Tarik K. Yuce

Background As the prevalence of class IV obesity (BMI ≥ 50) has continued to rise, the incidence of obesity-related gallstone disease and cholecystectomy in this population has also increased. Yet it remains unclear whether a robotic approach may offer selective benefits for these patients compared to traditional laparoscopic techniques. The objectives of this study are to (1) describe associations between obesity class and operative approach and (2) assess the impact of robotic approach and obesity class on perioperative outcomes. Methods The ACS-NSQIP database was queried from 2022 to 2023 to identify all laparoscopic and robotic cholecystectomies. Patients were stratified by obesity class. Associations between obesity class and operative approach were evaluated with multivariable logistic regression. Multivariable linear and logistic regression models examined associations between operative approach and obesity class with continuous and binary outcome measures, respectively. Sensitivity analysis was subsequently performed to adjust for postoperative biliary diagnosis. Results A total of 99,013 patients underwent minimally invasive cholecystectomy, with 11,951 (12%) cases performed robotically and 2403 (2.4%) with class IV obesity. Patients with class IV obesity were more likely to undergo robotic operations (21.0% vs not obese 11.0%, aOR 1.75, 95%CI 1.56–1.95). While the robotic approach was correlated with increased operative time (β = 9.6, 95%CI 8.8–10.0), it was associated with lower odds of perioperative complications compared to laparoscopic cases (2.5% vs 3.0%, aOR 0.88, 95%CI 0.77–0.99). When adjusted for postoperative diagnosis, the association between the robotic operative approach and lower perioperative complication rate was no longer statistically significant. Conclusions Patients with class IV obesity had increased odds of undergoing robotic cholecystectomy, and while the robotic approach did not improve operative time, it was associated with decreased odds of death or serious morbidity, although this association was likely due to differences in patient selection and case mix.

Objective: Evaluate associations between preoperative glucagon-like peptide-1 receptor agonist (GLP-1) use and postoperative weight loss after metabolic and bariatric surgery (MBS). Summary Background Data: Recent literature suggests reduced postoperative weight loss following preoperative GLP-1 use. However, these single center studies suffered from key design limitations. Methods: This retrospective cohort study utilized a statewide health information exchange enrolling adults undergoing MBS from 2020-2024. In the primary analysis, patients with ≥1 GLP-1 order in the 6 months preoperatively were compared with those with none. In a subgroup analysis of patients with type 2 diabetes, preoperative GLP-1 therapy was compared with non-GLP-1 antihyperglycemic therapy. Outcomes included BMI trajectory from 12 months pre- through 12 months postoperatively and percent total weight loss (%TWL) at 3, 6, 9, and 12 months. Associations were estimated using multivariable linear mixed-effects models. Results: Among 2,379 MBS patients, 193 (8.1%) had preoperative GLP-1 exposure. Adjusted BMI was higher for GLP-1 users 12 months pre-op (47.0 vs. 44.4 kg/m²; P P =0.81). Postoperative BMI and %TWL trajectories were similar through 12 months (GLP-1 users %TWL 20.7% vs. 22.0% nonusers, P =0.19). In the diabetes cohort (n=256; 149 GLP-1, 107 active comparators), trajectories were also similar (GLP-1%TWL 21.5% vs. 23.1% active comparators, P =0.39). Conclusions: Preoperative GLP-1 use was not associated with postoperative weight loss in a statewide, multi-system cohort, including in an active-comparator analysis among patients with type 2 diabetes. These findings suggest preoperative GLP-1 therapy is unlikely to compromise MBS weight loss outcomes.

Background The efficacy of Glucagon-Like Peptide-1 Receptor Agonists (GLP1RA) for the treatment of obesity has led to considerably increased demand for these medications. GLP1RA use prior to bariatric surgery may represent a novel approach to treating obesity. The objectives of this study were to (1) describe trends in pre-bariatric GLP1RA use, (2) investigate social and clinical factors associated with their use, and (3) evaluate differences in clinical outcomes based on preoperative GLP1RA use. Methods Patients who underwent bariatric surgery at three Indiana hospitals from 2018 to 2023 were identified. Patients who utilized GLP1RA in the year preceding surgery were compared to those who did not. Social factors included insurance, income, and unemployment. Outcomes included rates of GLP1RA use, 30-day postoperative readmissions, ED visits, and percent total weight lost (%TWL) at 1 year. Associations between preoperative GLP1RA use and outcomes of interest were evaluated using multivariable logistic and linear regressions. Results Of 2169 patients who underwent surgery, 293 (13.5%) utilized GLP1RA preoperatively. The rate of GLP1RA utilization increased threefold from 2018 to 2023. Males were more likely to receive preoperative GLP1RA (20.1% vs, 12.2%, p<0.001). There were no significant differences in social determinants of health or 30-day postoperative outcomes between patients who did and did not use GLP1RA preoperatively. Similarly, there were no significant differences in %TWL at 1 year postoperatively between groups (median 25.5% vs. 27.3%, coefficient, −0.78, 95%CI, −2.26 to 0.70). Conclusions Utilization of GLP1RA in the year prior to bariatric surgery has increased threefold. Preoperative GLP1RA use is not associated with worse 30-day outcomes or differences in %TWL at 1 year postoperatively. Further work is needed to evaluate whether GLP1RA dosing and duration of treatment impact postoperative outcomes.

Introduction Emergency department (ED) visits and readmissions following benign foregut surgery (BFS) represent a burden on patients and the health care system. The objective of this study was to identify differences in ED visits and readmissions before and after implementation of an early postoperative telehealth visit protocol for BFS. We hypothesized that utilization of telehealth visits would be associated with reduced post-operative ED and hospital utilization. Methods An early postoperative telehealth protocol was initiated in 2020 at an academic medical center to provide a video conference within the first postoperative week. Consecutive elective BFS including fundoplication, Linx, paraesophageal hernia repair, and Heller myotomy performed between 2018 and 2022 were included. Outcomes included ED visits and 30-day readmission. Bivariate analyses were performed using Chi-squared testing for categorical variables. The association between telehealth visits and outcomes were evaluated using multivariable logistic regression. Results 616 patients underwent BFS during the study period. 310 (50.3%) were performed prior to the implementation of telehealth visits and 306 (49.7%) were after. 241 patients in the telehealth visit group (78.8%) completed their telehealth visit. A total of 34 patients (5.5%) had ED visits without readmission while 38 patients (6.2%) were readmitted within the first 30 days. The most common cause of ED visits and readmissions included pain (n = 18, 25%) and nausea/vomiting (n = 12, 16%). There was a significant reduction in ED visits without admission following telehealth visit implementation (7.4% vs 3.6%; OR 2.20, 95% CI 1.04–4.65, p = 0.04). There was no difference in readmission rates (6.1% versus 6.5%; OR 0.89, 95% CI 0.46–1.73, p = 0.73). The telehealth cohort had significantly lower ED visits for pain (31% vs 16.7%, p = 0.04) and nausea/vomiting (23.8% vs 6.7%, p = 0.02). Discussion Early telehealth follow-up was associated with a significant decrease in ED visits following BFS. The majority of this was attributable to a reduction in ED visits for pain, nausea, and vomiting. These results provide a possible avenue for improving quality and cost-effectiveness within this patient population.

Quiz Ref ID Certificate of need laws provide state-level regulation of health system spending by restricting unnecessary expenditures on hospital or service-line expansion. Currently, 35 states and the District of Columbia maintain some form of certificate of need regulation. Although the policy was intended to curb health care expenditure, it was thought to improve quality and access to care by ensuring local need for services, preventing the proliferation of hospitals in wealthier areas, reducing overuse of services, and limiting high-risk procedures to high-volume hospitals.^1-5 With the recent encouragement of the Trump administration under executive order 13813,⁶ several states have renewed efforts to repeal their certificate of need regulations. Over the past 3 years, 12 states have introduced legislation to modify or repeal the regulation, with Florida repealing its law in 2019.⁷