter academic NHS Foundation Trust2 health system bariatric program participated in five separate focus Background groups on healthcare technology use Engagement with Tier 3 weight loss and development of a bariatric-program service is a pre-requisite to qualify for specific smartphone weight loss surgery in the UK. Tier 3

287 involves a Multi-Disciplinary Team effectiveness, its drop out rate and its approach to weight loss that is based on weight loss and health outcomes. dietary, lifestyle, psychological and medical interventions (when deemed necessary). Aim A426 The aim of this study was to assess Endoscopic trans-luminal abscess weight loss outcomes of Tier 3 services drainage following sleeve in patients referred to a single bariatric gastrectomy. surgeon. Alejandra Munoz Grand Rapids MI1, Methods Martin Thomas Grand Rapids MI2, A retrospective study of a single David Scheeres Grand Rapids MI2, bariatric surgeon’s patients over an 18 Stephen Thorp Grand Rapids MI3 months’ period. Demographics, weight Michigan State University1 General and weight loss data were collected Surgery Spectrum Health2 Spectrum from an electronic patient management Health/General Surgery/MSU3 software. Results Laparoscopic sleeve gastrectomy is Thirty five consecutive patients were becoming a commonly used procedure included in the study (30 females). The to treat morbid obesity, and gastric median age at time of operation was leaks remain a complication. We 47.5 (range 24-70)). The median describe an innovative method of weight when patients joined Tier 3 was endosopic abscess aspiration with leak 147.95 (98-182) kilograms and the control. median BMI was 53 (34.4-62.1). The This is a 35 yo woman who had a median time between joining Tier 3 and laparoscopic sleeve gastrectomy. Her referral for surgery was 260 (135-728) postoperative course was complicated days. Tier 3 resulted in a median by a bleed which was controlled. The weight loss of -6.1% ( -0.1 to -17%). rest of her stay was uneventful. The median weight loss of patients with On POD 10 she presented with pain BMI less than 50 was -6.2% and those and abdominal CT scan showed an air- with a BMI greater than 50 was -4.2%. fluid collection next to the sleeve, Discussion demonstrating a gastric leak at the This study shows that Tier 3 weight proximal staple line. Interventional management service might help radiology was unable to place a drain patients to lose weight before bariatric given the abscess location. On POD 15, surgery. However, a study of all CT scan showed an enlarging abscess patients who are referred to tier 3 despite antibiotic treatment. (rather than those who are referred She underwent an EGD with onward for bariatric surgery) is endoscopic transgastric aspiration of required to establish its overall the abscess with stent placement. Using

288 www.obesityweek.com a cannula and guidewire, contrast was Prior work has indicated that patients injected into the fistula for better seeking bariatric surgery have visualization. The guidewire was unrealistic expectations regarding post- advanced while exchanging the cannula surgical weight loss (WL). Unrealistic for a 7 Fr nasobiliary catheter. The expectations may contribute to patient guidewire was removed and contrast dissatisfaction, undue surgical risk, and was aspirated via the catheter. A program attrition. We aimed to explore covered metallic stent was used to 6-month and 1-year WL goals cover the leak. compared to measured outcomes in a On post-drainage day 1, follow-up CT pre-surgical population using the showed good stent positioning and Weight and Lifestyle Inventory decreasing abscess. She received an 8 (WALI). Fr naso-jejunal feeding tube and was discharged home. Two months later, From 10/2012-3/2014, 29 patients follow-up CT showed resolution of the responded to the WALI item “If you abscess and stent was removed. are successful in our program in Treating gastric leaks via endoscopic changing your eating and exercising transgastric aspiration successfully habits, how much weight do you provides patients with a minimially realistically expect to lose after 6- invasive, first-line treatment option. months and 1-year?” and had weight With less procedures needed and outcomes 6-months and 1-year post- decreased hospitalization time than surgery. other methods available, patients have better quality of life. 24 female and 5 male subjects ultimately underwent gastric banding, gastric bypass, or sleeve gastrectomy A427 (10%, 48%, 41%, respectively). Preoperative weight loss expectations Average WL goals at 6-months and 1- in patients seeking bariatric surgery year (55±20lbs and 86±24lbs, Andrea Stone Glastonbury CT1, Janet respectively) did not differ from actual Ng Corvallis OR1, Richard WL (60±27 and 85±36lbs, Seip Glastonbury CT1, Madison respectively). Gender differences O'Brien South Windsor CT1, Emma emerged at both time points for goal Tishler Glastonbury CT1, Nicholas and actual WL (p<0.001). Actual WL Duga Farmington CT2, Pavlos exceeded WL goals in females by 3% Papasavas Hartford CT1, Darren and fell short by 11% at 6-months and Tishler Glastonbury CT1 1-year, respectively, and exceeded in Hartford Hospital1 University of males by 33% and 30%, at the same Connecticut2 timepoints, respectively. In females who underwent gastric banding, actual WL fell short of goals by 54% and 51%

289 at 6-months, 1-year, respectively. hernia, Laparoscopic repair of HH with primary closure of the This study expands on previous work to crura,Laparoscopic Roux-en-Y gasric include sleeve gastrectomy. Patients bypass with creation of tubular gastric pursuing banding have the most pouch , 150cm Roux limb and 150cm elevated WL goals compared to actual, of biliopancreatic limb. while those pursuing other procedures Intraoperative gastroscopy have very realistic goals. This study is limited by the small numbers of male Postoperative outcomes: patients and patients with banding. D/C to home on POD #3,1 mo f/u: tolerate soft and liquid diet without nausea/ vomiting. A428 Previously reported severe reflux Giant incarcerated paraoesophageal completely resolved. 3 mo f/u . hernia in super morbid obese patient Tolerating normal bariatric diet. No with Concurrent Roux en Y Gastric s/sx of reflux or recurrent hiatal hernia Bypass BMI 65.8 > 57.21 > 55.4 Rami Mustafa cleveland OH1, Isabel Janmey Cleveland OH2, Heba Conclusions: Elghalban Cleveland OH1, Tomasz Rogula Chardon OH1 1.We recommend pre-operative University Hospitals of Cleveland, gastroscopy as a part of early diagnosis CWRU1 Case Western Reserve of HH. University2 2.Gastric bypass remain the best solution for patient with GERD in Title: Giant incarcerated Large HH. paraoesophageal hernia in super morbid 3.Laparoscopic Gastric bypass with HH obese patient with Concurrent Roux en repair can be done safely in super Y Gastric Bypass morbid obese patients. 4.Long term follow up is needed to Case Presentation: establish effectiveness and durability of such management. 68yo Caucasian MaleInitial BMI 65.8,Gastroesophageal reflux disease refractory to medical A429 therapy,Comorbidities: HPT, OSA, Safety of Over Sewing the Anxiety Reinforced Staple Line vs. 3 of 5 mm ports and 1 of 10-12 mm, Rt Reinforced Stapler only in Sleeve paramedian incision. Laparoscopic Gastrectomy; Comparing two reduction on incarcerated type 4 hiatal

290 www.obesityweek.com Surgeons' Techniques in a Single between 2016 and 2018 were Institution identified. Twenty seven cases Adel Alhaj Saleh Lubbock TX1, performed by Surgeon A vs. 65 by Michelle Estrada Lubbock TX1, Grant Surgeon B. Demographics, Sorensen Lubbock TX2, Amir comorbidities, and other variables were Aryaie Lubbock TX1 comparable between the 2 groups. Department of Surgery/ Texas Tech (Table 1). No statistical difference in University Health Sciences the compared outcomes in both groups. Center1 School of Medicine/ Texas (Tables 1-2). However Surgeon B has 1 Tech University Health Sciences case of mortality, 7 cases of Center2 readmission for different reasons, 4 cases of leak, 1 case of bleeding, and 4 Background: cases of reoperation. In sleeve gastrectomy (SG) only reports comparing over sewing the Conclusion: staple line versus stapler only are Although there was no statistical available in the literature. No data significance in all the variables comparing reinforced stapler only vs. compared between the 2 groups, a trend over sewing a reinforced staple line is toward higher rate of complications yet available. was noted with over sewing the Objective: reinforced staple line, hence it did not To determine whether over sewing the prevent the occurrence of bleeding or reinforced staple line would minimize leak after SG. unfavorable outcomes in 30-day after SG. Methods: A430 We analyzed the data of SG patients “Right Size Prescribing” Through performed by 2 bariatric surgeons in Statistical Analysis & Bariatric our institution. Surgeon A only used Surgical Patients’ e-Feedback to reinforced stapler while Surgeon B Prevent Prescription Opioid Misuse added over sewing to the reinforced and Related Overdose Deaths staple line. Outcomes compared Shelly Brimhall Murray UT1, R. included, readmission, reoperation, leak Richard Rasmussen Provo UT1, Sathya and bleeding. Univariate analysis, was Vijayakumar Salt Lake City UT1 done. T-test and Chi square were used Intermountain1 for comparing continuous and categorical variables respectively and From 1999 to 2016, more than 200,000 Fischer’s exact test for significance, P people died in the U.S. from overdoses value < 0.05 was considered significant related to prescription opioids. Results: Overdose deaths involving prescription Ninety two patients underwent SG, opioids were five times higher in 2016

291 than 1999 as reported by The Centers A431 for Disease Control and Prevention. Confusion and Misunderstanding the Utah is one of 22 states where the Mini-Gastric Bypass Leading to overdose rate is higher than the national Complications and Death in average. Intermountain Healthcare is a Surgeons with Limited Experience 23-facility healthcare system (including with the Procedure: The Need for 3 comprehensive, accredited, bariatric Standardization, Education and centers) based in Salt Lake City, UT Recognition with an organizational mission to help Robert Rutledge La Quinta CA people live the healthiest lives possible. Center for Laparoscopic Obesity In 2016-2017 Intermountain Surgery established opioid reduction as a system priority and leadership teams This paper was demonstrates confusion were tasked with reducing opioid and associated complications in the prescribing by 40% by 2019. In support performance of Mini-Gastric Bypass of the initiative Intermountain’s (MGB) by surgeons with limited Surgical Services Clinical Program experience. rolled out a quality improvement Methods project to determine the variability of International journals, publications, opioid prescribing practices for national and international bariatric surgical procedures. This organizations’ programs, meetings, project includes distributing surveys to personal communications and social bariatric patients to obtain self-reported media were searched for episodes of feedback about their pain medications confusion, disagreement and (e.g. amount consumed, disposition of misunderstanding the Mini-Gastric unused medications). A dashboard was Bypass often resulting in created from the survey data showing complications. prescribing trends, patient consumption Results: trends and disposal of excess opioids. Numerous examples of errors, Data shows the median consumption of confusion and misunderstanding of the opioids is about a third of what is Billroth II and MGB were documented prescribed. Providing recommendations in Journals, national and international to physicians concerning ideal “right organization and meetings, personal size” prescribing for bariatric surgeries communications and social media is key to our efforts to prevent many resulting in serious complications prescription opioid misuse and to and death. reduce overdose deaths among our Examples: 1. One series reported a rate patient population. of stricture of 16%. This high rate was seen in no other large scale reported series. 2. A 10% rate of liver disease,

292 www.obesityweek.com dysfunction, liver failure and death was not carefully follow the technical reported in a small series of MGBs. details of the surgical procedure. (Excessive BPLimb) 3. A reported acute onset of crippling Methods bile reflux esophagitis leading to early The surgical technique of the MGB is revision. (Unrecognized Short Pouch) presented with attention to common 4. A series of MGB patients converted errors reported by new MGB surgeons to RNY for excessive weight loss resulted in serious complications in Results more than 46% The MGB components include a gastric 5. Many more pouch (different in several important ways from the sleeve pouch) and ante- Conclusions: colic Billroth II gastro- More than than 20 studies like those jejunostomy. Important points include above have reported complications or avoiding a twist in the pouch, creating a death that are rare or absent in large wide distal tip of the gastric pouch for series by experienced MGB surgeons. the gastro-jejunostomy, avoiding the In most studies and by most measures esophago-gastric junction and the risk the MGB has been shown to be the of leak, avoiding the hiatus and the equal to or better than comparable diaphragmatic cura. The creation of bariatric surgery procedures, yet the bilio-panceratic limb allows the confusion on the performance and MGB to treat all manner of patients management of the MGB remains from the thin diabetic to the super widespread with obese but carries great power and thus attendant complications and death. is dangerous in inexperienced hands.

Conclusion A432 Now after 20 years the IFSO has Understanding the Important Details recognized the MGB is no longer of the Surgical Technique of the investigational. The MGB has been Mini-Gastric Bypass shown in numerous studies to be Robert Rutledge La Quinta CA1, KS simple, elegant, effective, durable > 15 Kular yrs, powerful, tailored to patient, Center for Laparoscopic Obesity reversible, revisable, studies also show Surgery1 inexperience can lea to complications and death so attention to detail is This is the first year of the MGB being important. recognized as a standard Bariatric procedure. Adoption is growing around the world. But Complications are being reported by surgeons who do A433

293 Meta-analysis of Suicide and Self- 1.83)], p<0.001 using a fixed-effects harm following Bariatric Surgery model. Moderator analyses did not Dawn Roberts Peoria IL1, Nicole yield any significant predictors of Pearl Peoria IL2 study-level odds ratios; however, the Bradley University1 Washington length of time since surgery and suicide University2 approached significance (p=0.06), indicating greatest risk for suicide or Bariatric surgery dramatically improves self-harm in the first years after the quality of life in several domains. procedure. This meta-analysis does not However, several researchers have address the issue of a nonequivalent reported an increased risk for suicide surgical group (i.e., persons at greater and self-harm following surgery. risk for suicide/self-harm are more Others have failed to find an increased likely to seek or obtain bariatric risk, and reasons for the disparity are surgery) and analyses for publication not obvious. This meta-analysis bias were inconclusive. examined the association between bariatric surgery and suicide or self- harm. It also explored possible moderators of this association. Twenty- A434 eight studies of persons who had Obstructive Sleep Apnea after Sleeve undergone bariatric surgery were Gastrectomy versus Roux-en-Y identified. Two independent Gastric Bypass Surgery researchers coded studies by outcome Matthew Mozzo Suwanee GA1, Aliu measure (e.g., completed suicide, Sanni Snellville GA, Gulsedef attempted suicide, psychiatric Arslan Suwanee GA, Vaishali hospitalization, suicide-related Jadhav Suwanee GA, Luis questionnaires), and potential Gutierrez Suwanee GA moderators (i.e., patient, procedure, and GA - PCOM1 study characteristics). Odds ratios (ORs) for studies without a comparison Obstructive sleep apnea (OSA) is a group were extrapolated using World very common co-morbidity in patients Health Organization suicide rates for who are morbidly obese. OSA is a the country and year of the study. ORs progressive life-threatening disorder for studies with a prospective design characterized by repeated interruptions used pre-surgical values as in upper airway breathing that causes comparisons. Mean OR for all studies strain on the heart and brain. Bariatric and outcomes suggests that bariatric surgery is the best treatment for morbid surgery patients had an approximately obesity. The aim of this study is to 75% increased risk of suicide or self- evaluate clinical outcomes for patients harm than those who did not have this with OSA after sleeve gastrectomy surgery [OR = 1.76 (95% CI: 1.69, (SG) versus Roux-en-Y gastric bypass

294 www.obesityweek.com (RYGB) surgery. Remission of Barrett’s Esophagus after Sleeve Gastrectomy, A Case A systematic review was conducted Study. through PubMed to identify relevant Stephanie Therrien Boston MA1, Daniel studies from January 2016 through Jones Boston MA1, Blaine Phillips 1 March 2018, with comparative data on Beth Israel Deaconess Medical Center1 OSA in SG versus RYGB. OSA reduction between the two groups were Introduction: Barrett's Esophagus analyzed. The other outcomes (BE),common in individuals with measured were the reduction of gastroesophageal reflux disease hypertension, diabetes mellitus, and (GERD), pre-disposes the affected dyslipidemia. Results are expressed as individual to the potential development standard difference in means with of intestinal metaplasia, dysplasia and standard deviation. Statistical analysis esophageal adenocarcinoma. Due to was done using fixed-effects meta- physiologic changes incurred post analysis to compare the mean value of Laparoscopic Sleeve Gastrectomy the different groups. (Comprehensive (LSG), there is an increased risk of BE Meta Analysis Version 3.3.070 development, or progression in patients software; Biostat Inc., Englewood, NJ). with active GERD. Because of this, many surgeons consider a patient who Four out of 57 studies were included in has BE to be contraindicated for LSG this meta-analysis. Among the four surgery. studies, there were 52,426 patients who underwent bariatric surgery; 9,692 SG Case: 64 y/o Caucasian female with and 42,734 RYGB. The incidence of impaired fasting glucose, GERD, OSA (0.042 ± 0.018, p = 0.022), hypercholesterolemia, hiatal hernia, Hypertension (0.071 ± 0.019, p = nonalcoholic steatohepatitis and class 0.000), Diabetes mellitus (0.059 ± III obesity presents for bariatric 0.016, p = 0.000), and Dyslipidemia surgery. An EGD biopsy taken at the (0.075 ± 0.020, p = 0.000) in post- gastroesophageal junction (GEJ) operative bariatric patients were lower showed cardia-type mucosa with in the RYGB group when compared to intestinal metaplasia consistent with the SG group. BE. Side effects of LSG verses the Gastric Bypass (GB), including the RYGB is more effective in the potential worsening of BE into improvement and resolution of OSA esophageal cancer, were explained. The when compared to SG. patient was concerned by the malabsorptive properties of the GB and wished to proceed with LSG. She A435 demonstrated good understanding of the risks and benefits and agreed to a

295 conversion to GB should her BE or etiology. This case report presents three GERD worsen. cases of omental torsion and necrosis with subsequent calcific change that Results: Patient undergoes LSG (36F resulted in chronic abdominal pain. Bougie) with no complications. Repeat CASE PRESENTATION EGD biopsy at the GEJ is performed Three cases of patients with chronic two years after LSG by the same abdominal pain are presented herein. Gastroenterologist. Tissue pathology All patients had previously undergone demonstrates normal squamous Roux-en-Y gastric bypass and epithelium with no BE identified. presented without laboratory abnormality. They were subsequently Conclusion: At two years post- taken for diagnostic laparoscopy and operative, patients GERD has found to have encapsulated, calcified, completely resolved. Her EGD results omental masses. Two had computed are consistent with the resolution of tomography imaging showing Barrett's. These results are short-term. encapsulated fat necrosis in the Long-term follow up and monitoring omentum. These patients were all will be necessary. This case report taken for diagnostic laparoscopy during questions the dogma that BE is an which masses of calcified fat from absolute contraindication to LSG. torsed omental leaflets were excised. Pain improved in two out of the three cases. A436 Omental Necrosis as a Cause of CONCULSIONS Chronic Abdominal Pain in Gastric Fat necrosis of the omentum is a Bypass Patients documented occurrence and a known Margaret Ahrens York PA cause of acute abdominal pain in Wellspan York Hospital gastric bypass patients. However, this case report is the first documentation of BACKGROUND it as a cause of chronic abdominal pain. Chronic abdominal pain is a common The described patients had no complaint following Roux-en-Y gastric laboratory abnormalities and their bypass (RYGB) and has a wide array of imaging studies were inconclusive. presentations and causes. Torsion of the Pathology in all confirmed fat necrosis. omental leaflets, created by cleavage of This report also illustrates the benefit of the greater omentum during the bypass diagnostic laparoscopy in gastric procedure, has been previously bypass patients with chronic pain of described as a cause of acute abdominal unknown etiology. pain. However, pathology of the omental leaflets has not been shown to cause chronic pain of a non-emergent A437

296 www.obesityweek.com Long-Term Update on the Efficacy year, 2 years, 3 years, 4 years, and 5 of Laparoscopic Adjustable Gastric years was 41±19%, 44±23%, 45±26%, Banding in the Treatment of 43±28%, and 44±27% respectively Adolescents with Morbid Obesity with an 80% follow up rate at 5 years. (age 14-17) Comorbid conditions improved with Shinban Liu Brooklyn NY1, Heekoung resolution of diabetes mellitus (50%, Youn New York NY1, Bradley n=6), impaired glucose tolerance (71%, Schwack New York NY1, Marina n=7), dyslipidemia (43%, n=46), and Kurian New York NY1, Christine Ren- hypertension (63%, n=8). Patients had Fielding 1, George Fielding New York a significant increase in mean iron level NY1 after LAGB (11 mcg/dL increase) and NYU Langone Medical Center1 no significant changes in folate, B12, vitamin D, phosphorus, magnesium, Introduction and albumin. Obesity in the adolescent population is an increasing and challenging national Conclusion epidemic. Our institution has LAGB is an effective and sustainable demonstrated favorable short and mid- form of bariatric weight loss for term results using laparoscopic adolescents with an EWL of 44% at 5 adjustable gastric banding (LAGB) in year follow up. Additionally, the adolescents. This analysis is a report of weight loss was found to be associated our long-term results in adolescent with excellent resolution of comorbid patients. conditions and no significant nutritional deficiencies. Methods Adolescents aged 14 to 17 who met criteria for bariatric surgery were A438 enrolled in our FDA-approved LAGB Clinical Outcomes of Single Stage trial. Demographic data, body mass Conversion of Gastric Banding to index (BMI), laboratory evaluations, Sleeve Gastrectomy or Gastric and comorbid conditions were collected Bypass: a Meta-analysis of the pre and postoperatively. Literature Caitlin Mueller Atlanta GA1, Jeremy Results Jose Lawrenceville GA1, FeTausha 112 adolescents underwent LAGB McCoy Suwanee GA1, Aliu since September, 2001. The mean Sanni Snellville GA2 preoperative weight of 298±57 lbs and PCOM- Georgia Campus1 Eastside BMI 48±7 kg/m were reduced to Bariatric and General Surgery2 233±67 lbs and 37±10 kg/m respectively at 5 year follow up. The Introduction: percent excess weight loss (EWL) at 1

297 Adjustable gastric banding has fallen (OR=0.687, p=0.007) with conversions out of favor in recent years due to its to LRYGB when compared to LSG. complications and inferior weight loss There was no difference in staple line achievement compared to other leaks (OR= 0.734, p=0.35) or %EWL bariatric surgical procedures. This at 12 months (SDM= -0.318, p= 0.063) study aims to evaluate the outcomes of between the two groups. single stage gastric banding revision to either laproscopic Sleeve Conclusions: Gastrectomy(LSG) or Roux-en-Y gastric bypass(LRYGB). Gastric band conversions to both LRYGB and LSG are both safe and Methods: effective options to help bariatric patients achieve their goals. Single A systematic review was conducted stage gastric band conversion to LSG is through PubMed to identify relevant associated with reduced postoperative studies from 2015 to 2018 comparing complications when compared to the outcomes of single stage gastric LRYGB. banding revision to LRYGB versus LSG. Four out of 27 studies were considered for quantitative analysis. A439 Outcomes included were anastomotic / Possible Role of Omentopexy in staple line leaks, 30-day readmission, Minimising Post Sleeve Gastrectomy 30-day reoperation, and percentage of Complications excess weight loss(%EWL) at 12 Ibrahim Hassan Kuwait months. Results are expressed as odds Sidra(Alomooma)Hospital,Kuwait ratio(OR) and 95% confidence interval(CI), and standard difference in Abstract: Laparoscopic Sleeve means(SDM). Statistical analysis was Gastrectomy(LSG)has recently been performed using fixed-effects meta- recognized as a potential stand alone analysis to compare the OR and SDM operation for the treatment of obesity (Comprehensive Meta Analysis worldwide.However,the incidence of Version 3.3.070 software, Biostat Inc., postoperative nausea and vomiting is Englewood, NJ). not uncommon in surgical practice,whereas other serious Results: complications might occur including leakage or bleeding. Objective: To A total of 5,053 patients were studied, evaluate the possible role of post-sleeve 1,566 undergoing band revision to gastrectomy staple line plication and LRYGB, and 3,487 revision to LSG. omentopexy to minimize the There are more 30-day reoperations aforementioned postoperative (OR=0.541, p=0.002) and readmissions complications. Subjects: This was a

298 www.obesityweek.com retrospective study that was performed Liver Retraction in Bariatric at Sidra (Alomooma)Hospital in Surgery kuwait.Data was collected from Donald Yarbrough Corvallis OR1, November 2014 to December 2017. Erika La Vella Corvallis OR2, Andrew Three hundred patients were selected Sweeny Corvallis OR2 for this study and divided into 2 groups Samaritan Health Services1 Samaritan to compare the outcome and the Weight Management Institute2 potential complications in each group. In group A,150 Patients had LSG with Background: Adequate liver retraction stapler line plication and omentopexy. is an essential in bariatric surgery, with In group B,150 patients had LSG alone. technical challenges due to an enlarged, Both groups were followed and fatty liver. Traditional methods utilize compared for the incidence of the externally-fixed, rigid retractors with aforementioned complications. Results: inherent drawbacks including an extra No patients had leakage in group incision, pain, scarring, and potential A(0%),wheres 1 patient in group liver injury. Advancement of B(0.66%)had leakage in postoperative laparoscopic techniques for liver day 1. Eight patients had early retraction methods has focused on postoperative vomiting in group simplicity, reproducibility, safety and A(5.33%);one of them required effective use to avoid patient hospital readmission for supportive comorbidity. treatment (0.66%). Eighteen patients in Objective: Evaluation of the safety and group B(12%) suffered from vomiting efficacy of a port-less internal, ,and 4 of them (2.6%) were atraumatic bulldog liver retractor hospitalized. Two patients in group versus standard retraction in a large B(1.33%) had postoperative bleeding series of patients undergoing due to haemoglobin drop from 14.9 to minimally-invasive bariatric surgery. 10 g and from 13 to 9.9 g.Both were Methods: Retrospective review on all treated conservatively with blood bariatric operations from April 2010 to transfusion. Conclusion: In this study December 2017. Standard retraction ,It was noticed that performing LSG (Nathanson or equivalent) was used in with staple line plication and 108 patients and a novel, internal omentopexy offers an extra guard and bulldog-rubber band retractor system against postoperative attached to the pars flaccida and nausea,vomiting,leakage or bleeding. anterior abdominal wall was used in 483 patients. Any operations with additional procedures, re-do operations, A440 or missing data were excluded. Comparison of a Novel, Port-Free Results: 551 procedures (gastric bypass Internal Liver Retractor to Standard and sleeve gastrectomy) were included. No significant differences

299 were found in demographics, validate this revised measure of food AST/ALT elevation, need for addiction, the YFAS 2.0, among additional retraction (9.8% of cases), or patients pursuing bariatric surgery. A length of stay (LOS) between the retrospective chart review was bulldog and standard conducted of 315 patients who retraction. Adjustment for underwent pre-surgical psychological demographics and procedure in a evaluation for bariatric surgery. multivariable logistic regression model, Information gathered included BMI >50 was more likely to require symptoms of food addiction (YFAS additional retraction methods (OR 2.8, 2.0), emotional eating (Emotional 95% CI 1.2 – 6.8) and gastric bypass Eating Scale; EES), and history of had higher risk of postop elevation problematic substance use and binge AST/ALT 3 times baseline than a eating. In this sample, 27.3% met sleeve. criteria for food addiction. Of those, Conclusion: Port-less internal bulldog 20.7% met criteria for mild addiction, retraction can safely and effectively 25.3% for moderate, and 54% for retract the liver and expose the stomach severe. The YFAS 2.0 was related to all and GE junction in bariatric surgery. factors of the EES: Anger/Frustration (p<.001); Anxiety (p<.001); and Depression (p<.001). There was no A441 relationship between the YFAS 2.0 and Validation of the Yale Food a history of problematic substance use. Addiction Scale 2.0 Among a The YFAS predicted a history of binge Bariatric Surgery Population eating above and beyond emotional Shannon Clark Detroit MI1, Kellie eating (p< .001; Exp(B)=1.29). Given Martens Beverly Hilld MI1, Christine the relationship between the YFAS 2.0 Mason Detroit MI1, Aaron and emotional eating, convergent Hamann Detroit MI1, Lisa Miller- validity is present. Divergent validity Matero Detroit MI1 was also established for the YFAS 2.0 Henry Ford Health System1 because it was not related to other substance addictions. Accordingly, the Symptoms of food addiction relate to YFAS 2.0 appears to be a valid obesity and may impede the success of measure and could be used in the pre- individuals who seek bariatric surgery. surgical assessment of bariatric The original Yale Food Addiction candidates. Scale (YFAS) was validated for use among patients who underwent bariatric surgery; however, the YFAS was revised to reflect the changes in A442 substance use criteria in the DSM-V. Concomitant Bariatric Surgery and The purpose of this study was to Ventral Hernia Repair

300 www.obesityweek.com Steven Schulberg Brooklyn NY1, Vadim no consensus for type. In certain Meytes Brooklyn NY1, George situations, it is appropriate to repair Ferzli Staten Island NY1 recurrent ventral hernias at the time of NYU Langone Brooklyn1 bariatric surgery. Overall, staged bariatric surgery and interval hernia Introduction: repair may lead to fewer complications As bariatric surgery becomes in this patient population. increasingly prevalent, new questions arise regarding management of Conclusions: coexisting surgical issues in this After a thorough review of the population. No clear consensus exists literature, no clear consensus exists for regarding treatment of patients concomitant treatment of hernias in undergoing bariatric surgery with bariatric surgery patients. Based on the concomitant or recurrent hernias. We current level of evidence, we aim to review the available literature in recommend interval repair with mesh order to provide recommendations in these patients. Additional research regarding hernia repair in these with randomized controlled trials patients. should be performed in order to provide level 1 evidence regarding this topic. Methods: A systematic review of the available literature was performed in October 2017 using Medline, PubMed, A443 Cochrane Library, and relevant Community Hospital Decreases journals. Search criteria included the Narcotic Usage In Postoperative terms ventral hernia OR incisional Bariatric Patients hernia AND repair AND gastric bypass Robert Felte Media PA1, Caitlin OR gastric sleeve OR gastric band OR Halbert Rockland DE1, Dakota bariatric. 114 articles were discovered Urban Newark DE1 and after review, 12 were included in Christiana Care Health System1 this study. Background Results: The use of opioids has had a significant All articles included in this study were impact on the surgical patient and the retrospective reviews. Based on the surgeon’s ability to control evidence, primary repair of hernias in postoperative pain but their use has the population undergoing bariatric been wrought with complications and surgery should be avoided due to dependency. increased rates of recurrence, seroma, and post operative complications. Mesh Objective repair is preferred in these patients with The purpose of this study is to assess a

301 multimodal pain management plan and Conclusions its effectiveness at reducing opioid Our multimodal pain protocol usage. successfully reduced opioid usage, specifically hydromorphone. Further Methods analysis and continued protocol Laparoscopic gastric bypass and driven management provides laparoscopic sleeve gastrectomy encouraging outcomes in the effort to patients were included in our reduce opioid consumption. retrospective cohort study. The postoperative opioid usage of 516 patients from 2016 was compared to A444 that of 96 patients from a 3 month The PromMera study – an RCT period in 2017 after initiating the new evaluating the effect of a smartphone pain management protocol. In the application to improve lifestyle after protocol, patients received 15mg bariatric surgery intravenous (IV) ketorolac and 975mg Mari Hult Stockholm 1, Stephanie oral acetaminophen every six Bonn Stockholm 1, Ellen hours. Oral gabapentin, 300mg, was Andersson Norrköping 2, Kristina given at bedtime. Patients experiencing Spetz Norrköping 2, Ylva Trolle pain were treated with oral oxycodone Lagerros Stockholm 1 or IV hydromorphone. Before the Karolinska Institutet1 Linköping protocol, patients were managed with University2 IV hydromorphone and transitioned to liquid codeine. Breakthrough pain was treated with IV hydromorphone. The Being physically active is highly Wilcoxon Ranked Sum test was used. recommended to optimize postoperative outcomes after bariatric Results surgery. To motivate and support The study included 494 of the 2016 physical activity, smartphone patients, 95.7%, required IV applications can be used as a new tool hydromorphone compared to 86 of the to deliver interventions directly to the 2017 patients, 89.6%. Hydromorphone individual patient. Our aim is to usage decreased, from 4.0mg (± 4.0) in evaluate a new smartphone application 2016 to 1.8mg (± 1.7) in 2017 to support physical activity and intake (p<0.001). Acetaminophen usage of supplementary vitamins and increased from 975.0mg in 2016 to minerals after bariatric surgery. We 3,280.6mg in 2017, (p<0.001). 8.5% of hypothesize that at follow-up, the patients in 2016 received intervention group will be more acetaminophen compared to 93.8% in physically active, have a greater weight 2017. loss, and be more compliant with vitamin supplement intake, compared

302 www.obesityweek.com to the control group. Pressure Vac: First Documented Case in the Southwest The ongoing PromMera-study includes Joseph Heller Gilbert AZ1, Albert patients undergoing bariatric surgery. Chen Gilbert Az1, Emil Graf Gilbert Inclusion began November 2017, and AZ1, Flavia Soto Gilbert AZ1, David both men and women are recruited. A Podkameni Gilbert AZ1 total of 150 patients will be included. Banner Gateway Weight Loss Center1 Participants are randomized 1:1 to intervention (application) or control This is a case of a 25-year-old female (standard care) group. The participants who presented with a leak from the in the intervention group use the proximal third of her laparoscopically smartphone application during 12 performed sleeve gastrectomy. After weeks (week 6-18 post-surgery). performing initial washout and Participants’ body weight, body drainage as well as placement of a composition, physical activity distal feeding tube, numerous attempts (accelerometer) and lifestyle were made to control the leak. These (questionnaires) are assessed pre- included endoscopic clipping as well as surgery, and at 18 weeks, 6 months, eventual surgical intervention. The leak and 1 and 2 years post-surgery. continued to persist and after a Compliance with vitamins and minerals literature search to find alternative is assessed through regular laboratory methods for resolution, an endoscopic tests, as well as through the prescribed negative pressure vacuum device was drug register. placed. This allowed for gradual closure of the fistulous tract to a state To date, over 80 participants have been where endoscopic clipping was able to enrolled. Among these, the majority control the leak. This was confirmed were women (83%). The mean age and with multiple methods including mean body mass index pre-surgery radiologic imaging and methylene blue were 40.0 (11.3) years and 41.1 (6.5) analysis. This is believed to be the first kg/m2. The recruitment process is attempt at such in the Southwestern estimated to be complete by the end of region. 2018.

The trial is registered at A446 ClinicalTrials.gov Identifier: Port-site hernias following robotic NCT03480464. colorectal surgery in people with obesity: a case series and review of literature. A445 Matthew Chang Rockville MD1, Resolution of Proximal Sleeve Leak Nicholas Morin Brooklyn NY, Vadim Using Endoscopically Place Negative Meytes Brooklyn NY, George

303 Ferzli Staten Island NY, Shinban Rutgers RWJ Medical School1 Liu Brooklyn NY, Josef Shehebar Brooklyn NY Background NYU Langone - Brooklyn1 Revisional surgery is rapidly growing within the field of bariatric surgery, Port-site hernia is a rare complication increasing from 6% of all cases in 2013 following robotic surgery that can to 13.9 % in 2016. Endoscopic result in disastrous outcomes. We gastrojejunal revision (EGJR) has been describe incarcerated port site hernias shown to be a safe, effective, and less in two patients with obesity. Both invasive alternative to revisional patients required laparoscopic surgery in addressing weight reduction. One patient was taken back regain. However, there is limited data to the operating room a third time available comparing EGJR to similar during his hospital admission for small laparoscopic techniques. We examine bowel resection due to pneumatosis the effectiveness of EGJR and intestinalis. laparoscopic gastrojejunal revision for weight regain after Roux-en-Y gastric It is standard practice to not close the bypass. fascia of port-sites less than 12 mm in robotic surgery. However, this allows Methods for the rare possibility of small bowel A retrospective review was conducted herniation through the port-site. We of 83 patients who underwent EGJR suggest that our patients’ history of using interrupted suture technique for obesity and metabolic dysfunction weight regain. Pre and post-revision contributed to difficult port retention weights, intraoperative factors, and during the case, and longer operating complications were collected and times which caused an increased analyzed. For comparison purposes, a amount of torque at the port-site. This systematic literature review was extended the fascial defect, ultimately conducted to identify peer-reviewed leading to the incarceration of small articles examining outcomes after bowel in the port-site. laparoscopic gastrojejunal revision.

Results A447 EGJR were performed in 83 patients Endoscopic Versus Laparoscopic (84% female, mean age: 50.6, BMI: Gastrojejunal Revision as 42.5 kg/m2). Technical success (stoma Therapeutic Options for Weight diameter 10 mm) was achieved in all Regain after Roux-en-Y Gastric cases. BMIL at 3, 6, and 12 months Bypass was 2.8 ± 2.0 (N = 42), 3.1 ± 2.4 (N = Keith King Piscataway NJ1, Ragui 22), 2.1 ± 3.0 (N = 12) Sadek New Brunswick NJ1 kg/m2 respectively. Eight articles met

304 www.obesityweek.com criteria with 156 pooled surgical program’s efficacy in patients. BMIL at 3, 6, and 12 months resolution or improvement of DM was 5.97 ± 1.22, 5.43 ± 1.23, and 7.55 following bariatric surgery compared ± 1.19 kg/m2 respectively. with previously published data Methods: A review of 82 adult diabetic Conclusions patients were treated with sleeve Laparoscopic gastrojejunostomy gastrectomy at our two affiliated revision has a greater impact on weight medical centers over one year. We loss when compared with conducted a single point analysis of EGJR. However, as a less invasive longitudinal data for one year through procedure with fewer complications, retrospective chart review. Primary EGJR may still be considered as part of outcome was resolution of DM the algorithm for addressing weight determined by glucose control without regain after RYGB. medication. Secondary outcomes included reduction of antidiabetic medications, EWL%, HgbA1c,BMI. A448 Results: 78 patients,55 females and 23 Resolution of Diabetes Mellitus with males,were included in the final study. Laparoscopic Sleeve Gastrectomy – 28 patients utilized insulin,while 50 A Single Institution Review were on only oral medication(s). 55 Joseph Heller Gilbert AZ1, Andy patients (70.1%)were glycemic Novak Gilbert AZ1, Eshaan controlled without medication within Daas Phoenix AZ2, Albert Chen Gilbert the first year. 41/50 patients (82.0%) on Az1, David Podkameni Gilbert AZ1, oral medications alone demonstrated Emil Graf Gilbert AZ1, Flavia resolution. HgbA1c drawn between 3-6 Soto Gilbert AZ1 months postoperatively resulted in a Banner Gateway Weight Loss mean of 6.31% ,median of 6.1% Center1 University of Arizona2 Conclusions: Sleeve gastrectomy is a proven surgical method for weight loss Background: Laparoscopic sleeve and DM resolution. Our institution has gastrectomy (LSG) is a proven acceptable data when compared to intervention to induce metabolic national literature. In our review, changes resulting in weight loss and resolution was much higher in patients comorbidity resolution. Its applications on oral hypoglycemic medications vs as a surgical procedure which result in insulin which could be open to further metabolic therapy in chronic conditions study. such as diabetes mellitus (DM), are well established in the literature. This paper will analyze pre- and post- A449 operative metrics at established time Techniques for ERCP access in the intervals to determine this metabolic post Roux-en-Y Gastric Bypass

305 Patient: A novel approach and biliopancreatic disease which is seen review of the literature R. Robalino with increased frequency in people DO, V. Meytes DO, George Ferzli with obesity. Endoscopic adjuncts, MD, NYU Langone Hospital – such as balloon and spiral enteroscopy, Brooklyn have similar success rates cited at Ryan Robalino Brooklyn NY1, Vadim approximately 60%. When Meytes 2, George Ferzli Staten Island unsuccessful, the classic approach is NY3 laparoscopic-assisted gastrostomy with NYU Langone Hospital - trans-gastric ERCP. This technique Brooklyn1 Fellow2 Attending3 requires the coordination of the Introduction: As the prevalence of surgeon, endoscopist, and procedural people with obesity continues to rise so staff to function simultaneously for a do surgical weight loss one-time access point to the procedures. Approximately 25% of the ampulla. Our technique (modified tube nearly 200,000 procedures performed gastrostomy) allowed multiple ERCPs annually are Roux-en-Y Gastric to be performed and subsequent Bypasses (RYGB). RYGB patients gastrostomy reversal when definitive present unique challenges to the biliary drainage was obtained. management of biliary pathology. When endoscopy is Conclusion: A modified tube insufficient to access the ampulla, a gastrostomy to the distal gastric surgical approach is mandated. remnant is a safe alternative for repeat ERCP access to the ampulla in RYGB Methods: In our patient with recurrent patients with choledocholithiasis. choledocholithiasis following previous biliary clearance we anticipated multiple procedures for definitive decompression. The superior/posterior A450 position of the gastric remnant, in Laparoscopic sleeve gastrectomy relation to the costal margin and comorbidity reduction: a six months gastrojejunal anastomosis respectively, to one year-follow up. required a lengthening procedure to Omar Quiroz MEXICO MEXICO1, reach the abdominal wall. A modified Alfredo Peniche MEXICO , Víctor tube gastrostomy was created along the Cuevas México greater curvature of the gastric remnant PEMEX1 which provided adequate length and allowed multiple ERCPs to be Background performed. Laparoscopic sleeve gastrectomy (LSG) has become the most popular Discussion: Endoscopic access to the procedure worldwide for management ampulla is needed for the treatment of of the obese patient. Just recently it has

306 www.obesityweek.com been gaining popularity amongst Our results show LSG is a safe and bariatric surgeon in our country. effective weight-loss procedure with results similar to those of gastric bypass Introduction and superior to laparoscopic adjustable According to WHO data from 2016, gastric banding. Additional long-term Mexico has the highest prevalence in studies are still needed to accurately obesity amongst Latin American compare laparoscopic sleeve Countries and has become the number gastrectomy with gastric bypass. one in Latin America.

Objectives The purpose is to assess the impact of A451 the changes in laparoscopic sleeve Decreasing Narcotic Prescribing and gastrectomy on 6 months, 1 year, 2 Availability in a Post-Operative years, and to evaluate the impact of Bariatric Program those changes in the excess weight loss, Ginny Andreasik Baltimore MD, Karen complications, and resolution of Wheeler Baltimore MD1, Andrea comorbidities. David Baltimore MD1 MedStar Franklin Square Medical Methods Center1 A retrospective data collection in a single institution was performed in our INTRODUCTION: While date registry of LSG from 2012-2017, prescription narcotic abuse and misuse data analysis was conducted at 6 can be found all across the United months, 1 and 2 years to asses the States and the world, the state of percentage of excess body weight loss Maryland has one of the highest and comorbidity status change, in all overdose rates from prescription drugs. cases we used the same procedure. A quality improvement project was designed to evaluate and assess the Results need to decrease prescribing narcotic The percentage of resolved sleep apnea pain medication in the post-operative from baseline in 6 months and 1 year bariatric surgical program at MedStar were 45.7% and 84.1%, for reflux Franklin Square Medical Center in disease 33.1% and 48.2%, Baltimore, Maryland. This project also hyperlipidemia 45% and 57%, provided an opportunity for patients to hypertension 38.9% and 42.2%, bring their unused narcotic medication diabetes 57% and 75% respectively. to the office for safe, convenient, The percentage of excess body weight secure disposal. The goal of this project loss at the 6 months, 1-and 2-years was was to decrease the overall prescription 46%, 59% and 52% respectively. narcotic medication prescribed to the post-operative bariatric patient by 25%.

307 METHODS: In April 2017, UIC1 prescribers conducted a review of prescription practices. Adjustments to Introduction. PMVT after LSG is the amount of narcotic pills prescribed relatively rare in patients with a were made on an individual prescriber previously non-cirrhotic liver, with a basis. Also, patient education began in reported incidence between 0.3-1.8%. April 2017 to discuss the importance of Symptoms are usually non-specific, properly destroying unused prescription severity depends on location and narcotics, pain management and pain degree of venous obstruction. We control techniques, and non-narcotic present a case of a 60-year-old male pain management efforts which patient with PMVT after LSG. included ambulating, hydration, Methods. This patient had a distraction, and massage therapy. Staff preoperative BMI of 42.8 and history members were also trained on the safe of paroxysmal Afib (not on disposal of unused prescription anticoagulation), hypertension and narcotics. hyperlipidemia. He underwent an RESULTS: In January of 2017 uneventful LSG. Discharged on POD1, bariatric patients were prescribed a ambulating and tolerating clear liquids. total of 591 narcotic pills. By The patient presented to emergency on September 2017, the number of POD11 with abdominal pain, bloating prescribed narcotic pills decreased by and loose stools. Labs were 66% with a total of 204 narcotic pills unremarkable other than WBC of 23.5. prescribed. An increase in the amount CT without contrast reported diffuse of prescription narcotics being bowel wall edema suspicious for destroyed safely by trained staff was infectious enteritis. Patient improved also seen. with IV fluids and antibiotics and was discharged on day 14. Returned 5 days post-discharge with increasing shortness of breath, abdominal pain, A452 loose dark stools and Afib with RVR. Portomesenteric Thrombosis A CT with intravenous contrast (PMVT) after Laparoscopic Sleeve demonstrated left upper lobe Gastrectomy (LSG) pulmonary embolism and a thrombus in Michael Cudworth Chicago IL1, the portal vein extending into the Gabriela Aguiluz Chicago IL1, Roberto splenic and superior mesenteric veins Bustos Chicago IL1, Mario and ascites, of which 5L were drained Masrur Chicago IL1, Antonio percutaneously. The patient was treated Gangemi Chicago IL1, Lisa Sanchez- with esmolol, systemically heparinized. Johnsen Chicago Illinois1, Chandra Later transitioned to apixiban per Hassan CHICAGO IL1, Pier Cristoforo hematology consult due to repeated CT Giulianotti Chicago IL1 scan demonstrated stable but persistent

308 www.obesityweek.com PMVT. Discharged on day 13. At From November 29, 2017 to April 24, follow-up, patient reported feeling well, 2018, 39 patients had laparoscopic and a Dupplex-scan showed a patent vertical sleeve gastrectomy at our portal vein and normal flow. institution utilizing a disposable gastric Conclusions. When non-occlusive clamp to fix the relationship of the PMVT after LSG occurs, a stomach to the stapler. hypercoagulable workup should be Results obtained. PMVT management entails Of the 39 patients, five patients hospitalization, electrolyte replacement, required three staple loads to complete bowel rest, and systemic sleeve gastrectomy. The remaining 34 anticoagulation. patients required four staple loads to perform the operation. There were no intraoperative adverse events and no A453 postoperative staple line complications Use of disposable stomach clamp in this group of patients. No patients results in efficient usage of staple had any postoperative nausea. loads at time of Vertical Sleeve Discussion Gastrectomy Vertical Sleeve Gastrectomy utilizing a Aviv Ben-Meir Cleveland OH stomach clamp reduces the number of Lake Health loads fired to an average of 3.9 loads per operation. This is a reduction in the Introduction number of loads used in our There is a tremendous amount of institution. In addition to a time and variability in technique for performing cost savings performing the operation, laparoscopic vertical sleeve there appears to be a more consistent gastrectomy and in the number of appearance of the postoperative day staple loads used to perform the one upper GI appearance of the operation. In our experience, five to stomach. six loads are typically required to perform the operation. Recently, a disposable gastric clamp has become available to aid in performance of A454 vertical sleeve gastrectomy with a goal Reducing Wait times to the 1st of standardizing vertical sleeve Scheduled Weight Management gastrectomy. This retrospective study Clinic Appointment after Bariatric evaluated the number of staple loads Seminar Attendance used to perform vertical sleeve Mary Ellen Lawless Cleveland OH1, gastrectomy in the first 39 patients Sheila Vacha Cleveland OH2, undergoing sleeve gastrectomy with Mary this device. Madal Cleveland OH2, Karen Methods Yuhasz Cleveland OH2, Adam

309 Perzynski Cleveland OH2, Charles (March 2018) and interventions A+B Thomas Cleveland OH2, Janeen attendees (April 2018). Leon Cleveland OH2, Elaine Results: Mead Cleveland OH2, Eileen Wait times decreased by 28 days (65% Seeholzer Cleveland OH2, Sergio improvement) and variation decreased Bardaro Cleveland OH2 64 days (77% reduction). Mean and The MetroHealth System1 MetroHealth range for each group included: baseline Medical Center2 (n=112) 43, 6-89 days; Intervention A (n=30), 30, 9-50 days and Intervention Background: A+B (n=20) 15, 2-21 days. Two Prospective Weight Loss Surgery independent sample t-Tests resulted in (WLS) patients complete a lengthy significant differences between the presurgical process. Common first means: Baseline > Intervention A steps include: attending an information (p=0.035), and Baseline > Intervention session and scheduling a weight A+B (p=0.00001). management clinic (WMC) appointment. Process delays can be an Conclusions: area to improve patient access. Prioritizing presurgery patients by Objective: blocking appointment slots and Decrease average wait time and scheduling appointments onsite variation between WLS seminar following WLS seminar significantly attendance and first WMC appointment reduced average wait time and by >50% within three months using variation. QI methods can be used to two scheduling interventions: A) monitor process changes to optimize blocking WMC appointments slots for patient access. WLS seminar attendees and B) offering appointment scheduling services onsite post seminar. Methods: A455 Process mapping identified time delays Outreach to laparoscopic adjustable to first scheduled WMC appointment gastric band patients: A quality post seminar. Monthly seminar improvement project attendee lists were reviewed for Catherine Cline East Kingston NH1, baseline trends. Mean, minimum, and Sara Tortorici Burlington MA1, Pamela maximum wait times were calculated O'Brien 1, Thomas and an Xbar-R and range chart Schnelldorfer Burlington MA1, Dmitry calculated average and variation for Nepomnayshy Burlington MA1, David wait times. Independent sample t-tests Brams Burlington MA1 compared time to appointment for Lahey Hospital and Medical Center1 baseline attendees (Nov 2017 – Feb 2018) to intervention A attendees

310 www.obesityweek.com Background: Recent research has the 6 month following the mailing, shown patients experience long term compared to the prior year. complications related to laparoscopic Conclusion: The simple, one time adjustable gastric band (LAGB) mailer allowed for improved quality including but not limited to: suboptimal patient care by addressing weight loss, significant food complications, increase appointment intolerances or maladaptive eating and surgical volume and improve behaviors, vomiting, reflux, lap band patient care to address long term postop slip and lap band erosion. complications. Introduction: The Lahey Hospital and Medical Center Surgical Weight Loss Program (SWL) has placed 896 lap A456 bands between 2003 and VARIATION BY AGE IN 2014. Significant loss to follow-up has BASELINE CLINICAL been noted with postop LAGB CHARACTERISTICS AND POST- patients. This quality improvement OPERATIVE OUTCOMES AFTER project was developed to communicate LAPAROSCOPIC ROUX-EN-Y negative outcomes from LAGB GASTRIC BYPASS (LRYGB) surgeries and to recapture patients. Christopher Bashian Vineland NJ1, Gus Methods: 803 laparoscopic adjustable Slotman Vineland NJ1, Malinda gastric band patients were identified Lyon Vineland NJ1 through a surgical weight loss database Inspira Health Network1 from 2003-2010. Additional patients were captured through the MBSAQIP Introduction: Baseline data and database from 2011-2014. Exclusion LRYGB clinical outcomes by age are criteria included deceased patients. A unknown. Objective: To identify age simple, one time mailed letter outlining variation in pre-operative LRYGB possible complications was sent to characteristics and post-operative patients in August 2017. An algorithm outcomes. was developed support care pathways for the anticipated surge in patients Methods: 83,059 LRYGB patients returning for care. from the Surgical Review Results: Of the 803 letters sent, 156 Corporation’s BOLD database were returned for appointments to reestablish analyzed pre-operatively through 24 care. As of March 2018, there have months by age: <30, 30-40, 40-50, 50- been 20 conversion surgeries 60, 60-70, >70. Statistics: ANOVA, completed, 6 conversion surgeries Chi-squared, linear and categorical scheduled and 3 patients are ready to be models. scheduled. As a result of the letter, 19% of patients were seen in the Results: Female/male <30 (85%/15%) clinic. Appointments nearly doubled in to >70 (63%/37%) (p<0.0001). Race:

311 Caucasian <30-68%/>70-88%; patients fared best. This advance African-American 30-40-14%/>70- knowledge could help LRYGB patient 3.5%; Hispanic <30-14%/>70-4% selection and optimize management. (p<0.0001) Insurance: Medicaid: <30- 9.9%/>70-2.2%; Medicare: <30- 2%/>70-53%; Private; 40-50-87%/>70- A457 42% (p<0.0001). Baseline to 24 Risk of anemia in morbidly obese months, diabetes, hypertension, back patients after bariatric surgery in and musculoskeletal pain, gout, Taiwan dyslipidemia, peripheral vascular Hsien-Hao Huang Taipei 1, Ming-Shun disease, pulmonary hypertension, sleep Hsieh Taoyuan 1, Chih-Yen apnea (OSA), and stress urinary Chen Taipei 1 incontinence increased linearly <30- Taipei Veterans General Hospital1 >70 (p<0.0001) as did 24 month angina and leg edema (p<0.0001) support Background: Bariatric surgery is a group and GERD (p<0.05). Weight promising long-term body weight loss and BMI (p<0.001), PCOS, for morbidly obese patients, but the pseudotumor cerebri, and smoking increasing rate of anemia was a varied by inverse age, <30 highest to challenging problem.1 5% of patients 24 months, as did baseline substance after bariatric surgery had anemia.2 abuse, and alcohol abuse to 12 months, Method: We conducted a population- (p<0.0001). 30-40: highest baseline-12 based cohort study by using claims data mental health diagnosis and 12 month from the Taiwan National Health alcohol. 50-60: highest baseline Insurance Research Database. The asthma, GERD , liver study cohort comprised 4,922 patients disease, depression, and psychological diagnosed with morbid obesity. impairment. 60-70: highest angina, Results: Among the morbidly obese OHS, cholelithiasis, panniculitis, leg patients, 3,086 underwent bariatric edema, and fibromyalgia. Liver surgery. Females and younger subjects disease, panniculitis, asthma, mental were more prevalent in the surgical health, pulmonary hypertension, and group than non-surgical group. substance abuse did not vary by age Bariatric surgery reduced all obesity- after LRYGB. related comorbidities. Cox proportional hazards regression was performed, Conclusion: Clinical characteristics which revealed increased risk of and LRYGB outcomes vary by anemia after bariatric surgery among age. Older patients who have obesity obese patients (adjusted hazard ratio: the longest had highest weight-related 2.36, p=0.0001). After adjusting for sex problems, and resolved them least. In and age, the incidence of anemia was spite of greater weight, BMI and increased in the females population alcohol/tobacco abuse, youngest (adjusted hazard ratio, 2.48, p<

312 www.obesityweek.com 0.0001), in 30–64 years-old-group Methods: A retrospective cohort study (adjusted hazard ratio: 2.37, p < 0.001) of women aged 18-45 who underwent and 20–29 years-old-group (adjusted bariatric surgery at Bellevue Hospital hazard ratio: 3.83, p < 0.05). between 1/1/14-12/31/15. Demographic Malabsorptive procedures has higher characteristics and information about hazard of anemia than restrictive contraceptive counseling and use prior procedures. The cumulative incidence to bariatric surgery was collected rate of anemia showed a significant through electronic medical record increased rate in those undergoing review. Data analysis was conducted bariatric surgery by log-rank test (p= using descriptive statistics, and 0.0002). associations were examined with chi Conclusion: Based on the Taiwan square tests and logistic regression. database population-based cohort study, bariatric surgery increases the Results: Of 1087 women who risk of anemia among morbidly obese underwent bariatric surgery during the patients, especially in the female study period, 86.9% had population and patients aged 20–29, recommendations for delayed and 30–64 years. The malabsorptive childbearing documented, and 26.9% procedures have more effect than the were using contraception at time of restrictive procedures on anemia after their preoperative visit. Of those not bariatric surgery. using contraception, 59.3% were referred to gynecology but only half (53.7%) attended a gynecology visit. A458 While 79.9% of those women attending A Single-Center Retrospective a gynecology visit had contraception Cohort Study of Contraceptive prescribed to them, 66.4% being long Counseling, Referral and Uptake acting contraceptive methods. Age was Among Women Undergoing inversely associated with odds of Bariatric Surgery referral (OR=0.95, p<0.001), while Beatrice Telzak New York NY1, there was no association with Veronica Ades New York NY, race/ethnicity or BMI. Akuezunkpa Ude Welcome , Cara Discussion: The majority of women Dolin New York NY were not using contraception at time of New York University1 bariatric surgery preoperative visit. Preoperative bariatric surgery workup Objectives: Assess contraceptive provides an opportunity to counsel counseling and use among women high-risk women regarding family undergoing bariatric surgery and planning, and referral to gynecology determine predictors of referral to clinic can improve contraceptive contraceptive counseling. uptake, Gynecologist and bariatric surgeons should work together to

313 improve contraceptive counseling and these patients had in-person uptake among reproductive-aged postoperative follow-up visits. Follow- women. up occurred at 1 and 4 weeks for both cohorts.

A459 Results: Telemedicine Follow-up After A total of 1140 TFVs were scheduled Bariatric Surgery between April 2016 and December Adam Meyers Sacramento CA1, 2017. The rate of successful TFV Elizabeth Pontarelli Sacramento CA2, connection was 76%. The average Sanjoy Dutta Fremont CA2, Gary duration of each TFV was 4.9 minutes. Grinberg Elk Grove CA2, Pandu 72% (681) of our patients completed a Yenumula Sacramento CA2 TFV for at least one of their two Univerisity of California Davis Health follow-up appointments. 49% (558) System1 Kaiser Permanente South completed TFVs for both follow-up Sacramento Medical Center2 appointments. The frequency of emergency room visits before and after Background: implementing TFVs was 12.4% and Telemedicine is evolving as an efficient 14.0% (P=0.29). The frequency of and cost-effective method for hospital readmission was 1.8% and conducting surgical follow-up care. We 2.2% (p=0.48). began offering telemedicine follow-up visits (TFVs) after non-revisional Conclusion: laparoscopic gastric bypass (LGBP) Telemedicine is an efficient method for and non-revisional laparoscopic sleeve surgical follow-up after bariatric gastrectomy (LSG) in April 2016. We surgery. Preliminary data suggests that evaluated the rate of emergency room there is no significant difference in the visits and readmissions before and after rate of emergency room visits or offering TFVs. hospital readmission when telemedicine is used for routine follow- Methods: up after non-revisional LGBP and LSG. This a retrospective review of prospectively entered medical record data from a single bariatric surgery A460 center. Nine hundred and forty patients Long-term outcomes comparing underwent non-revisional LGBP or conventional surgical management LSG during the first 21 months in versus new minimally invasive which we offered TFVs. Nine hundred techniques of pilonidal sinus disease. and five patients underwent non- Meta-analysis and review of revisional LGBP or LSG in the 21 literature. months prior to offering TFVs and

314 www.obesityweek.com Grace Yi Alpharetta GA, Bo Soyele 1, analysis pooled rate of 1.90% (95% Maxwell Bempah 1, Luis Valdes 1, Judy CI = 1.29–2.80) for recurrence, Trang 1, Assia Miller Loganville GA1, 1.04% (95% CI = 0.65–1.65) for Christian Cruz Pico Atlanta GA1, complications, and 1.5 minimally Angelina Postoev Loganville GA1, invasive procedures vs.19.2 days of Christopher Ibikunle Loganville GA1 conventional procedure days for GeorgiaSurgiCare1 healing time. Conclusions Background The meta
analysis demonstrates that Pilonidal disease is a subcutaneous minimally invasive techniques have infection occurring in the upper half of distinct advantages. These include high the gluteal cleft. The optimal treatment success rate, possible in all types of of this disease is controversial and pilonidal disease (simple and complex), more complex techniques do not low complication rate, short operating obviate the risk of failure or recurrence. time, and early return to normal routine A consensus on its efficacy and and work. This procedure can be outcomes of minimally invasive performed conveniently under local techniques versus standard surgical anesthesia as an outpatient procedure. treatment has not been reached. We reviewed the efficacy of minimally invasive techniques versus A461 conventional surgical methods. Outcomes of bariatric surgery in Methods patients undergoing complex PubMed, Medline, Scopus, Ovid and incisional hernias with loss of Google scholar databases were domain. searched. All studies describing Turna Mukherjee Gaithersburg MD, minimally invasive techniques versus Nara Tashjian Omaha NE1, Margaret standard surgical treatment were Siu Omaha NE, Sarah Aurit Omaha included. The primary outcome NE, Nicholas Whitenack Omaha NE, parameter was recurrence and the Robert Fitzgibbons Omaha NE, secondary outcome parameters were Kalyana Nandipati OMAHA, NE NE complication rate, operating time, Creighton University School of return to work and healing time. Medicine1 Results A total of 265 studies were screened. Introduction: Out of these, 14 studies were finally This study investigates outcomes in included for the analysis. Sample sizes patients undergoing bariatric procedure for minimally invasive procedures and with concurrent complex incisional conventional methods were 2806 and hernia (CIH) with loss of domain 1639 respectively. The analysis (LOD). demonstrated a net proportion meta

315 Methods: Bariatric surgery can be safely In this retrospective study, patients performed in patients with CIH and undergoing bariatric surgery at our LOD with comparable outcomes. institution between 2007 and 2018 with at least 12 month follow up were included. Patients were stratified into two groups dependent on presence of CIH with LOD. The Mann-Whitney and the Fisher’s exact tests were used for statistical comparison of continuous and categorical variables, A462 respectively. Analysis of covariance The role of the NLRP3 (ANCOVA) analyzed BMI at 12 inflammasome and Caspase-1/11 in months after adjusting for baseline lipid inflammatory metabolism and BMI; p < 0.05 was considered gut microbiota profile of obese significant. animals high fat diet-induced. Livia Sant'Ana Brasilia 1, Luís 1 Results: Henrique Corrêa Brasília , Corinne Maurice Montreal 2, Kelly Twelve patients were found to have 1 CIH with LOD undergoing bariatric Magalhães BRASILIA University of Brasilia1 McGill procedure, five underwent laparoscopic 2 sleeve gastrectomy (LSG) and seven University underwent laparoscopic roux en Y gastric bypass (LRNYGB). Twenty- Background: Obesity is a disease nine patients underwent bariatric recognized by the WHO since 1997. procedure without CIH, five with LSG Currently, this disease affects a large and twenty-four with part of world population and is LRNYGB. Patients with CIH had associated with several other excess weight loss (EWL) of 51.81% at pathogenicities, like cancer, as shown 12 months postoperatively compared to in several studies. Inflammation is 67.18% in patients without CIH with related to obesity and cancer. Pro- no statistical significance (p = 0.368). inflammatory mediators cause local and Resolution of comorbidities including systemic effects. The inflammasome diabetes, hypertension and sleep apnea NLRP3, an important protein complex was not significantly different between in inflammatory process, is responsible groups. ANCOVA model results for maturing pro-inflammatory showed no significant difference in cytokines IL-1 and IL-18. Absence of BMI at 12 months between the CIH components of NLRP3 has already and non-CIH groups (p = 0.289). been related to enhanced weight gain. Another factor closely related to Conclusion: obesity, inflammation and cancer is the

316 www.obesityweek.com microbiota. Phylogeny and metabolites RI1, Yuqi Zhang Woodbridge CT1, of gut microbiota may play a beneficial Alicia Alterio Providence RI1, Gary or harmful role to the development of Roye 2, Todd Stafford 2, Beth diseases in the host. This study Ryder Providence RI2, Sivamainthan evaluated the role of inflammasome Vithiananthan Providence RI2 NLRP3 in inflammatory profile of Brown University1 Lifespan2 obese animals and modulation of gut microbiota. Methods: wild type, Introduction : Emergency department caspase 1/11 and NLRP3 knockout visits (ED) for medical care leads mice were fed with a conventional diet increased costs to the health care or high fat diet for 90 days. The lipid system. metabolism, inflammatory response and phylogeny of gut microbiota were Methods: This study looked into a analyzed. Results: caspase 1/11 single institution’s post-operative ED knockout mice were more susceptible visit patterns in patients who underwent to obesity, with consequent changes in primary bariatric surgery. Data was markers of lipid and inflammatory collected retrospectively from 2015 to metabolism (hepatic steatosis, lipid 2017. In the settings of a negative work droplet biogenesis, IL-12 secretion) and up, preventable causes of ED visits alteration in abundance of gut were defined as: nausea, abdominal microbiota, presenting phyla involved pain, constipation, dehydration and with weight gain and hepatic dysphagia. steatosis. Conclusion: Taken together our data rise a new function for caspase Results: During this period 305 1/11 in modulation of gut microbiota. primary bariatric procedures were In addition, our results suggest that performed. Also, 114 patients were obesity diet-induced and the absence of evaluated in the ED, for a total of 316 caspase 1/11 may regulate lipid visits. There were 14 outlier patients metabolism, inflammatory response who resulted in 133 ED visits. 61 ED and gut microbiota. visits were found to have GI complaints, and rest were medical/psychological complaints, A463 which were excluded. 48 visits (79%) Patterns of Preventable ED visits were for abdominal pain, 7(11.4%) for within two years after bariatric nausea, 2 (3.3%) for constipation, 3 surgery. Retrospective Chart Review (4.9%) for dehydration and 1(1.6%) for In A Single Institution. dysphagia. There were 18 patients who RICHIE GORIPARTHI north needed surgeries (10 internal hernias, 2 providence RI1, Cullen bowel obstruction and 2 for Roberts Providence RI1, Marco intraabdominal bleeding, 1 marginal Giorgi 1, Seungjun Kim Providence ulcer perforation, 3

317 Cholecystectomies). Endoscopies with muscle. We aim to conduct a dilations for nausea/dysphagia systematic review and meta-analysis to secondary to stricture were carried out access the effectiveness of this new in 7 patients. Total readmissions to the treatment. hospital were 27, out of which 18 were Methods: PubMed, Embase, OVID for GI issues. Readmission rate was were searched using predefined 5.9% over a 2-year period. inclusion criteria for relevant articles published up to April 2018. A total of Conclusion: Abdominal pain is the 143 studies were screened. Seven common cause of ED visits. Some studies were finally included for the outliers attributed to 1/3 all visits. meta analysis. The evaluation focused Appropriate teaching and triaging may on quality of life and the Wexner help reduce unnecessary, no- emergent incontinence score. visits to the ED , thereby reducing Results: In the majority of clinical health care costs. studies, the SECCA procedure has been shown to be an effective treatment of mild-to-moderate fecal incontinence. A464 Meta analysis of a baseline sample of The usability of temperature- 131 patients revealed statistically controlled delivery of ablative significant improvement of Wexner techniques in managing fecal incontinence scores (p= 0.001) and incontinence. Review of literature quality of life (p=0.0001) after and meta-analysis. treatment. Luis Valdes 1, Maxwell Bempah 1, Bo Conclusion: Radiofrequency is a valid Soyele 1, Assia Miller Loganville GA1, treatment option for patients with mild- Angelina Postoev Loganville GA1, Kola to-moderate fecal incontinence. When Ibikunle 1, Christopher patient selection is appropriate, radio Ibikunle Loganville GA1 frequency ablation has demonstrated GeorgiaSurgiCare1 clinically significant improvements in symptoms and could be used as bridge Background: Fecal incontinence is a between medical and surgical debilitating condition that can be management. socially and personally incapacitating. Though a broad range of medical and surgical management options are available, definitive treatment is A465 challenging. New treatment is REVISION SURGERY FOR developed such as a minimally invasive MALNUTRITION AFTER AFTER endoanal procedure based on BARIATRIC SURGERY Ju-Jun temperature-controlled radio frequency Chou,CBN 1; Wei-Jei Lee energy delivered to the anal canal MD&PhD1,2; Jung-Chien Chen

318 www.obesityweek.com MD1,2; Kong-Han Ser MD2; Pei- for revision. All the malnutrition can Ling Tsai, RN2. Shu-Chu Chen RN2. be corrected after conversion to normal 1.Central Clinic Hospital, Taipei, anatomy (2) or SG (46). Protein Taiwan. 2.Min-Sheng General deficiency tend to develop when the Hospital, Taoyuan, Taiwan bypass limb (bilio-pancreatic limb) Ju Chou Taipei longer than 200cm or the common Central clinic hospital channel shorter than 400cm. Conclusion: Some patients might Background: Bariatric surgery is an develop intractable malnutrition after effective therapy for morbid obesity but gastric bypass surgery. Revision may reduce nutrients absorption and surgery to normal anatomy of SG was induce malnutrition. Revision surgery effective for the conversion of is sometimes indicated for the intractable malnutrition. intractable malnutrition. This study examined the prevalence, cause and outcome of revision surgery for malnutrition after previous bariatric A466 surgery, including sleeve Percutaneous Therapy of gastrectomy(SG), roux-en gastric Choledocholithiasis After Roux-en-Y bypass (RYGB), single anastomosis Gastric Bypass and Past Excision of gastric bypass (SAGB), SG with Gastric Remnant duodeno-jejunal bypass (SG-DJB) and Noe Rodriguez Boca Raton FL1, laparoscopic adjustable gastric banding Fernando Rivera Delray Beach FL2, (LAGB). Theodore Doukides Boca Raton FL3, Methods: Between October 2001 and Ariel Rodriguez Boynton Beach FL4 December 2015, 508 morbidly obese Florida Atlantic University, patients received primary bariatric Department of Surgery1 Delray surgery (1759 SG, 805 RYGB, 1839 Medical Center, Interventional SAGB, 200 SG-DJB and 475 LAGB) Radiology2 Delray Medical Center, as primary bariatric procedure at the Florida Atlantic University, Min-Sheng General Hospital were Therapeutic Endoscopy and recruited. We identified 47 patients Gastroenterology3 Florida Atlantic had revision surgery for their University, Department4 intractable malnutrition after surgery. The charts of patients were Background: Obese patients who reviewed. undergo Roux-en-Y gastric bypass Results: The prevalence of intractable (RNYGB) have a higher incidence of malnutrition was 1.4%(11/805) after gallstones. RNYGB excludes the RYGB and 2.0%(36/1839) after biliary tree from traditional evaluation SAGB. Anemia (28) and protein with endoscopic retrograde deficiency (19) were the major reasons cholangiopancreatography (ERCP).

319 Excision of the gastric remnant further technique for patients with excluded restricts options including EUS- biliary tree and hostile abdomen. It directed and laparoscopy-assisted could be applied more extensively to transgastric ERCP. Double balloon manage RNYGB choledocholithiasis enteroscope-assisted ERCP has limited safely and more efficiently. A higher success, and transenteric ERCP level of interventional radiology exposes patients to higher perioperative training is needed. risks. Given the limited therapeutic options, we report the successful percutaneous transhepatic therapy of choledocholithiasis in a patient with A467 RNYGB and remnant gastrectomy. Bariatric Surgery Patients Can Be Routinely Discharged Without Case Presentation: Eighteen years Dispensing Narcotics after receiving a RNYGB and 7 years Timothy R. Heider Mooresville NC1, after subsequent gastric remnant Yvonne Kelly Mooresville NC1 excision, a 74-year-old man presented Lake Norman Regional Medical with abdominal pain, emesis, malaise, Center1 and itching. He had a history of congestive heart failure status post Introduction: Rates of prescription pacemaker defibrillator and prostate opiod usage and abuse are at epidemic cancer status post radiation. Imaging levels in the United States. Recent identified choledocholithiasis. He data indicate that a large proportion of underwent percutaneous transhepatic postoperative opiods are not consumed cholangiography and transhepatic by patients and that the risk of opiod balloon dilation of the papilla of Vater. naïve patients continuing to take Basket lithotripsy was used on stones narcotics after surgery is not >15 mm, and advanced into the insignificant. Therefore, we sought to duodenum using a Fogarty balloon determine if implementation of an catheter. Complete clearance of the enhanced recovery after surgery biliary tree was achieved in a 45- (ERAS) program could effect the minute procedure requiring 13.2 amount of in-hospital narcotic usage as minutes of fluoroscopy time. Liver well as the number of postoperative function tests were normal by post narcotics dispensed upon procedure day 3 and the patient was discharge. Methods: Data from two discharged the next day. hundred consecutive patients undergoing elective bariatric surgery Discussion: This case suggests that were collected after institution of the percutaneous transhepatic access for ERAS protocol. The protocol stone expulsion into the duodenum consisted of extensive coaching both through the papilla is a feasible preoperatively and during the

320 www.obesityweek.com hospitalization, preoperative oral experimental studies have pointed out a pregabalin and carbohydrate loading, causal link between OSA and Type 2 scheduled oral acetaminophen ad lib diabetes, but the molecular mechanisms oral intake 2 hours after surgery, early causing the development of insulin ambulation and cessation of routine resistance and glucose intolerance are upper GI series. Results: The study yet to be explained. One of the possible population (81% female, average BMI biomechanisms leading to a higher 42.1 kg/m2, 92% sleeve gastrectomy) lipide level in OSA patients is the was discharged after an average length reductive Krebs cycle (TCA). The aim of stay of 1.1 days. Hospital narcotic this study was to verify the TCA's consumption averaged 12.56 morphine effect by exposing 3T3-L1 milligram equivalents (MME) differentiated preadipocytes to mild compared to 18.86 MME prior to hypoxia. ERAS protocol initiation. In-hospital Materials and methods: 3T3-L1 cells narcotic administration was not have been cultivated and differentiated required in 11% of patients and no in a CO2 incubator at 37°C on gas- patient required a discharge analgesic permeable fluorocarbon plates. The prescription. Upon follow-up survey, differentiated cells have been kept in

93.6% of patients stated that their post- hypoxic (4% O2 + 5% CO2) and control discharge pain control was satisfactory (20% O2 + 5% CO2) environments for and only 5.6% stated they would have 14 days. 5-13C L-glutamine (2.5 mM) preferred a narcotic prescription upon was used for analysis. For the control discharge. Conclusions: Routine group, unlabeled L-glutamine (2.5 mM) postoperative narcotics after discharge was used. The analysis itself was can be avoided after bariatric surgery performed using a GC-MS. without negatively impacting patient Results: Exposing the 3T3-L1 cells to a satisfaction. prolonged state of mild hypoxia causes an increase in palmitic acid (C16:0) by 91.01% and palmitoleic acid (C16:0) by 101.90%. When using 5-13 L- A468 glutamine, the culture contained 71.2 % Exposure 3T3-L1 differentiated C16:0 0 13C, 22,9% 1 13C, 4,6% 2 13C preadipocytes to mild hypoxia and 1,3% 3 13C. The natural state is 13C stimulate de novo biosynthesis of for C16:0 is 82,65% 0 13C, 15,58% fatty acids by reverse Krebs cycle. 1 13C, 1,73% 2 13C and 0,14% 3 13C. Martina Musutova Prague Conclusions: OSA can contribute to Charles University Type 2 diabetes via a heightened fatty acid synthesis through the reductive Introduction: Obstructive sleep apnea Krebs cycle. (OSA) is a condition affecting 5-15% of adults. Epidemiological and

321 A469 were Black, Non-Hispanic, with a Cardiometabolic Changes in an mean age of 16.6 ± 1.6. BMI was 49.5 Ethnically Diverse Sample of ± 7.8 with a BMI z-score of 2.7 ± Adolescents Following Bariatric 0.3. A total of 65% were pre- or stage Surgery 1 hypertensive, 49% had dyslipidemia Melissa Santos Newington CT1, and 13% had a fasting glucose at or Zachary Patinkin Hamden CT, Alan above 100. HOMA-IR for this sample Ahlberg Hartford CT, Shefali was 9.9 ± 9.9. Significant Thaker Hartford CT, Nicole improvements were seen within six Boone Hartford CT, Meghna months in the subset who underwent Misra Hartford CT, Priya bariatric surgery (n = 43; 49% Phulwani Hartford CT, Jessica Hispanic); including reductions in BMI Zimmerman Hartford CT, Christine (p< .001), BMI z-score (p< .001), Finck Hartford CT triglycerides (p<.03), LDL-C (p<.03), Connecticut Children's Medical Center1 Insulin (p<.03) and HOMA-IR (p<.03).

Background: Research has shown that Conclusions: This abstract lends youth presenting for bariatric surgery support to the benefits of bariatric carry a significant number of medical surgery for all, regardless of race and comorbidities, which can be resolved ethnicity. Future research should with surgery. However, studies to date continue to examine long-term have primarily been performed in longitudinal outcomes from bariatric White, Non Hispanic populations. This surgery in ethnically diverse samples to abstract will present findings from a document the sustained efficacy of this bariatric center that consists of a treatment. significant minority population. We will describe patients’ presenting medical comorbidities and symptom A470 pattern after bariatric surgery Females with Obesity Are Not All the Same: Variation of Pre-operative Methods: This study is a retrospective Clinical Characteristics by Health review of 91 adolescents presenting to Insurance in Sleeve Gastrectomy an adolescent bariatric surgery Women program, 43 of whom underwent Jessica Tyrrell Vineland NJ1, Gus surgery. Primary outcomes for the Slotman Vineland NJ1 study were: BMI, blood pressure, Inspira Health Network1 cholesterol, fasting glucose and HOMA-IR. Introduction: Clinical variation among women with obesity by health Results: Of the 91 patients, 69% were insurance has not been female; 43% were Hispanic, and 15% explored. Objective: to identify pre-

322 www.obesityweek.com operative clinical variation by health (p<0.01). Self-Pay: highest alcohol; insurance among sleeve gastrectomy lowest cardiopulmonary (n=9), females. abdominal/hepatobiliary (n=6), somatic (n=3), diabetes, gout, dyslipidemia, Methods: Pre-operative data on 6,685 menstrual irregularity, fibromyalgia sleeve gastrectomy females from the (p<0.001). Surgical Review Corporation’s BOLD database was studied in four insurance Conclusion: Clinically, pre-operative cohorts: Medicaid (n=330), Medicare female sleeve gastrectomy patients vary (n=126), Private (n=4,424), and Self- by insurance. Medicare females were Pay (n=1,366). Variables: oldest, heaviest, affected most by 24 Demographics and 33 obesity co-morbidities and disabilities, medical/behavioral but smoked, drank, and used drugs conditions. Statistics: ANOVA, Chi- least. Medicaid were youngest with squared equation. highest asthma, liver disease, and tobacco use. Private and self-pay Results: Medicare/Medicaid/Private/Se women had fewer co-morbidities in lf-Pay age (56+-13/40+-5/45+-11/44+- spite of doubled alcohol use versus 12) and BMI (52+-12/50+-10/46+- Medicare/Medicaid. This advance 8/44+-12) varied knowledge of increased risks for (p<0.0001). Medicare: highest Medicare and Medicaid sleeve hypertension (69%), angina, CHF, gastrectomy females may facilitate DVT/PE, ischemic heart disease, operation choice and improve pulmonary hypertension, sleep apnea outcomes. (52%), obesity hypoventilation, hernia, panniculitis, cholelithiasis, stress incontinence, diabetes (55%), gout, dyslipidemia, menstrual irregularity, A471 leg edema, back/musculoskeletal pain, Medical Therapy in Weight Regain fibromyalgia, disabled, psychological and Suboptimal Weight Loss impairment, unemployed (67%) Following Metabolic Surgery (p<0.0001), GERD (p<0.001), mental Michael Alexander Sarasota FL1, health diagnosis (MHD, p<0.01); Joseph Chebli Venice FL2, Robert lowest alcohol (p<0.0001), smoking Dubin Englewood FL1 (p<0.001), substance abuse, PCOS Florida State University School of (p<0.05). Medicaid: highest asthma, Medicine1 Venice Metabolic and liver disease, smoking (p<0.0001), Bariatric Surgery2 substance abuse (p<0.05). Private: highest PCOS (p<0.05), second While metabolic surgery remains an alcohol; lowest psychologic effective treatment for many patients impairment (p<0.0001), MHD with obesity, weight regain (WR) and

323 suboptimal weight loss (SWL) occurs warranted to understand factors that after surgery. There are few studies determine response to medical therapy addressing the efficacy of medical in these patients. interventions for these patients. A retrospective review was performed on 20 patients to evaluate the effect of medical therapy in treating WR and A472 SWL. Medical therapies included Helicobacter pylori infection does not phentermine/topamax ER (PTER), impact one-year outcomes after naltrexone/buproprion (NB), Roux-en-Y gastric bypass phentermine (P), and liraglutide (L). Yasamin Ghiasi , Ashar Ata , Kristian Two diabetic patients were treated with Singh , tejinder Singh , Jessica GLP-1 agonists (GLP1). Response to Zaman Albany NY1 therapy was defined as weight loss > Albany Medical Center1 5%. The mean age was 63.8 + 11.0 years. Background: Helicobacter pylori (HP) Eighteen (90%) patients were female. is most often associated with gastritis, Surgeries included: Roux-en-Y gastric but there is also a link with bypass (55%), sleeve gastrectomy obesity. Eradication of HP can lead to (40%), and gastric banding (5%).Mean weight gain with an increase in plasma BMI at start of treatment was leptin and ghrelin levels. It is likely 37.1 + 7.2 kg/m2. Mean weight regain that HP infection also affects outcomes in all patients was 12.2 + 10.0% from after bariatric surgery, but few studies baseline. Medical treatments have been performed. We sought to included: PTER (35%), NB (30%), P determine if HP status affects peri- (15%), L (5%), PT (5%), and GLP1 operative and long-term outcomes in (10%). Five patients (25%) responded patients undergoing Roux-en-Y gastric to medical therapy, 9 (55%) patients bypass (RNY). were non-responders and 6 (30%) Methods: A retrospective analysis of patients discontinued therapy due to patients undergoing RNY at a tertiary side effects. Mean weight loss from care, academic medical center from baseline in responders was 9.5 + 4.5%. 2012-2014 was performed. Electronic PTER and P were used in 80% of medical records were reviewed to responders. Years from procedure determine results from upper correlated with weight loss percentage endoscopies performed as part of the (p=0.03, r=0.46); no correlation existed pre-operative assessment for with subject age, initial BMI or patients. Patient demographics, peri- percentage of weight regain. operative outcomes, 30-day, and 1-year There was a low response rate (25%) post-operative outcomes were extracted using current medical therapies in WR from the MBSAQIP longitudinal and SWL subjects. Further studies are database for our institution. Statistical

324 www.obesityweek.com analyses were performed using Stata Objective version 14.0. The aim of the study was to Results: Of 170 total patients compare between patients who lose undergoing RNY, only 6 were positive weight and those who don’t lose weight for HP on pre-operative upper before sleeve gastrectomy Background endoscopy. Although none of the HP There are conflicting data in the positive patients were symptomatic, literature regarding the true effect of a treatment was administered at the two- preoperative weight loss regimen on week post-operative period. There various aspects of clinical outcome were no statistically significant after bariatric surgery. differences in operative times, length of Materials and methods stay, readmission rates, or rate of re- fifty morbidly obese patient admitted operation within 30-days post- to General Surgery Department in operatively (see Table 1). Weight loss Menoufia University Hospital from was similar and statistically January 2016 to January 2017. Patients insignificant for both cohorts. were randomly divided into two Conclusion: HP colonization and groups: Experimental Group (A) treatment do not impact short or long- included 30 patients, they were term outcomes after RNY. A series subjected to a preoperative weight loss with a larger population and studies at a (PWL) using VLCD for 4-6 weeks, and molecular level would be necessary to control group (B) included 20 patients distinguish a subtle effect the bacteria were not included in any recent weight may have on outcomes after RNY. loss program. Then after, all patients in group (A), and group (B) were subjected to vertical sleeve gastrectomy operation by surgeons with initial A473 experience in bariatric surgery. Preoperative weight loss regimen, Results does it affect the outcomes of Operating time was significantly Bariatric surgery? shorter in the PWL group, 75±10 Adel Zedan Menoufia 1, hatem versus 91±11 min, also blood loss was soltan New cairo 2, Mohammed significantly less in PWL Sabry 2, Rami Mustafa cleveland OH3, group74±30ml versus 173±81.7 ml and mahmoud hagag 2, Tomasz finally length of hospital stay was Rogula Chardon OH3 shorter in PWL group1.4±0.3 day General Surgery Dep. - Menoufia versus 2±0.4-day, P-value0.001. PWL Universi1 Menoufia University, caused significant reduction in liver General surgery Dep2 University size, and also reduction of waist Hospitals of Cleveland, CWRU3 circumference but without statistical significance Conclusion

325 PWL cause reduction in operative time with obesity, 897 girls and 605 boys, and blood loss due to reduction of liver were included in this review. Pediatric size and improved visibility which is of patient age ranged from 11 to 16 years great value for surgeon with initial old. Three references showed there was experience. PWL is associated with a higher prevalence of white 44 to 64% shorter hospital stay but it was not able compared to black 29 to 43% and to show reduction in complication or Hispanic 2 to 7%. Adolescent obesity is excess weight loss. defined as a BMI at or above the 95th percentile for adolescents of the same age and sex. Those who reported a history of childhood sexual abuse were more prone to develop obesity in A474 adolescence than those who denied a Adolescent Obesity Resulting in a history of sexual abuse. Devastating Sequela from Childhood Conclusion: Pediatric patients who had Sexual Trauma: A Systematic experienced sexual abuse in childhood Review had an increased risk of adolescent 1 Lauren Poliakin brooklyn NY , Pratibha obesity. A bariatric team comprising of 1 Vemulapalli brooklyn, Ny 11201 NY psychologists, dietitians, internists, and 1 The Brooklyn Hospital Center surgeons through their own methods of intervention can treat comorbidities of obesity resulting from previous sexual Background: Previous studies have trauma at an early age. This will shown an association between improve the patient’s quality of life, childhood sexual abuse and early both psychologically and metabolically, adulthood obesity. The aim of this as well as structurally. study is to review the literature investigating the relationship between childhood sexual abuse and adolescent A475 obesity. Late Leak After Sleeve Gastrectomy Methods: MEDLINE/PubMed was Treated with Endoscopic Stenting systematically searched for articles on Morgan Pomeranz Las Vegas NV1, childhood sexual abuse and adolescent Allan MacIntyre Las Vegas NV1 obesity. Sunrise Health GME Consortium1 Results: Of the eight references identified by the search, five included studies providing estimated odds ratios Late gastric leaks after sleeve greater than 1 indicating that there is an gastrectomy present a unique association between childhood sexual challenge. They occur during the period abuse and adolescent obesity in both of healing and inflammation that makes boys and girls. 1,502 pediatric patients

326 www.obesityweek.com operative interventions not only prospective data is needed to determine difficult but also dangerous. standards for timing and duration of treatment. A 49-year-old female, 5 weeks status- post laparoscopic sleeve gastrectomy, had been recovering well and tolerating her diet. She presented with four days A476 of acute epigastric abdominal pain Effects of Roux-en-Y Gastric Bypass accompanied by nausea and high and Very Low Calorie Diet on the fevers. Upper GI study revealed Thermic Effect of Feeding contrast extravasation consistent with a Jamie Mullally New York NY1, Gerardo gastric leak. A hostile abdomen was Febres New York NY1, Marc encountered on laparoscopy, prompting Bessler New York NY1, Judith drain placement for the abscess, and Korner New York NY1 closure. Endoscopy shortly thereafter Columbia University College of confirmed a leak immediately distal to Physicians and Surgeons1 the GE junction. A Boston Scientific 153 mm covered esophageal stent was Background: The thermic effect of placed. The stent was exchanged during feeding (TEF) is an increase in the repeat endoscopy after 2 weeks, and metabolic rate after ingestion of a meal repeated twice for a total of 3 stents and accounts for 3-10% of total energy over a period of 8 weeks. A repeat expenditure. TEF may increase after upper GI series demonstrated no further Roux-en-Y gastric bypass (RYGB) and contrast extravasation. contribute to the sustained weight loss post-RYGB compared to treatment The use of stents has been described for with diet. Our objective was to management of post-op leaks, however compare change in TEF before and there is a wide variation in several key after weight loss with RYGB vs a very- areas; including early vs intermediate low calorie diet (VLCD). vs late leaks, full vs partial covered stents, duration of individual stent Methods: Resting energy expenditure placement, and duration of overall (REE) and post-prandial energy treatment. Non-operative management expenditure were measured using with drains and stents for late leaks indirect hood calorimetry, pre- and after sleeve gastrectomy is safe and three weeks post-weight loss in effective, and may often obviate the subjects treated with RYGB and an need for revision surgery and its inpatient 500 kcal/day diet designed to associated morbidity/mortality. After mimic the post-RYGB diet. TEF was ensuring stability and initial response to calculated using incremental area under treatment, select patients may continue the curve from baseline REE over the their course as outpatients. Further post-prandial period. Lean mass was

327 measured by DXA. Torsion of falciform ligament (FL) has been described in literature as a rare Results: There were 9 subjects in each cause of acute abdominal pain. There group with similar baseline are no reports of FL torsion in literature (mean±SEM) BMI (40.0kg/m2±1.7) after Roux-En-Y gastric bypass and total (114.7kg±6.3) and lean mass (RYGB). We present a case of FL (64.5kg±3.0). The RYGB subjects lost torsion after RYGB presenting as acute somewhat more weight than the VLCD abdominal pain. subjects (10.2% vs 6.8%, p=0.11), which was adjusted using a mixed Case report: 56 y/o female with morbid effects model. Both groups trended obesity (BMI 41) and multiple medical towards a within-group reduction in comorbidities was taken to the TEF from pre- to post-weight loss operating room for a laparoscopic (change in TEF: RYGB -6.5kcal±4.8, RYGB. Port placement included 12 p=0.21; VLCD -5.3±3.1kcal, p=0.13), mm trocar above the umbilicus slightly but the groups did not differ towards the left of the midline and two significantly in change in TEF from pre 5 mm in left upper quadrant. We then to post-weight loss (p=0.63 adjusted for took the falciform ligament off of the weight loss). anterior abdominal wall using ultrasonic shears; a step routinely Conclusions: RYGB and VLCD result performed in our practice to facilitate in a similar non-significant reduction in placement of trocars in the right upper TEF at an early follow-up time point. quadrant. An antecolic antegastric Thus, TEF is unlikely to contribute RYGB was then performed, using significantly to the weight change linear stapled anastomosis, and hand- following RYGB. sewn common enterotomies. The patient had uneventful recovery and was discharged home on post-operative A477 day 2. A case report: Torsion of Falciform ligament as a cause of abdominal Patient returned 2 weeks post pain post Roux-en-Y gastric bypass operatively with severe RUQ Adil Khan Winchester TN1, Laura abdominal pain. WBC count was 14. Doyon Concord MA2, David CT scan showed findings inflammatory Brams Burlington MA3 changes around falciform ligament. On southern Tennessee regional operative exploration necrotic falciform healthcare1 Emerson hospital, concord ligament was found which was MA2 Lahey hospital and medical dissected and excised using ultrasonic Center3 shears. Patient tolerated the procedure well and was discharged home on post operative day 1.

328 www.obesityweek.com (BMI), procedure duration, Discussion: Although the occurrence of complications, percent total body FL torsion is very rare, surgeons must weight lost (%TBWL), and percent be aware of the pathology as a cause of excess weight loss (%EWL). Patient abdominal pain after RYGB. We follow up ranged from 1 month to 30 recommend change in practice not to months postoperatively. mobilize FL during surgery to avoid this complication. Results: 89 patients underwent RYGB between January 2014 and May 2016. The cohort consisted of 71 females A478 (80%) and 18 males (20%) with a mean Single Surgeon Outcomes for Roux- preoperative BMI of 47.0 kg/m2 en-Y Gastric Bypass (range, 29.5 to 68.1 kg/m2). The mean Shinban Liu Brooklyn NY1, Vadim operative time was 81 minutes (range, Meytes Brooklyn NY1, George 48 to 168 minutes), mean %TBWL was Ferzli Staten Island NY1 26.8% (range, 3.4 to 43.2), and mean NYU Langone Hospital1 %EWL was 60.4 (range, 6.7 to 92.8). Only two patients had complications, Introduction: Within the United none requiring a return to the operating States, obesity has become a common, room or readmission. costly, and severe epidemic. For patients that are incapable of losing Conclusion: Herein we describe a safe weight, Roux-en-Y gastric bypass and reproducible laparoscopic (RYGB) has emerged as a safe and technique shown to effectively decrease effective treatment option. The purpose operative times with efficacious long of this study was to report the term weight loss results. successful laparoscopic technique of a single surgeon. A479 Methods: Retrospective analysis of Conversion of a SADI-S procedure to prospectively collected data was a Roux-en-Y Gastric Bypass. performed for patients undergoing Indications, technical details and laparoscopic RYGB performed by a review of the literature. single surgeon between January 2014 Alvaro Galvez Philadelphia PA1, and May 2016 at a single institution. Daniel Galvez Richmond VA2, The procedure is performed in an ante- Alexander Onopchenko Egg Harbor colic, ante-gastric fashion with 150cm Twp NJ3 biliopancreatic and Roux limbs, hand- Drexel University College of sewn anastomosis, and no surgical Medicine1 Virginia Commonwealth drains. The data collected included University2 AtlantiCare Regional patient demographics, body mass index Medical Center3

329 not been previously described in We present the case of a 46-year-old current literature. male with an initial BMI of 44.7, who underwent a laparoscopic single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S). A480 Postoperatively he developed an Long-term outcomes of bariatric anastomotic leak at the duodeno-ileal surgery in adolescents with morbid (DI) anastomosis that would not obesity with a follow-up of at least 5 resolve despite reoperation and bowel years: A systematic review rest. A conversion to a Roux-en-Y Patricia Ruiz Cota Tijuana, Baja gastric bypass (RYGB) was performed California 1, Arturo Jimene- 14 days after the index case. Cruz Tijuana, Baja California 1 The DI anastomosis with the defect Autonomous University of Baja was resected, along with a subtotal California1 remnant gastrectomy. The ileum was re-anastomosed and a standard Roux- Background: Effectiveness of bariatric en-Y reconstruction was performed surgery among adolescents has been with a 30 cm bilioenteric limb and a 75 widely reported. The aim of this study cm Roux limb. A feeding jejunostomy is to review the outcomes of bariatric was placed 10 cm distal to the JJ surgery in adolescents with long-term anastomosis. The patient was follow-up. discharged 2 days following surgery. Methods: Pubmed, EMBASE, and The patient would present with a Cochrane databases were duodenal stump leak, presumed to be systematically searched; Inclusion secondary to kinking at the feeding criteria were 10-19 yo adolescents with tube site. This would be managed five years minimum of follow-up. conservatively with percutaneous Adiposity indicators outcomes, co- duodenostomy and removal of the morbidities remission, and feeding J tube. At one year follow up complications were analyzed. the patient has lost 76% of his excess body weight and BM is now 27 kg/m2. Results: Eight articles met the inclusion criteria. Surgeries performed In this article we review current included gastric bypass, gastric band, effectiveness and complication data and sleeve gastrectomy. Age of the with the SADI-S procedure; as well as participants ranged from 13-17.2 years. discuss the indications for revision and The longest follow-up after the different techniques described in intervention was 149.9 months. Mean the literature. We describe and illustrate BMI at baseline and follow-up was the details of our conversion, which has 46.87 kg/m2and 31.47 kg/m2,

330 www.obesityweek.com respectively. All studies reported reductions in BMI, mean percentage of Objective: Laparoscopic sleeve excess BMI loss was of 71.8%. Most of gastrectomy, laparoscopic roux-en-y the studies reported weight regain after gastric bypass and revisional bariatric 2 to 10 years of follow-up. Remission surgery are the most popular bariatric rate of co-morbidities after follow-up surgical procedures performed today was 85% for dyslipidemia, 83% for for treatment of morbid obesity, musculoskeletal problems, 83% for accounting for 90.7% of all bariatric hypertension, and 85% for type 2 surgeries in 2016. Many bariatric diabetes. The most frequent patients pose unique issues for the complication reported was anemia (16- surgeon due to body habitus. Robotic 46%), followed by vitamin and surgery is gaining popularity among minerals deficiencies. The rate of bariatric surgeons as a way to perform participants who underwent a second many of these surgeries. The enhanced bariatric procedure in patients who visualization and ergonomic dexterity initially underwent gastric band was may offer these surgeons advantages in 26%. the morbidly obese.

Conclusion: This review indicates that Methods: In order to assess the safety long-term outcomes of bariatric surgery and utility of robotic bariatric surgery, in adolescents shown a substantial a retrospective review of a single reduction in BMI; it was also reported surgeon’s experience for both weight regain and frequent remission of laparoscopic and robotic bariatric cardiometabolic comorbidities. Studies surgeries was evaluated. Surgeries reviewed were of low quality, did not evaluated included sleeve gastrectomy, report statistical power, were non- roux-en-y gastric bypass and revisional randomized controlled trials, and had bariatric surgery. Intraoperative and low retention rate; besides, perioperative complications along with complications and adverse effects were weight loss at 3- and 6- months postop not appropriately reported. were examined and compared between the laparoscopic and robotic groups.

Results: From February 2012 through A481 April 2017 there were a total of 279 Comparison of Laparoscopic to patients undergoing robotic bariatric Robotic Bariatric Surgery in surgery and 721 patients undergoing Community Hospital Program laparoscopic bariatric surgery by a Katie Novitski Pelham AL1, Robert single surgeon in a teaching community Flores Birmingham AL, Andrew hospital. Specific outcomes included DeWitt Birmingham AL blood loss, days of hospital stay, 30- Brookwood Baptist Health System1 day postoperative complications and

331 readmissions, operative times, and 3- scan of the chest/abdomen/pelvis which and 6-month postoperative weight loss demonstrated no additional abnormal were used. Robotic surgery resulted in findings. The patient completed a similar weight loss to the laparoscopic course of chemotherapy with a regimen surgery group. Complication rates were of pemetrexed and cisplatin and is similar with a trend towards decreased currently in remission. leak and intraoperative complication rates among the robotic group. Discussion Well-differentiated papillary mesothelioma (WDPM) is a rare variant of malignant peritoneal mesothelioma (MPM). This disease is most prevalent in women of reproductive age and most commonly A482 arises in peritoneal surfaces of the Incidental Well-Differentiated pelvis. There are no reported Papillary Mesothelioma Discovered associations with asbestos exposure and in Laparoscopic Sleeve Gastrectomy lesions are typically identified Shinban Liu Brooklyn NY1, Vadim 1 incidentally during surgeries performed Meytes Brooklyn NY , George for other indications. Due to the rarity Ferzli Staten Island NY1 1 of this entity, there is no consensus for NYU Langone Hospital the optimal treatment of this malignancy. However, WDPM is Case Presentation considered to be a low-grade 34 year-old female with past medical malignancy with a high cure rate history significant for morbid obesity, following complete surgical resection. obstructive sleep apnea, asthma, Unlike MPM, cytoreductive surgery hypertension, and hyperlipidemia and hyperthermic intraperitoneal underwent an uncomplicated chemotherapy are not indicated as the laparoscopic sleeve gastrectomy. potential to progress is low. Following Intraoperatively, a 5cm omental nodule resection, patients should have long- was identified and resected for term follow-up to monitor remission. pathologic examination. She tolerated This case highlights the importance of the procedure well and was discharged surgical vigilance and gross anatomic home the next hospital day with a examination during operations. bariatric clear liquid diet. The pathology would ultimately return as well-differentiated papillary A483 mesothelioma of peritoneal primary Case report: “2 steps” Laparoscopic origin. She was subsequently referred Roux-em-Y Gastric Bypass due to to an oncologist and underwent CT Important Hepatomegaly.

332 www.obesityweek.com Carolina Ribeiro Rio de Janeiro 1, ability to eat larger volumes of food. Guilherme Pinheiro Rio de Janeiro 1, The upper digestive tract endoscopy Bruno Serrano RIO DE JANEIRO 2, showed an abundant gastric fundus and Paula Perricelli 3, Paula da Silva Rio de an estimated GJA of 2cm, and the Janeiro 3, Taisy Ingrund São Paulo 1, abdominal ultrasonography showed Loraine Ferraz Rio de Janeiro 1, Victor remission of the hepatic steatosis. Luiz Filgueiras Rio de Janeiro - RJ. With a weight of 122kg and BMI Brazil 3, Luiza Lourenço Rio de 50.8kg/m2, she underwent a new LS Janeiro 1 for gastric reduction. In this surgery, Hospital Federal do the liver was normal in appearance and Andaraí1 Multidisciplinar2 Hospital size. So, we were able to identify the Federal do Andarai3 Hiss angle and perform a "re-sizeing" of the stomach and the GJA. SHRV, female, 49 years old, weight Again, patient had a good postoperative 163kg, height 1.55m, BMI 67.9kg/m2 evolution and restarted the process of Comorbidities: systemic arterial weight loss. The last registered weight hypertension, type 2 diabetes, hepatic was 92.8kg (6 months after surgery). steatosis and dyslipidemia. On 01/26/2016, the patient underwent laparoscopic surgery (LS) to perform A484 Roux-en-Y gastric bypass, in which we Nurses Attitudes toward Handling of could identify an important Patients with Morbid Obesity hepatomegaly, preventing access to the Cheryl Newton Columbus OH1, Joann Hiss angle. It turns very difficult to North Columbus OH2, Inga make an adequate gastric pouch. So, we Zadvinskis Columbus OH, Esther performed an horizontal gastrotomy at Chipps Columbus OH the level of the upper body with a Ohio State Wexner Medical posterior gastrojejunoanastomosis Center1 Ohio State University Wexner (GJA) along the small curvature, and a Medical Cen2 Roux-en-Y intestinal deviation. Patient showed no complications and followed the postoperative protocol as we expected. Purpose There was a significant weight loss in The purpose of this study was to the first year after surgery (minimum understand nurses’ attitudes toward weight of 116.3kg) and the patients with morbid obesity and the comorbidities were controled with no propensity to use safe patient handling medications. However, she did not equipment (SPHE). reach the loss goal and started Background/Significance regaining weight after this period. Obesity is a common issue in two Patient reported more appetite and thirds of the U.S. population

333 .1 Attitudes regarding patient handling and equipment use influence adoption of safe patient handling practices.2,3 It A485 is unknown if there is an association Delayed postoperative bleeding after between nurses’ own body a laparoscopic sleeve gastrectomy in image/weight, their attitudes toward a patient with factor VII deficiency patients with obesity, and propensity to Roberto Alatorre Adame Monterrey, use SPHE. N.L. 1, Javier Rojas Mendez Santa Research Questions: Catarina TX1, Alan E. Ramos Mayo Monterrey 1, Eduardo Flores 1. What are nurses’ attitudes Villalba 1, Montserrat Guraieb toward use of SPHE for patients Trueba San Pedro 1 with morbid obesity? Hospital San José Tec de Monterrey1 2. Is there an association between nurses’ weight bias toward obese Roux-en-Y gastric bypass (LRYGB) patients and use of SPHE? and sleeve gastrectomy (SG) are the most commonly performed procedures Methods worldwide, and because of recent We used a cross-sectional descriptive evidence SG has become more design with a convenience sample of accepted as stand-alone bariatric RNs that were members of the Ohio surgery. Bleeding from staple line Nurses Association and practiced in an represent about 1-2% of patient adult setting (n=244). Nurses complications. completed a 26-item We present a case of a patient with instrument, Nurses Attitudes Regarding background of a SG procedure which the Safe Patient Handling of Persons present postoperative bleeding 3 who are Morbidly Obese , via associated with coagulation factor VII email. Data analysis included deficiency. descriptive and inferential statistics. A 19-year-old woman, she had no Results: Nurses indicated that using chronic diseases or bleeding history, SPHE was time consuming and that nor use of medication, body mass index their workload interfered with their (BMI) 37 kg/cm2; she underwent SG ability to use it. There was no without staple-line reinforcement association between nurses’ bias without any surgical complications, and toward patients with obesity and the patient was discharged two days motivation to use SPHE, or perceived after surgery. On post-op 6, she time/work load. presented to emergency department Conclusions: Nurses’ attitudes toward with complaining of 6-hour 38.7°C patients with morbid obesity and the fever. She underwent to computed use of SPHE is highly variable. tomography showing a 10x10x7cm, heterogeneous left sided collection,

334 www.obesityweek.com with 50 Hounsfield unit (HU) density, intragastric erosion. We present a 45 consistent with a left sub phrenic y/o female with h/o morbid obesity and hematoma for which she underwent lap band placement 10 years ago in percutaneous drainage, with resolution outside hospital with multiple episodes of the symptomatology and was of band slippage, recurrent epigastric discharged after an uneventful pain and recent significant weight recovery. Twenty-one days after regain. The patient consulted our ED discharged, she presented to emergency due to new episode of epigastric pain. department complaining of untreated A CT sowed no perigastroesophageal 38.5°C fever. A CT scan was collection. An EGD showed an eroded performed showing an increased size band in the upper stomach in 2 left sub phrenic collection and a new different places with approximately 50 collection adjacent to the stomach % band erosion. Because of the stapled line of approximately 800 ml of recurrent upper abdominal surgeries volume, consistent with an infected due to band slippage and the significant hematoma. A diagnostic laparoscopy band erosion, the decision was made to with drainage of the infected hematoma remove the band laparoendoscopically. was performed obtaining The band was deflated with approximately 1.5 liters of blood clots fluoroscopic guidance. Surgical and hematic-purulent material. Due to technique is presented step by step. The inexplicable bleeding a coagulation mucosa was separated from the band factor test was performed and a Factor with blunt dissection with the VII (FVII) deficiency was diagnosed endoscopy tip. An ERCP guide-wire with 19.1% of activity. was passed between the mucosa and the band into the stomach in excess. The wire was looped only around the lap A486 band. The wire was then fed into Laparoendoscopic removal of eroded a Sohendra mechanical lithotripter and gastric banding after multiple was used to cut the silicon band under surgeries for band slippage. endoscopic retroflexed view in the Jacob Skeans Cleveland OH1, D. Roy stomach. Laparoscopically, the tubing Ferguson Cleveland OH1, Ronnie was cut to release the silicon band from Fass Cleveland OH1, Eileen the bumper. With snare in place around Seeholzer Cleveland OH1, Sergio the buckle of the lap band, gentle Bardaro Cleveland OH2 rotational force was used to pull the Case Western Reserve University1 Case band completely into the stomach, Western Reserve University - which was then completely MetroHealth Medical Center2 removed via oral route. Endoscopic removal of eroded band is One of the complications of feasible and avoids extensive dissection laparoscopic gastric banding is

335 on a complex and hostile surgical field. criteria for this study. 105 underwent laparoscopic sleeve gastrectomy, 23 underwent Roux-En-Y gastric bypass, and five underwent laparoscopic band A487 removal. The average TT was 43 A Novel Measure to Improve minutes, compared to an average ETT Turnover Time in the Operating of 70 minutes, for a difference of 27 Room minutes of non-operative time. Mohammed Nimer 1, Steven Schulberg Brooklyn NY2, Vadim Conclusion: Meytes Brooklyn NY2, George Our results demonstrate that there is a Ferzli Staten Island NY2 significant amount of time spent non- St. Georges University1 NYU Langone operatively that is not currently Brooklyn2 captured in the TT metric. We recommend employing ETT to better Background: capture non-operative time between Turnover time (TT) in the operating patients for optimization of OR room (OR) is an important indicator of protocols. We believe that ETT may be efficiency. Traditionally, TT is defined decreased through improved as the time between one patient leaving preoperative preparation, attending the OR and the next arriving. However, availability prior to patient arrival, and the TT metric does not accurately decreased PACU hold times. Precisely reflect the time lapsed between capturing extended turnover time will procedures. This study aims to refine allow implementation of solutions to the definition of TT with a new streamline OR processes, decrease staff parameter called extended turnover stress, and conserve resources. time (ETT), the time period between extubation and next intubation. A488 Methods: Striking Decrease in Insulin We conducted a retrospective review of Requirement for Type I Diabetes patients who underwent bariatric after Roux en Y Gastric Bypass surgery at our institution between July Vivian Sardone Iowa City IA, Marwa 2017 and March 2018. TT was defined Abu El Haija Coralville IA1, Peter as minutes between patient exit and Nau Iowa City IA next patient entry to the OR. ETT was University of Iowa Hospitals and defined as the time between extubation Clinics1 and next intubation. Roux en Y Gastric Bypass (RYGB) is Results: an effective treatment for obesity and Of 224 patients, 133 met inclusion its related metabolic profile. It is

336 www.obesityweek.com known to improve hypertension, to have a hemoglobin A1c of 6% and hypercholestrolemia, Type II diabetes needing 3-4 units/day of insulin. (T2D), and few report improvement in Type I Diabetes (T1D). This is interesting as the pathophysiology of A489 development and treatement of T1D is A Comparison of 5 Year Weight Loss different than T2D, with the former and Major Complications at 30 Days being an autoimmune disease and latter Between Primary RNY Gastric being a disease of obesity. Here we Bypass and Sleeve Gastrectomy present case of a 38 year old patient Procedures. A Single Surgeon’s with T1D who is needing minimal Experience at a Center of Excellence. amount of insulin 3 months post Amjad Ali Erie PA1, Zakariya Ali Erie RYGB. PA, Muhammad Asad Erie PA2, Jawaid Kalim Erie PA2, Fozia This is a 38-year-old female with T1D Ahmed Baltimore MD3 and morbid obesity who underwent UPMC Hamot Medical Center1 UPMC RYGB on February 2018. Her Hamot2 Johns Hopkins University3 additional comorbidities included obstructive sleep apnea, hypertension, The objective of this study is to gastroesophageal reflux, menstrual evaluate 5-year weight loss and major irregularity and migraines. She was complications in the first 30 days after initially misdiagnosed with T2D and primary RNY gastric bypass (RNY) failed metformin therapy. Her brother and sleeve gastrectomy (SG) performed was diagnosed with T1D and she by a single surgeon at a community transferred her care to our center where hospital. Methods: A prospective antibodies were performed at that time. database (Lapbase ®) was maintained Her glutamic acid decarboxylase on patients undergoing bariatric (GAD) antibodies was found to be surgeries by the author. This review elevated at 118.8 (normal < 5.0 IU/mL) covers all primary RNY and SG which confirmed diagnosis of T1D. Her surgeries performed between July diabetes was subsequently well 2000-December 2018. Results: A total controlled using an insulin pump at a of 707 primary RNY and 405 SG were basal rate of 2.9 units/hour (69.6 units performed during that period. There per day). Follow up visit showed her were 14 leaks (1.9%) after RNY, and 6 regimen consisted of 66.71 units/day of (1.4%) after SG, 5 (0.7%) bleedings basal insulin and 75 units/day of bolus after RNY and 1 (0.24%) after SG, 35 insulin, hemoglobin A1c 7.8%. She (4.9%) strictures after RNY and 11 underwent RYGB for obesity and other (2.7%) after SG and 1 death each after related comorbodities in 2018. On her both procedures due to PE. Average % three months follow up she was found excess weight loss (%EWL) after RNY was 32 at 3 months, 46.9 at 6 months,

337 57.5 at 9 months, 63.2 at 12 months, 70 underwent a duodenal switch. She was at 18 months, 72.2 at 24 months, 74.2 a smoker preoperatively but quit. For at 36 months, 77.3 at 48 months and one week she did well and had no 72.5 at 60 months. Average %EWL evidence of diabetes but. She returned after SG procedures was 17 at 3 with acute onset abdominal pain. CT months, 35 at 6 months, 46.7 at 9 scan demonstrated a large fluid months, 50.9 at 12 months, 54.4 at 18 collection in the right upper quadrant as months, 52.8 at 24 months, 60.8 at 36 well as pneumoperitoneum. Diagnostic months, 59.7 at 48 months and 63.9 at laparoscopy revealed a perforated 60 months. Conclusion: This review of marginal ulcer. This was confirmed a non-randomized prospectively with endoscopy. The abdominal cavity collected data shows lower incidence of was washed out and drains were left. major complications except mortality at The perforation was repaired primarily 30 days (the difference didn’t reach and patched with momentum. statistical significance) and similar 5- year weight loss after SG compared Outcomes: Upper gastrointestinal series with RNY. with fluoroscopy demonstrated no leak on postoperative day 5. She was discharged on post operative day 7 on a full liquid diet. Drains were removed A490 before discharge. Feeding tube remains Case report of perforated marginal in place. All vitamin levels tested in the ulcer 7 months following duodenal hospital were within normal limits. She switch smokes 1/2 pack per day of cigarettes Dustin Bermudez Raleigh NC1, Peter right now. Ng Raleigh NC2, Lindsey Sharp Raleigh NC3, Jillian Vari Raleigh Conclusions: While the incidence of NC3, Erica McKearney Raleigh NC marginal ulcers with BPD-DS is Rex Hospital1 UNC Rex Hospital, drastically lower than that of a gastric Raleigh NC2 UNC Rex3 bypass, it is not impossible. The pathophysiology is likely different from Background: Marginal ulcers are quite that of the gastric bypass. This patient rare with biliopancreatic diversion with was non-compliant but the real risk duodenal switch (BPD-DS) compared factor was her continued smoking. We to the gastric bypass. Our practice has recommend strong preoperative and performed over 300 BPD-DS postoperative counseling for tobacco procedures in the past 5 years. We dependence. describe here our first experience with a perforated marginal ulcer. A491 History: This 65 year old woman

338 www.obesityweek.com “ Two birds, one stone” : ITP managed at the time of bariatric surgery. A492 Varun Jain Phoenix AZ1, James Adjustable Gastric Band to Sleeve Madura Phoenix AZ1 Gastrectomy to Roux-en-Y Gastric Mayo Clinic Hospital, Arizona1 Bypass: Bariatric Surgery in Evolution There is a growing prevalence of John Morton Stanford CA1, Luis obesity, with a subsequent increase in Garcia Fargo ND bariatric surgeries. As a result, the Stanford School of Medicine1 patient population undergoing surgery has become widely varied with Background: Past studies have multiple additional medical and examined outcomes after conversion of surgical problems. Some of those Adjustable Gastric Band (AGB) to additional problems, on occasions, laparoscopic sleeve gastrectomy (SG) require surgical management. This can or Roux-en-Y gastric bypass (RYGB). sometimes become tricky and pose a Limited data are available regarding challenge in the decision to proceed patients who undergo conversion from safely with an elective bariatric AGB to SG and subsequent conversion procedure. One such consideration is to RYGB. ITP (idiopathic thrombocytopenic purpura), which, if refractory to Methods: This study is a retrospective medical management requires surgical review of patients’ electronic medical treatment. Low platelets are known to records. We present 2 patients with a increase the risk of bleeding history of AGB and SG who underwent complications. Besides chronic anemia, RYGB at our university hospital due to thrombocytopenia has been described poor weight loss between 2015 and as a potential hematological alteration 2017. Weight loss was assessed 12 after bariatric surgery and this can months postoperatively. understandably create a decision dilemma. Results: Both patients were female. Here we present a novel case of a 33 Prior to RYGB, patients were 54 and year old lady with medically refractory 61 years old with body mass indices of ITP who underwent surgical 42.6 and 41.2 kg/m2. 1 patient management for her ITP along with underwent all procedures at our bariatric surgery, and rather than being hospital, whereas the other underwent a contra-indication for the weight loss AGB and SG elsewhere. In 2010, procedure, her thrombocytopenia was Patient A weighed 271 lbs. managed effectively and safely at the preoperatively and 212 lbs. same time. (%EWL=61%) 12 months after AGB. In 2012, Patient A weighed 267 lbs.

339 preoperatively and 251 lbs. experience fluctuating weight gain and (%EWL=18%) 12 months after SG. In loss? This abstract will review a case in 2015, patient A weighed 288 lbs. adolescent obesity that may highlight preoperatively and 176 lbs. the set point theory. (%EWL=94%) 12 months after RYGB. Patient B underwent AGB in 2009, SG The patient was a 14-year-old female in 2012, and presented in 2017 for with a BMI of 48.01 kg/m2, presenting RYGB. Patient B weighed 255 lbs. to our multidisciplinary bariatric clinic preoperatively and 194 lbs. in April 2016. Her pre-operative (%EWL=61%) 12 months course was marked by weight gain and postoperatively. No complications or loss. She was started on Liraglutide readmissions were observed for without any result, and primary or conversion procedures. Phentermine/Topamax, which resulted in about 3.4% body weight loss over Discussion: Few cases of AGB to SG three months. She underwent a pre- to RYGB conversion have been operative workup, including normal described. The observed weight loss cardiac stress test and sleep study. She suggests that RYGB is efficacious and was cleared by physical therapy for safe in patients with previous history of being physically fit. She underwent a AGB and SG. laparoscopic sleeve gastrectomy (LSG).

(see table)

A493 Do these results represent regulation of Metabolic Set Point in Obesity: Can body weight by a set point? Little this explain weight fluctuations after research is available to demonstrate Laparoscopic Sleeve Gastrectomy? whether metabolic set point is affected Nicole Boone Hartford CT, Melissa after LSG in adolescents. Many factors Santos Newington CT1, Meghna affect the set point, including sleep Misra Hartford CT, Jessica disturbances, stress, and Zimmerman Hartford CT, Priya genetics. While little research is Phulwani Hartford CT, Christine available, this patient’s experience may Finck Hartford CT indicate internal regulation of weight Connecticut Children's Medical Center1 despite medical and surgical interventions. Obesity is a multifactorial disease. Set point theory describes an internal control mechanism that maintains a specific body weight through regulation A494 of appetite and energy expenditure. Can this explain why some patients

340 www.obesityweek.com Abdominoplasty as integrated Mean operating time was 146 minutes. approach after massive weight loss Mean readmission rate was 9%. The performed by general surgeons complication rate according to the Christof Ihle Torsby Clavien-Dindo-classification was I 7%, Torsby Hospital II 3%, IIIa 4%, IIIb (re-operation) 3%. There were Introduction no complications of higher grading. Weight loss after bariatric surgery These leaves the patient with a completely results are comparable to those changed body published by plastic surgeons. appearance. This can lead to immense frustration. Frequently, formerly obese Conclusion individuals start a completely new life We strongly believe in an integrated with respect to physical activity as well approach to the bariatric patient. These as socially. Sagging excess skin can individuals experience a life-changing make sportive activities mechanically treatment not only in regard to difficult. comorbidities Patients may have large problems with like metabolic syndrome, but to intimacy. their lives as human beings. We feel In Sweden´s national health system that these patients are eligible to body restoring patients should not be left alone with surgery. the results of massive weight loss in The plastic surgery departments in our this respect. country cannot keep up with the We were able to establish demand. As abdominoplasty on a high quality an integrated approach at our bariatric level in the hands of center we therefore introduced none-plastic surgeons. abdominoplasty as a standard operation performed by none-plastic surgeons. A495 Association of pre-operative Methods behavioral measures with All 150 patients who received an antidepressant medications one year abdominoplasty at our hospital since after bariatric surgery the year 2014 Shawn Hondorp Grand Rapids MI1, were analyzed. Rebecca Preston Grand Rapids MI1, Operation type was standard Erin Schroeder Grand Rapids MI2, abdominoplasty or fleur-de-lis- Margaret de Voest Ada MI2, Minji abdominoplasty (17% of Sohn Big Radpis MI2, Jon all patients). Schram Zeeland MI1 Spectrum Health System1 Ferris State Results University2

341 measures. Results provide further Many patients hope to discontinue evidence that while weight loss surgery medications following bariatric does lead to the amelioration of many surgery, yet little is known about health comorbidities and therefore a factors associated with antidepressant reduction in many medications; few use after surgery. We conducted a patients discontinue antidepressant retrospective chart review to examine medication after bariatric surgery. No associations between pre-operative predictive variables were identified in measures (e.g., anxiety, depression, and the current study, and descriptive somatic symptom scales of the analyses suggest that the patients who Personality Assessment Inventory) and discontinue antidepressant medication change in antidepressant medication vary significantly in terms of starting prescription from baseline to one-year weight, weight loss, and baseline mood post-operatively. Of 216 patients variables. (90.0% gastric sleeve), 95 (44.0%) were never prescribed an antidepressant, 90 (41.2%) stayed on the same antidepressant, 20 (9.2%) A496 added, increased, or changed IMPACT OF WEIGHT LOSS ON medications, and 11 (5%) decreased or THE BODY COMPOSITION OF discontinued antidepressant PATIENTS 1 YEAR AFTER medication. Higher scores on the GASTRIC BYPAS depression, anxiety, and somatic GLAUCO DA COSTA BALVAREZ symptom clinical scales were all ALVAREZ SANTA MARIA 1, DEISE significantly associated with SILVA DE MOURA Santa Maria RS antidepressant prescription before and Brazil 2, LUCIANA DAPIEVE after surgery, but were not significantly PATIAS Santa Maria - RS 1, associated with changes in these CRISTINA MACHADO BRAGANCA medications. Notably, changes in DE MORAES Santa Maria 2, medication and particularly NATHALY MARIN HERNANDEZ 2, discontinuation of antidepressant RAQUEL PIPPI ANTONIAZZI 2, medication were rare, thus small LUISA COMERLATO sample sizes limited power to detect COMERLATO Santa Maria 2, ANA smaller effects. Examination of CRISTINA MACHADO SANTA descriptive variables among the few MARIA 1 patients who discontinued Federal University of Santa antidepressant medication (n = 11) Maria1 Franciscana University2 revealed significant variability in starting weight (range: 36 to 71 kg/m2), Background: Obesity is a percent excess weight loss (range: 32% multifactorial disease and involves to 108%), and psychological symptom genetic, psychosocial and nutritional

342 www.obesityweek.com aspects characterized by chronic and a fat mass of 55.39kg (± 8.48kg) to inflammatory state. Bariatric surgery is 20.37kg (± 7.47) in the postoperative a resource used in cases of failure in the period. There was a significant weight clinical treatment for obesity and reduction, BMI, lean mass and fat mass promotes an efficient reduction in (P <0.001). weight. Gastric bypass is the most Conclusion: Weight reduction through practiced technique in Brazil, gastric bypass in the 1-year accounting for 75% of the surgeries postoperative period had a significant performed, due to its safety and impact on the modification of the body efficacy, providing a weight loss composition of bariatric patients. around 70% to 80% of the initial Approved by the Research Ethics weight and control of the main Committee of the Franciscan associated comorbidities. The objective University: 1,830,670. of this study was to evaluate the impact of weight loss on the body composition of patients submitted to bariatric surgery. Methods: Longitudinal study carried out in southern Brazil. The sample A497 consisted of 43 subjects who underwent Length of Stay Reduction In Primary bariatric surgery and returned after 1 Roux En Y and Sleeve Gastrectomy year for follow-up visits with a Procedures by Clovis Community multidisciplinary team. The Medical Center (CCMC) presented anthropometric data of weight, height, by Susan Ghera, RN BSN PHN & BMI, body composition (lean mass and Ashley Pinheiro MSN, RN, CNS, fat mass) of the patients were obtained ACCNS-AG. by analyzing the patients' medical Susan Ghera Clovis CA1, Ashley records. Pinheiro Clovis CA1 Results: The mean age of participants Clovis Community Medical Center1 was 39.48 years (± 10.68), with 76.74% women and 23.26% men. The mean Review of CCMC’s length of stay weight was 113.47 kg (± 14.66) in the (LOS) data revealed an opportunity to preoperative period, and 71.57 kg (± decrease the number of postoperative 11.28) in the postoperative period of 1 inpatient days for bariatric patients. year, being the percentage of excess Monthly LOS data retrieved from weight loss (% PEP) of 95.53%. The Premier’s database allows us to mean BMI was 41.90kg / m (± 4.52) benchmark ourselves and set goals for and 26.45kg / m (± 3.57), respectively, quality improvement. For calendar before and after surgery. In relation to year 2016 the average LOS for RYGB the lean mass there was a reduction of was 2.23 days. When compared to 32.76kg (± 6.46) to 27.93kg (± 5.72) Premier the observed/expected (O/E)

343 ratio was 1.37. The average LOS for Body Composition as an Important SG was 2.16 days. When compared to Ancillary Measure in Premier the O/E ratio was 1.52. Both Adolescent/Young Adult Bariatrics patient populations had a LOS longer Megan Ratcliff Duluth GA1, April than like patients within the premier Alexander Duluth GA1, Tasha database. Temple 1, Debra Proulx Duluth GA1 A process improvement (PI) plan was Gwinnett Medical Center1 implemented to decrease the LOS for RYGB and SG patients to < 2 days. A Background: Body mass index (BMI) counter measure for this PI plan was to and percent excess weight loss maintain an all cause readmissions O/E (%EWL) are widely used but imperfect rate <1. The plan for improvement bariatric metrics. They do not began by developing a discharge differentiate between fat mass (FM) criteria outlining hydration, mobility and fat free mass (FFM), and their use and symptom management goals for among adolescents/young adults discharge on postoperative day one (AYA) may be problematic given the (POD 1). possibility of continued height and Staff were educated on the discharge weight increases during the pubertal pathway and the expectation for stage. Our AYA Program began communicating patient progress systematically measuring body towards discharge with the surgeon. composition (including FM and FFM) Patients were educated to have an using bioelectrical impedance in an expectation of being discharged on attempt to better assess and inform POD 1. After education was treatment. implemented, monitoring was conducted and opportunities for Methods: A retrospective clinical chart improvement were reviewed. review of patients completing our six- Review of data and project results month AYA pre-surgical program from demonstrated a reduction in length of August 2016-February 2018 was stay without a significant increase in conducted (n=13). Clinical data readmissions, patient satisfaction due to including patient age, sex, height, shorter inpatient stay and improved weight, body composition (Body Fat organizational throughput. The Mass [BFM], Dry Lean Mass [DLM]), metabolic and bariatric committee will and fitness (treadmill test, push-ups) continue to monitor and report the were reviewed. Dietary adherence outcomes related to this project. (rated as Good, Fair or Poor in Dietitian’s clinical note) was classified as 100%, 70-99%, and <70% Good.

A498 Results: Three patient profiles emerged and are presented as case series. Over

344 www.obesityweek.com the course of treatment, Patient A treating Vitamin D deficiency is best demonstrated 100% diet adherence managed with cholecalciferol (D3) or with improved fitness resulting in loss ergocalciferol (D2). of 37.7lbs BFM and 5.7lbs DLM. Patient B demonstrated 70-99% diet METHODS adherence with no change in fitness After approval by the institutional resulting in loss of 8.2lbs BFM and review board, a retrospective chart 7lbs DLM. Patient C demonstrated review was conducted at an MBSAQIP <70% diet adherence with no change in verified center on patients 30 days or fitness resulting in gain of 4.2lbs BFM more post gastric bypass or vertical and loss of 1.1lbs DLM. sleeve gastrectomy undergoing routine post-surgical follow-up between April Conclusion: Not all pre-surgical 1, 2016 and April 30, 2017. Inclusion weight loss is equivalent or beneficial. criteria included patients with Vitamin Routine assessment of body D levels under 30 ng/mL being treated composition in AYA bariatric programs with either D2 or D3 with follow-up provides clinically useful information labs at 3-month intervals after beyond standard weight metrics. treatment initiation. Exclusion criteria included missing lab values or treatment information, and non- A499 compliance with therapy. In addition, TREATMENT CONTAINING common demographics, medical and CHOLECALCIFEROL IS surgical history were collected. SUPERIOR TO Analysis of variance was conducted ERGOCALCIFEROL ALONE IN using SPSS Statistics version 24 (IBM- TREATING PATIENTS WITH SPSS, Armonk, NY) to identify VITAMIN D DEFICIENCY POST- differences in treatment regimens. BARIATRIC SURGERY Kathleen Kinser Nashville TN1, RESULTS Matthew Spann Nashville TN1, Chetan 42 patients met criteria and were Aher Nashville TN1, Cynthia divided into three treatment categories: Blalock Nashville TN1 no treatment, therapy with D2, therapy Vanderbilt University Medical Center1 with D3. Statistically significant variations were observed between the three groups shown in TABLE 1 (p = INTRODUCTION <0.005). D3 treatment resulted in Patients after bariatric surgery may 39.7% higher levels than with D2. have increased rates of Vitamin D There was no statistically significant deficiency due to diet changes and difference between post-gastric bypass malabsorption of the procedures. and post-sleeve gastrectomy patients. Current data is unclear regarding if

345 CONCLUSIONS Sexual Function Index (FSFI) and the Treatment of vitamin D deficiency after Sexual Quality of Life - Female bariatric surgery with vitamin D3 may (SQOL-F) questionnaires. Females of be superior to treatment regimens non-obesity (BMI<28) were also excluding D3. Larger sample sizes in recruited as control. Clinical data was prospective studies are needed to collected and analyzed. confirm observations of this retrospective study. Results: Mean age and BMI of the study group (n=60) and control group (n=77) were (31.40±7.26 years, 37.65±9.35 kg/m2) and (30.94±12.58 A500 years, 20.97±2.73 kg/m2), respectively. Increasing the frequency of sexual Mean score of SQOL-F and FSFI in life may improve the sexual function study group and control group were and quality of females with obesity in (75.28±21.76 vs 77.51±12.43, p=0.91) China and (19.31±8.65 vs 25.29±4.87, Wah Yang Guangzhou 1, Luping p<0.001). Frequency of sexual life in Sun Guangzhou 1, Pik Nga study group (3.78 times/month) was Cheung Guangzhou 1, Cunchuan lower than that in the control group Wang Guangzhou Guangdong 1 (6.03 times/month), and which were The First Affiliated Hospital of Jinan positively correlated with SQOL-F University1 (p=0.013) and FSFI (p<0.001). Testosterone (R=-0.296, p=0.023) and Background: It is always embarrassing progesterone (R= -0.310, p=0.017) to talk about sexual function among were negatively correlated with FSFI. Chinese population due to conservative Hypertension, T2DM, smoking, tradition, especially for females. Sexual drinking, education, marriage and function and quality in Chinese female income were not statistically significant bariatric surgery candidates was seldom (P > 0.05) between two groups. studied. Conclusions: Sexual function of Objective: To investigate the factors Chinese female bariatric surgery affecting the sexual function and candidates is lower than that of the quality in Chinese female bariatric females with normal BMI. Increasing surgery candidates. the frequency of sexual life may improve the sexual function and quality Methods: Females with obesity of females with obesity in China. (BMI28) met the indications for bariatric surgery in our center were assessed by two comprehensive A501 assessment tools, namely the Female

346 www.obesityweek.com Impact of preemptive acetaminophen were seen at the 8 and 16-hour time administration on postoperative points. C group reported scores >7 opioid use and complications in more frequently than the APAP group laparoscopic sleeve gastrectomy (53% vs 43%). Total hospital length of Marjan Sadegh Boston MA stay was marginally shorter in the Brigham and Women's Hospital APAP group. All analyzed outcomes were statistically insignificant. Objective: Opioids are commonly used Conclusion: These findings suggest in postoperative care following that adding pre-emptive oral APAP, laparoscopic sleeve gastrectomy (LSG). when added to the standard of care, has These agents are not without risk of a statistically insignificant impact on adverse events. Multimodal and opioid consumption and associated preemptive analgesia methods have complications in 24-hour been implemented to reduce opioid postoperatively. consumption. This study aims to evaluate the effect of preemptive oral acetaminophen (APAP) on postoperative opioid consumption and A502 complications following LSG. Do the Cleveland Clinic Behavioral Methods: We performed a prospective Rating System and Flanagan Quality study of sequential patients who of Life Scale Predict Outcomes After received preemptive 975 mg of oral Bariatric Surgery? APAP and a historical control who did Sara Monfared Indianapolis IN1, not. The main outcome evaluated the William Hilgendorf Carmel IN2, Don difference in the hydromorphone Selzer Carmel IN1, Jennifer equivalent dose consumed within 24 Choi Indianapolis IN1, Ambar hours after LSG. Secondary outcomes Banerjee Indianapolis IN1, Dimitrios included differences in a postoperative Stefanidis Carmel IN1 pain intensity, use of antiemetic agents, Indiana University School of and hospital length of stay. we applied Medicine1 Indiana University Health student’s t-test or Mann-Whitney U test North Hospital2 for continuous data and Chi-square test for nominal data. Statistical Background: Social support is significance was set at p-value of important to optimize bariatric surgery 0.05. outcomes but limited tools exist for its Results: Total of 53 patients were reliable assessment preoperatively. identified in the C group and of 37 Objectives: To assess whether the patients were included in the APAP Cleveland Clinic Behavioral Rating group. The median 24h-hour HEqD System (CCBRS) completed by a (IQR) in group A vs C was 2.1 mg vs psychologist, and a patient self-report 2.8 mg respectively. Similar trends measure, the Flanagan Quality of Life

347 Scale (FQOLS), can predict weight loss A503 and comorbidity resolution after Conversion of One-Anastomosis bariatric surgery. We also examined Gastric Bypass to Roux-en-Y Gastric any associations between these two Bypass : A Retrospective, Two- tools. Center Analysis Methods: Patients with 1 year follow- Joshua Landreneau Cleveland OH1, up after bariatric surgery at a center of Andrew Strong South Euclid OH1, John excellence, who also had the CCBRS Rodriguez Cleveland CA1, Ricard and FQOLS completed as part of their Corcelles Abu Dhabi 2, Matthew preoperative psychosocial evaluation, Kroh Abu Dhabi 2 were identified. A logistic regression Cleveland Clinic1 Cleveland Clinic was performed with patients’ CCBRS Abu Dhabi2 and FQOLS scores as independent variables, and postop BMI, comorbidities, length of stay, and loss Background: to follow-up as dependent variables. One-anastomosis gastric bypass The prediction of CCBRS ratings from (OAGB) has become increasingly FQOLS social support items was also popular for its relative simplicity but is evaluated. associated with complications that Results: A total of 199 patients were require revisional surgery. Herein we included. Neither the CCBRS nor the present a two-center experience of FQOLS scores were predictive of converting OAGB to roux-en-y gastric postop BMI, comorbidity resolution, bypass (RYGB). length of stay, or loss to follow-up (table 1). There was, however, a Methods: significant correlation between the Patients who underwent conversion of CCBRS and the FQOLS (p<0.001) OAGB to RYGB at the Cleveland with the FQOLS subscales for family Clinic or Cleveland Clinic Abu Dhabi and significant other support being from January 2010 to August 2017 strong predictors of CCBRS scores were retrospectively reviewed. (table 2). Conclusion: The two behavioral Results: assessment tools were not predictive of Twelve patients with previous OAGB outcomes 1 year after bariatric surgery. underwent conversion to RYGB during The family and significant other the study period, with six patients support subscales were predictive of included from each institution. The CCBRS scores. Longer term cohort was 83.3% female with a mean assessment of patient outcomes is age of 51.3 years and median BMI of needed. 33.2 kg/m2. Three patients (25.0%) had at least one prior bariatric surgery conversion. The most common

348 www.obesityweek.com indications for conversion were bile University Hospitals of Cleveland, reflux gastritis (50.0%) and CWRU1 Cleveland Medical nausea/vomiting (25.0%). The median Center2 Lake Erie college3 Menoufia time for OAGB to RYGB conversion University, General surgery Dep4 was 30 months. Seven (58.3%) were completed laparoscopically, with four Background: converted to open (33.3%) and one Bariatric patients are at particular risks (8.3%) with a planned open approach. of opioids-related respiratory A handsewn gastrojejunal anastomosis complications postoperatively. was fashioned in four patients (33.3%). Adjuvant pain therapy includes The mean operative time and estimated local/regional blocks with the aim to blood loss was 276 minutes and 160 reduce opioid intake. The objective of milliliters. One patient required the study is to asses opioids intake in reoperation for anastomotic leak and patients undergoing transversus one patient had percutaneous drainage abdominis plane (TAP) block at the of an abscess. The median length of time of laparoscopic bariatric surgery. stay was 7 days. There were no Methods: 130 patients underwent mortalities at a median follow-up of standard laparoscopic laparoscopic 10.2 months. gastric bypass. TAP block was done with infusion of a total 50 ml of Conclusions: Marcaine 0.5% injected in standardized OAGB to RYGB conversion can be fashion into preperitoneal space near challenging, though is safe and feasible port sites under laparoscopic guidance. for the correction of OAGB-related Patients were matched with a control complications. While a laparoscopic group with similar age, weight, BMI, approach is possible in most cases, comorbidities, gender. Patients with complications are relatively common. prior opiod use, chronic pain, revision or additional surgeries were excluded. Pain scores, sparing morphine consumption, and early recovery items A504 were evaluated at 1, 24, and 48 hours Transversus Abdominis Blocks in postoperatively. Findings were Bariatric Surgery compared between groups using Rami Mustafa cleveland OH1, Tomasz ASPSS 24, Chi Sq. and T-test. Rogula Chardon OH2, Leena Results: Khaitan Chardon OH1, Ebony After matching, 11 patients out of 130 Tinsley Painesville OH3, Heba patients were included in the study with Elghalban Cleveland OH1, hatem an allocation ratio of 1:1 to the control soltan New cairo 4, Mohamed group. Opioid intake was significantly Sabry Shebein Elkoom 4 decreased in a study group (p<0.005) with similar or better pain scores.

349 Conclusions: TAP block in laparoscopic bariatric Results: surgery decreases opiod intake and provides adequate pain control. Postoperative BMI at the maximum Key Words: Bariatric surgery, TAP, time of follow-up, mean 2.26 years Outcomes (range 1-4 years), was 28 (range 23 to 45). Only one patient did not lose enough weight and was A505 considered a failure. There were no Is Bariatric Surgery to be offered in mortality or morbidity. All co- Adolescence? morbidities disappeared. Family and MAHENDRA patients were pleased with the surgery. NARWARIA ahmedabad ASIAN BARIATRICS HOSPITAL Conclusions:

Background: Early surgical intervention should be offered to a greater number of Bariatric surgery in morbidly obese adolescents to minimize adolescents is controversial. Many the emotional and physical argue that morbidly obese individuals consequences of morbid obesity . QOL should be of adult age before will also improve after the surgery in undergoing bariatric operations, despite these patients. the progressive and debilitating course of this increasingly common disease. Objective: A506 To examine the safety and 30-Day Readmissions of 605 patients effectiveness of adolescent bariatric submitted to bariatric surgery in a surgery and to improve treatment SRC Bariatric Center recommendations for this age group. Carlos Pizani São Paulo 1, Thomaz MONCLARO São Paulo 1, Ana Materials and Methods: Caroline Fontinele São Paulo 1, Dirceu Santos São Paulo 1, Eduardo Sticca São 19 consecutive adolescent patients, Paulo 1, Marcelo CARNEIRO Sao aged 12-19, underwent Sleeve,Banded Paulo 1, Sansiro de Brito São Paulo 1, Sleeve, Carlos De Souza Filho São Paulo 1, Roux-en-Y gastric bypass,Mini Gastric PAULO SALLET SAO PAULO SP1, Bypass between May 2014 and August Afonso Sallet São Paulo 1 2017. Average BMI was 49 Instituto de Medicina Sallet1 kg/m2,range 38-67. All had one or more co-morbidities.Follow-up was Year after year the rate of obtained up to 1-4 years. complications and mortality after

350 www.obesityweek.com bariatric surgery has been dropping. surgical treatment in the first 30 days The medical community knows that the after bariatric surgery and all of them use of new technologies, high volume had a good evolution. centers and expertise of the surgical team, especially concerning diagnosis and treatment of complications is A507 essential to further reduce morbidity The absence of Caspase 1/11 leads to and mortality rates. The objective was fat tissue modulation and a anti- to analyze complications and hospital tumor activity of Brown adipose readmissions for clinical care or tissue against breast cancer cells surgical treatment in the first 30 days Luis Henrique Correa Brasilia 1, Lívia after surgery. This Observational study Sant'Ana Brasilia 1, Aline included 605 consecutive patients Martins Brasilia 2, Kelly Magalhães 2, submitted to Laparoscopic Roux-en-Y Marcos Eberlin 3 Gastric Bypass and Sleeve Gastrectomy University of Brasilia1 University of in a SRC credited center in 2017. All Brasília2 UNICAMP3 patients were classified through the Clavien-Dindo grade. Of the 82 Fat tissues can regulate cancer (13,5%) patients that were admitted to development by modulating the emergency room, only 21 (3,5%) inflammatory response. However, the needed rehospitalization. The main role of NLRP3 inflammasome in white causes were bleeding in 7 patients and brown adipose tissues in this (34%); small bowel obstruction, context is poorly understood. Here, we postoperative ileus, respiratory disease aimed to characterize the role of and thrombosis of the portal system in caspase 1/11 and NLRP3 3 patients each (14%); and 2 patients inflammasome components in the (10%) with changes in food passage lipidomic profile of brown and white through the anastomosis: one with adipocytes and their function in breast foreign body obstruction and one with a cancer cells activation. Brown and stenosis due to edema. Of these, 7 white adipose tissue were isolated from (33%) had Clavien-Dindo I, 9 (43%) wild type, caspase-1/11 and NLRP3 Clavien-Dindo II, 2 (10%) Clavien- knockout mice. White and brown Dindo IIIA and 3 (14%) Clavien-Dindo adipocytes tissues from these mice IIIB. Only three patients needed were analyzed by Electrospray surgical treatment, all of them with Ionization Mass Spectrometry (ESI- intestinal obstruction. There was no MS). Conditioned medium from these mortality. We have a low incidence of adipocytes were used to stimulate complications and hospital breast cancer cells 4T1. Breast cancer readmissions (3.5%) when we compare cells lipid droplet biogenesis was with another bariatric excellence analyzed by Bodipy or Oil Red staining centers. Only 0,5% of patients needed followed by flow cytometry or

351 Microscopy analysis, respectively. Breast cancer cells viability was Excessive weight regain after Roux-en- assessed by MTT assay. Our data Y gastric bypass (RGBP) is observed in showed that white adipocytes more than 20% of patients in long-term conditioned medium triggered follow-up. Its management is significant higher levels of lipid droplet challenging. Laparoscopic single biogenesis in breast cancer cells anastomosis modified duodenal-switch compared to brown adipocytes (LMDS) is a promising technique but stimulation or unstimulated cells. The its success demands skilled, highly secretion product of brown adipose experienced teams. We present a series tissue decreased the viability of tumor of patients who had a conversion to cells. ESI-MS data showed that both fat LMDS for weight regain after RGBP. tissues have distinct lipidic metabolites Between April 2016 and June 2017, and the absence of inflammasome four patients underwent LMDS 77 to components changed significantly the 174 months after an initial RGBP. All profile of these fat cells. Taken patients complained about 24kg to together, our data showed white and 33kg weight regain and severe labor brown adipocytes presented distinct dysfunction. Additional comorbidities lipidomic profile and the absence of were hip arthrosis, excessive vomiting. NLRP3 inflammasome components One of these patients had a previous may influence directly their lipidomic conversion from RGBP to open sleeve composition and their ability to activate gastrectomy because of severe breast cancer cells, suggesting an neuroglycopenia. One patient had a important mechanism that may be hiatal hernia repaired and a perigastric involved in their differential function in ring removed, while other patient carcinogenesis. Support: CNPq developed a postoperative fever which was managed with antibiotics. Hospital stay ranged from 24 to 48 hours. One A508 patient needed two endoscopic dilations Modified duodenal switch, a surgical of the gastro-gastric anastomosis 30 option for weight regain following and 45 days after the operation. BMI Roux-en-Y Gastric Bypass decreased from 36,7Kg/m – Carlos Madalosso Passo Fundo - RS 42,0Kg/m to 22,0Kg/m – 28Kg/m in BRAZIL 1, Alexandre Tognon 2, Fabio 10 to 24 months follow up. All patient Barão Passo Fundo 3, Kalil complained of occasional heartburn and Fontana Passo Fundo 1, Iran Moraes one patient is currently in on proton Jr 1, Daniel Navarini Passo Fundo NM4 pump inhibitor. Evacuatory frequency GASTROBESE CLINIC, varies from 1 to five episodes per day. HSVP1 HSVP2 University of Passo These presented cases show that LMDS Fundo - UPF3 Gastrobese Clinic, is feasible, with acceptable FMUPF, HSVP4 complications, minor side effects and

352 www.obesityweek.com important weight loss after one year white ethnicity, 95.2% female, 51.6±17 follow up. Further studies are needed to months of follow-up). Pre-surgery and support LMDS as a therapeutic option current BMI were 49±7.4 and 32.8±4.9 to treat weight regain after RGBP. kg/m2, respectively, with 68±16.6% excess body weight lost. Multivitamin supplementation was used in 86.7% and calcium tablets in 53%; 85.5% consumed dairy products. In the last A509 medical visit, 71% of patients were Secondary Hyperparathyroidism and taking vitamin D [23,000IU weekly

Hypovitaminosis D one year after (P25-7516,000–28,000)] and of them. post-bariatric surgery Mean 25(OH)D was 20.6±7.9 ng/ml at Luciana Verçoza Viana PORTO first and 25.6±7.9 ng/ml in the last ALEGRE 1, Luiza Sperb Porto Alegre 2 evaluation (P<0.01). SHPT was HCPA - UFRGS1 Medical Student - identified in 43.4% [PTH = 76.2 pg/dl 2 UFRGS (P25-75 55.1–93)]. An inverse correlation (P<0.05) was observed between BMD Introduction: Patients with obesity and PTH in lumbar spine (r=-0,375) submitted to bariatric procedures have and total hip (r=-0.243), but not with a high risk of secondary vitamin D. hyperparathyroidism (SHPT) (up to Conclusion: Vitamin D deficiency and 53%) and hypovitaminosis D (33 to SHPT were frequent after bariatric 96.7%). These morbidities could imply surgery, and BMD was inversely in future adverse bone conditions. The correlated to PTH. aim of this study was to evaluate vitamin D deficiency and SHPT in South Brazilian patients after one year of bariatric surgery (Y-en-Roux bypass A510 procedure). COMBINED SURGERY: Methods: In this retrospective cohort ABDOMINOPLASTY AND study (March 2016 to September 2017) ABDOMINAL SURGERY vitamin D deficiency was defined as LAPAROSCOPIC IN ONE serum 25(OH) vitamin D <20 ng/ml SURGICAL TIME AFTER and SHPT as PTH >68 pg/ml post- SLEEVE GASTRECTOMY surgery, in patients with normal serum Renato Roriz-Silva Porto Velho 1, creatinine and calcium. Bone mineral RAMON density (BMD) was estimated by DXA VILALLONGA BARCELIONA 2, - Lunar (g/cm2). Sergio Sánchez-Cordero Igualada 3, Results: From 151 patients who Bernard Cambier Barcelona 4 underwent bypass surgery, 83 were University of Rondonia and Universitat included (49.7±10.6 years, 12% non- Autónoma de Barcelon1 Hospital de

353 Barcelona,2 Hospital de these procedures, but avoids skin Barcelona3 Esthetische-chirurgie- incisions and can reduce the potential Belgium4 risks of multiple anesthesia for each procedure, shorten total hospital stay, INTRODUCTION surgical time, as well as, reduce costs The combined surgery of several and postoperative recovery. procedures in a surgical time, generally plastic surgery and general or gynecological interventions, can alter the morbidity of the patient and the A511 postoperative hospitalization when LAPAROSCOPIC SLEEVE compared with similar procedures GASTRECTOMY FOR THE carried out by separated. Nevertheless, TREATMENT OF PATIENTS in selected cases, we obtain benefits for WITH MASSIVE HERNIAS WITH the patient in terms of costs, reduction LOSS OF DOMAIN of postoperative stay and the inherent Renato Roriz-Silva Porto Velho 1, risk of two anesthetic interventions. We RAMON present two clinical cases of major VILALLONGA BARCELIONA 2, laparoscopic abdominal surgery Sergio Sánchez-Cordero Igualada 2 combined with plastic surgery after the University of Rondonia and Universitat first intervention of bariatric surgery. Autónoma de Barcelon1 Hospital de The first case is a male who after Barcelona2 having undergone a sleeve gastrectomy, a tummy tuck and breast INTRODUCTION liposuction was proposed, while a The repair of a complex abdominal cholecystectomy was performed hernia has an important morbimortality. laparoscopically. The second case is a We propose laparoscopic sleeve patient who underwent a first-time gastrectomy as the first step in the sleeve gastrectomy and then was treatment of hernias with loss of proposed to perform a hiatoplasty and domain in patients with morbid obesity. Hill intervention due to a diaphragmatic hernia combined with a CLINICAL CASE tummy tuck. The result of both This is a 56-year-old male patient with surgeries was satisfactory and the a history of diabetes mellitus and postoperative course of both patients arterial hypertension, with a BMI of 48 was uneventful, being both discharged kg / m 2 and a large incisional hernia from hospital on the third day. with a previous midline laparotomy. He CONCLUSION underwent a sleeve gastrectomy for The combination of two or multiple morbid obesity before the repair of the abdominal procedures requires careful incisional hernia. In this case, it was patient selection to safely combine proceeded with the placement of 5

354 www.obesityweek.com trocars in working position away from Marchini Ribeirao Preto, Brazil 2, the infraumbilical eventration and the Doroteia Souza São José do Rio Preto, creation of pneumoperitoneum with the SP 3, Carla Nonino Ribeirão Preto 2 Veress needle. We release the largest University of Sao Paulo - curvature of the stomach, from the USP1 University of São Paulo2 Sao Jose middle to the upper part with ultrasonic do Rio Preto Medical School3 bipolar. A minimal opening of the greater curvature is made in the Introduction: The exact mechanism for retrogastric space. All short vessels of increasing cardiovascular mortality the fundus are identified and exposed in (CVD) in obese individuals is not fully the vertical position, and their entire understood, however, a reduction in section is made to the left pillar. A 40-F heart rate variability (HRV) may be a tube is inserted into the pylorus and the potential pathway involved in sudden stomach is resected with a linear death. In addition, the expression of mechanical endostapler. An extra sixth genes involved in cardiovascular trocar was needed to make the first restoration may be altered in these stapling. The postoperative course was patients. However, both HRV and the uneventful. expression of these genes could be CONCLUSION remodeled following treatments for Laparoscopic vertical gastrectomy is a significant weight loss, such as bariatric safe procedure in obese patients before surgery. Methods: Thirteen women a major repair of an incisional hernia. with grade III obesity and 9 eutrophic The loss of body weight after surgery women were selected. Patients with may be an opportunity for the repair of obesity were evaluated before and after an incisional hernia with loss of 6 months of bariatric surgery and once dominance. in control group. Peripheral blood was collected for RNA extraction and analysis. The Polar RS800CX heart rate monitor was used to capture the RR A512 intervals of the electrocardiogram and Bariatric surgery causes genetic the Kubios HRV Premium software for cardiovascular remodeling and calculating the HRV variables. improvement in heart rate variability Statistical Analysis: We used the in women with grade III obesity Shapiro-Wilk, t-test or Mann-Whitney Marcela Pinhel Ribeirao Preto - Sao U tests and genomic software Paulo 1, Carolina Ferreira (GenomeStudio®). All tests were Nicoletti Ribeirão Preto 2, Natalia performed in the SPSS 17.0 program, a Noronha 2, Bruno Oliveira Ribeirão p value <0.05 was considered Preto 2, Cristiana Cortes- significant. Results: After six months Oliveira Ribeirão Preto 2, Wilson of bariatric surgery, there was a Salgado Junior Ribeirao Preto 2, Julio significant increase in HRV indices,

355 including: SDNN, RMSSD, pNN50, one of the most commonly performed LF, SD1, SD2 and Lmean (p <0.05). In surgery to treat obesity, reducing 75% addition, there was an increase in the of the excess weight loss in the first expression of genes (NFKB1, XIAP, year. BIRC2, BIRC3, MMP9, TIMP1, TIMP2, BAX and TGFB1 p <0.001) Objective involved with postoperative To evaluate the long-term results of cardiovascular remodeling pathway. weight loss and remission of Conclusions: Weight loss after bariatric hypertension in patients submitted to surgery improves HRV and positively RYGB after 10 years of surgery in a modulates genes involved in University Hospital in Rio de Janeiro. cardiovascular remodeling, which should be thoroughly investigated as Methods possible biomarkers for CVD. A retrospective review of patient’s data was completed in all patients undergoing RYGB between 2000 and A513 2007. ROC curve was constructed to Results of Bariaric Surgery on BMI evaluate weight loss 10 years after and Hypertension after 10 years of RYGB and Pearson coefficient follow up in Clementino Fraga Filho correlation was calculated to assess the University Hospital of Federal relationship between weight loss and University of Rio de Janeiro remission of hypertension. (HUCFF - UFRJ) Camila Oliveira Rio de Janeiro 1, Results André Ricardo Santos Rio de Janeiro 2, The complete data was collected in 34 Fernado Ponce Leon 1, Andre Luiz patients who underwent RYGB. Zacaron Rio de Janeiro 1, Antônio Patients had a mean age of 39.4 ± 10.4 Augusto Souza Rio de janeiro DE1 years and a mean baseline BMI of 49.7 Universidade Federal do Rio de ± 11.2 kg/m. There was a mean weight Janeiro1 Universidade Federal Rio de reduction of 41.9kg and a mean excess Janeiro2 weight loss of 60.3 ± 17.9%. The ROC curve compared base line weight with Introduction weight 10 years after surgery with an In Brazil, the prevalence of obesity area under the curve (AUC) = 0.89. have increased 60% in the las 10 years. The weight loss was associated with the Obesity is related to metabolic diseases remission of hypertension in 68% of such as type 2 diabetes, hypertension, patients. Pearson coefficient revealed cardiovascular disease and cancer. The strong positive correlation between bariatric surgery is the best treatment weight loss and remission of for obesity when medical therapy fails. hypertension (r=0.741, p<0.0001). Roux-en-Y Gastric Bypass (RYGB) is

356 www.obesityweek.com A514 final weight of 69.5 Case report: Loss greater than 30% Kg and BMI of 28, representing a wei of total bodyweight with the use of an ght loss of 40.5 kg or 36% of the intragastric balloon. total body weight. There was Eduardo Grecco Santo André 1, Manoel improvement in blood pressure and Galvão Neto Doral FL1, Thiago cholesterol levels Souza 1, Luiz Gustavo Quadros Sao The patient was asymptomatic during t jose do rio preto 2, Luana Baldim Santo he use of the André 1, Calisto Paschoa Filho São balloon and presented no complications Paulo 1 . Faculdade de medicina do ABC1 Universidade Federal de Discussion Pernambuco2 The intragastric balloon is an option for the treatment of obesity and reduces the ris Introduction ks and The primary endoscopic treatment for complications in comparison to patients obesity is indicated for patients with who have undergone bariatric surgery. overweight and mild obesity. The Although the reported case presented a intragastric balloon is the most used weight loss above the expected, the use endoscopic method due to its good of the intragastric balloon may be an result in this group of patients alternative treatment in morbidly obese associated with low morbidity and patients who refuse or have mortality. contraindication to the performance of There are different models of intragastr bariatric surgery. ic balloons with no significant differenc e in weight loss between them, with tot al mean body weight loss around 12- A515 18%. Changes in gene expression modify the resting metabolic rate in women Case report after bariatric surgery Patient VSS, 39 years old, female, with Bruno Oliveira Ribeirão Preto 1, a personal history of hypertension and Marcela Pinhel Ribeirao Preto - Sao dyslipidemia. Initial weight of 110 kg Paulo , Natália Noronha , Carolina and BMI (body mass index) of 43.7. Ferreira Nicoletti Ribeirão Preto , The Spatz model balloon was Cristiana Cortes-Oliveira Ribeirão implanted in april 2017, after refusal of Preto , Wilson Salgado Junior Ribeirao the patient to undergo a surgical Preto , Carla Nonino Ribeirão Preto procedure. University of São Paulo1 At the end of the 12- month treatment, the patient had a

357 Analysis of gene expression related to analysis (r2:0.971; p=0.02; energy metabolism and subsequent CI:901;1655). There was significant association with the resting metabolic weight loss, decreasement of BMI and rate (RMR) may elucidate the increasement in the expression of genes understanding of genetic factors that related to energy metabolism after of contribute to obesity. The aim of this surgical treatment. Understanding this study was to analyze the expression of pathway related to energy metabolism, genes related to energy metabolism and can lead us to develop in the future new associate it with the RMR in women treatments for obesity. with obesity before and after bariatric surgery. The sample consisted of 13 women before and after six months of A516 bariatric surgery. The nutritional status Aluminum and arsenic serum was performed using Body Mass Index concentration decreases after (BMI). The RMR was determined by bariatric surgery in obese women the measurement of the oxygen Natalia Yumi Noronha Ribeirão Preto - consumed (O2) and carbon dioxide SP 1, Bruno Affonso Parenti de produced (CO2) using the QUARK- Oliveira Ribeirão Preto 1, Marcela RMR equipment. The gene expression Augusta Pinhel Ribeirão Preto 1, analysis was performed in peripheral Carolina Ferreira Nicolleti Ribeirão blood by microarray methodology, Preto 1, Cristiana Cortes de BeadChip- Illumina™ and with Oliveira Ribeirão Preto 1, Vanessa subsequent validation by the Oliveira Souza 1, Juliana Kazumi quantitative Real Time PCR Saeki 1, Fernando Barbosa Junior 1, method. Data were analyzed by SPSS Carla Barbosa Nonino Ribeirão Preto 1 (p<0.05). Differences were observed in University of São Paulo1 weight (115.3±19.4 vs 85.3±13.8kg, p<0.01), BMI (42.5±7.0 Introduction: Obesity has been linked vs 31.8±5.4 kg/m2, p<0.01) and RMR to lifestyle and recently have been (2.052±267 vs 1.743±154 kcal, p<0.01) associated to environmental toxicants, after six months of bariatric surgery. it is widely accepted that these There was an increasement in the gene xenobiotics have a negative impact on expression of six targets related to human health and may contribute to the energy metabolism after bariatric development of diseases and its surgery, genes/fold change comorbidities. Metals exposure is a respectively, very concerning event, and in this (CTNNB1/5.42, LEP/2.96, PPP2CB/3.3 context, arsenic (As) is a metal that is 5, RAP1B/5.51, GNB4/2.96, MLX/2.19) commonly used in industry in .The association of genes with the combination with sulfur and other RMR after bariatric surgery, was metals. The contamination occurs confirmed by multiple regression mainly by the respiratory (particulate

358 www.obesityweek.com matter) and oral (grains, cereals, Are the size of the sleeve reservoir seafood, drinking water) routes. and anthropometric measurements Aluminum (Al) is also a metal that may associated with reflux esophagitis reach people through diet. This type of after laparoscopic sleeve gastrectomy contamination usually occurs due to (LSG) food packaging and utensils Carlos Madalosso Passo Fundo - RS composition, which may contaminate BRAZIL 1, Daniel Navarini Passo food during preparation and storage Fundo NM2, Guilherme processes. This study aimed to evaluate Mazzini Richmond 3, Fabio arsenic and aluminum serum Barão Passo Fundo 4, Gabriela concentration in obese women before Ambrós Passo Fundo 5, Richard and after bariatric surgery. Materials Gurski Porto Alegre 3 and Methods: This study enrolled GASTROBESE CLINIC1 UPF, obese women and anthropometric data Gastrobese clinic2 UFRGS3 UPF; such as weight (kg) and height (m) Gastrobese clinic4 HSVP5 were collected. As well as peripheral blood samples after 12 hours fasting for Background: Reflux esophagitis (RE) is biochemical analysis, serum related to LSG. It has been suggested concentration of metals was determined that a narrow sleeve may lead to by inductively coupled plasma mass RE. This cross-sectional study spectrometry (ICP-MS). Statistical addresses this issue. Methods: 18 analysis included the Shapiro-Wilk and consecutive patients were submitted to paired t test (p<0.05). Results: A total LSG and completed one-year of 16 subjects participated in the study: evaluation. LSG was calibrated with a 2 IMCbefore= 43.9±6.1 kg/m ; 32 F Bougie, and the staple line started 2 IMCafter=33.1±4.9 kg/m Age=37.±8.1 2cm proximally to the pylorus. Based years old. Serum concentration of Al on postoperative upper endoscopy, and As were different after the surgery patients were divided in Group 1: with (Before-As:13.8±0.9μg/L, After- RE grade B or C; and Group 2: with As:12.6±0.7ug/L, p=0.001; Before- RE Grade A or absent. Sleeve size and Al:77.7±65.5ug/L, After-Al hiatal hernia (HH) were evaluated ;34.1±11.9μg/L, p=0.021). Conclusion through 3D CT scan. Results: 16 : Serum concentration of toxic metals female, 38 ± 14 yo, 12 ± 0.7 months are different after bariatric surgery follow-up. RE occurred in 12 (67%) andthis might be a new perspective in patients as follows: 6 had no RE, 2 obesitytreatment. patients had grade A, 7 grade B and 3 grade C. Group 1 had an increased sleeve reservoir and larger HH at CT scan than Group 2 (215 ± 53.8 mm3 vs. A517 154 ± 40 mm3; P = 0.018) and (0.65 ± 0.9 cm vs. 1.8 ± 1.0 cm; P = 0.035)

359 respectively. Group 1 had a higher the questionnaire AUDIT, to identify abdominal circumference and BMI than problems related to alcohol abuse, 12 Group 2 (98 ± 8.6 cm vs. 86.9 ± 2 cm; years after surgery. P = 0.004). The present study shows Alcohol abuse was observed in 1 out of that a large sleeve reservoir at CT scan, the 46 patients assessed before surgery, as well as an increased central adiposity and was found in 21.7% (n=10) after associate to moderate or severe RE, at surgery through the AUDIT least as long as one year following questionnaire. BED before surgery was LSG. Prospective and long-term studies present in 52.17% (n=24) of patients, are needed to support these findings. and after 12 years in 39% (n=18). Patients with pre-surgery BED (n=24) that developed alcohol abuse was 16.7% (n=6;p=0.384). Among 10 A518 patients that developed alcohol abuse Association of Alcohol abuse and 12 years after surgery, 7 patients also Binge Eating Disorder Post Bariatric developed post-surgery BED or 70% Surgery and a significant association was found Cristina Freire São Paulo 1, Andréa Z between south disorders (p=0.024). Pereira S.Paulo 1, Adriano Segal 2, Our results have demonstrated a high Glaucia Carneiro 1, Maria Teresa prevalence of alcohol abuse long after Zanella São Paulo 1 surgery, and that the occurrence of pre- UNIFESP1 USP2 surgery BED is not a predictive factor for the development of alcohol abuse. Some studies have demonstrated an However, 12 years after surgery the increase in alcohol abuse after bariatric presence of BED has been associated surgery. The purpose of this study is to with the development of alcohol abuse. determine the prevalence of alcohol abuse in post-bariatric surgery, and test the hypothesis of an association between binge eating disorder before A519 bariatric surgery, and alcohol abuse Single Anastomosis Duodenal after-bariatric surgery. Switch: Effects on Weight Loss and Patients (n=46) submitted to bariatric Reduction of Weight Related surgery have gone through clinical and Comorbidities anthropometric assessment before and Rex Farrer Toledo OH1, Matthew after surgery. Additionally, they have Fourman Toledo OH1, Gregory answered the questionnaires of eating Johnston Toledo OH1, Brenda and weight patterns (QEWP-R) to Bal Toledo OH1 assess the binge eating disorder (BED) Mercy St. Vincent1 before and 12 years after bariatric surgery. They were also submitted to

360 www.obesityweek.com Introduction: Single Anastomosis Duodenal Switch (SADS) is a novel To date there have been no adverse bariatric procedure where a single loop complications. There have been no anastomosis is made between the first post-operative complications and there portion of the duodenum and the have been no vitamin or nutritional jejunum. Our study is an investigational deficiencies study to determine if SADS results in weight loss and reduction of associated Conclusion: The SADS is a new comorbidities compared with bariatric procedure that has the traditional bariatric procedures. We potential to have greater weight loss also compare the risks of nutritional and reduction of comorbidities than and vitamin deficiencies. current bariatric procedures with less Objectives: nutritional deficiencies and greater quality of life. 1. Describe short term weight loss within the first 12 months following a SADS. 2. Describe maintenance of weight loss following SADS at 12 and 60 months 3. Describe reduction following SADS for HTN, HLD, Type II A520 DM “Postoperative care of bariatric 4. Describe quality of life medical tourism: A public health concern” following SADS 1 5. Describe nutritional deficiencies LaRae Seemann Augusta GA , Jaine McKenzie Augusta GA1, Karen following SADS 1 Methodology: This is an ongoing Draper Augusta GA , L. Renee Hilton Augusta GA1 prospective, investigational study 1 following patients who have undergone Medical College of Georgia the SADS procedure. They are being followed at 3 month intervals until a Introduction: Despite considerable year when they will be followed with evidence supporting the efficacy of annual visits. bariatric surgery, poor insurance coverage in the United States restricts Results: The current results are for the access to the procedure, encouraging first 5 patients at the 3 month follow medical tourism. There is no long-term up. The median weight loss has been 69 postoperative (PO) care from foreign lbs. Of our first 5 subjects, none have health services for bariatric medical had DM, all have HLD and all have tourists (BMTs). Consequently, BMTs had HTN. become the responsibility of US physicians after bariatric surgery

361 abroad. We are using the experience of will continue long-term surveillance of a patient who returned from Mexico her case. with PO complications to illustrate Conclusion: When medical tourism for public health consequences of medical the purpose of bariatric procedures tourism. results in complications, US physicians Clinical Case: A 33-year-old female usually manage the long-term follow patient presented with acid reflux, up. Even when no complications occur, dysphagia, and vomiting 3 years after patients will need long-term bariatric undergoing vertical sleeve gastrectomy surveillance in the US. The in Mexico. Postoperatively, she had postoperative complications and required numerous surgeries and continued surveillance of BMTs should procedures to manage a sleeve leak. An be viewed comprehensively as a public upper GI obtained at our facility health concern. Providing adequate showed sleeve stricture and a hiatal insurance coverage for bariatric hernia. Endoscopy confirmed these procedures in the US will help alleviate findings. The patient required the negative outcomes of patients conversion to a Roux-en-Y Gastric seeking more affordable, but often Bypass (RYGB) to relieve obstruction. unsafe, procedures abroad without She recovered well thereafter with follow-up options. resolution of her symptoms. Our center

362 www.obesityweek.com

Financial Disclosures

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372 www.obesityweek.com

373 Author Index

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