Roux-en-Y gastric bypass (RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis (GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation (APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication.

A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA. Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel. Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later.

APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.

With the cumulative increase in the number of patients undergoing bariatric surgery, postoperative weight regain has become a considerable challenge. Mechanisms for weight regain are not fully understood and the process is likely multifactorial in many cases. Endoluminal revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective and less invasive management strategy for this population.

We critically review data from case series, retrospective and prospective studies, and meta-analyses pertaining to weight regain after gastric bypass. A variety of endoscopic revision approaches are reviewed, including technique details, procedural safety and efficacy, and post-procedure care.

Given the proliferation of endoluminal therapies with evidence showing safety and efficacy in the treatment of weight regain, it is likely that endoscopic revision will be the gold standard to treat weight regain in patients with gastric bypass.

The rapid development of technological tools to record data allows storage of enormous datasets, often termed "big data". In the USA, three large databases have been developed to store data regarding surgical outcomes: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). We aimed to evaluate the clinical impact of studies found in these databases concerning outcomes of bariatric surgery.

We performed a systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines. Research carried out using the PubMed database identified 362 papers. All outcomes related to bariatric surgery were analysed.

Fifty-four studies, published between 2005 and February 2017, were included. These articles were divided into (1) outcomes related to surgical techniques (12 articles), (2) morbidity and mortality (12), (3) 30-day hospital readmission (10), (4) outcomes related to specific diseases (11), (5) training (2) and (6) socio-economic and ethnic observations in bariatric surgery (7). Forty-two papers were based on data from ACS-NSQIP, nine on data from NIS and three on data from MBSAQIP.

This review provides an overview of surgical management and outcomes of bariatric surgery in the USA. Large databases offer useful complementary information that could be considered external validation when strong evidence-based medicine data are lacking. They also allow us to evaluate infrequent situations for which randomized control trials are not feasible and add specific information that can complement the quality of surgical knowledge.

Obesity has generated significant worries amongst health policy makers and has obtained increased attention in health care. Obesity is unanimously defined as a disease in the health care and health policy literature. However, there are pragmatic and not principled reasons for this. This warrants an analysis of obesity according to standard conceptions of disease in the literature of philosophy of medicine. According to theories and definitions of disease referring to (abnormal functioning of) internal processes, obesity is not a disease. Obesity undoubtedly can result in disease, making it a risk factor for disease, but not a disease per se. According to several social conceptions of disease, however, obesity clearly is a disease. Obesity can conflict with aesthetic, moral, or other social norms. Making obesity a "social disease" may very well be a wise health policy, assuring and improving population health, especially if we address the social determinants of obesity, such as the food supply and marketing system. However, applying biomedical solutions to social problems may also have severe side effects. It can result in medicalization and enhance stigmatization and discrimination of persons based on appearance or behavior. Approaching social problems with biomedical means may also serve commercial and professionals' interests more than the health and welfare of individuals; it may make quick fix medical solutions halt more sustainable structural solutions. This urges health insurers, health care professionals, and health policy makers to be cautious. Especially if we want to help and respect persons that we classify and treat as obese.

To evaluate the impact of health insurance expansion on racial disparities in severity of peripheral arterial disease.

Lack of insurance and non-white race are associated with increased severity, increased amputation rates, and decreased revascularization rates in patients with peripheral artery disease (PAD). Little is known about how expanded insurance coverage affects disparities in presentation with and management of PAD. The 2006 Massachusetts health reform expanded coverage to 98% of residents and provided the framework for the Affordable Care Act.

We conducted a retrospective cohort study of nonelderly, white and non-white patients admitted with PAD in Massachusetts (MA) and 4 control states. Risk-adjusted difference-in-differences models were used to evaluate changes in probability of presenting with severe disease. Multivariable linear regression models were used to evaluate disparities in disease severity before and after the 2006 health insurance expansion.

Before the 2006 MA insurance expansion, non-white patients in both MA and control states had a 12 to 13 percentage-point higher probability of presenting with severe disease (P < 0.001) than white patients. After the expansion, measured disparities in disease severity by patient race were no longer statistically significant in Massachusetts (+3.0 percentage-point difference, P = 0.385) whereas disparities persisted in control states (+10.0 percentage-point difference, P < 0.001). Overall, non-white patients in MA had an 11.2 percentage-point decreased probability of severe PAD (P = 0.042) relative to concurrent trends in control states.

The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe PAD and resolution of measured racial disparities in severe PAD in MA.

Studies are unclear regarding optimal intraoperative fluid management during laparoscopic bariatric surgery. The purpose of this 1-year study was to investigate the role of intraoperative fluid administration on hospital length of stay (hLOS) and postoperative complications in laparoscopic bariatric surgery.

Patient data analyzed included previously reported demographics, comorbidities, and intraoperative fluid administration on the duration of hLOS and incidence of postoperative complications.

Logistic regression analysis of demographic and comorbidity variables revealed that BMI (P = 0.0099) and history of anemia (P = 0.0084) were significantly associated with hLOS (C index statistic, 0.7). Lower rates of intraoperative fluid administration were significantly associated with longer hLOS (P = 0.0005). Recursive partitioning observed that patients who received <1,750 ml of intraoperative fluids resulted in longer hLOS when compared to patients who received ≥ 1,750 ml (LogWorth = 0.5). When intraoperative fluid administration rates were defined by current hydration guidelines for major abdominal surgery, restricted rates (<5 ml/kg/h) were associated with the highest incidence of extended hLOS (>1 postoperative day) at 54.1 % when compared to 22.9 % with standard rates (5-7 ml/kg/h) and were lowest at 14.5 % in patients receiving liberal rates (>7 ml/kg/h) (P < 0.0001). Finally, lower rates of intraoperative fluid administration were significantly associated with delayed wound healing (P = 0.03).

The amount of intravenous fluids administered during laparoscopic bariatric surgery plays a significant role on hLOS and on the incidence of delayed wound healing.

Analyze the effect of some measures on the costs of bariatric surgery, adopting as reference the remuneration of the procedure provided by the Unified Health System (SUS).

A retrospective evaluation conducted in the Costs Section of the University Hospital of Ribeirão Preto, of the costs involved in the perioperative period for patients submitted to bariatric surgery from 2004 to 2007. Changes in the routines and protocols of the service aiming at the reduction of these costs during the study period were also analyzed.

Nine patients in 2004 and seven in 2007 submitted to conventional vertical banded 'Roux-en-Y' gastric bypass were studied. All patients presented good postoperative evolution. The average cost with these patients was R$ 6,845.17 in 2004. Even though an effort was made to contain expenditures, the cost in 2007 was of R$ 7,525.64 because of the increase in the price of materials and medicines. The Government remuneration of the procedure in the two years was R$ 3,259.72.

Despite the adoption of diverse measures to reduce the expenditures of bariatric surgery, in fact there was an increase in the costs, a fact supporting the necessity of permanent evaluation of the financing of public health.

The cost of medication for the treatment of hypertension and diabetes in the morbidly obese is a significant economic healthcare burden. In the present study, we assessed the effect of gastric bypass surgery on the average annual costs for hypertension and diabetes medication.

A prospective database of gastric bypass patients at the Palo Alto Veterans Affairs Health Care System was reviewed. The preoperative and postoperative medication requirements to treat hypertension and diabetes were identified before surgery and at 1 year postoperatively. Comparisons were made between the annual costs of the antihypertensive and diabetic medications before and after bariatric surgery using the Student paired t test.

Of 106 patients who had undergone gastric bypass, 90 (85%) had either hypertension or diabetes. Of these 90 patients, 88 (98%) had hypertension and 60 (67%) had diabetes before surgery. Complete remission of hypertension occurred in 44% and remission of diabetes in 80% at 1 year after surgery. The annual cost of medications to treat hypertension was reduced by 65% at 1 year after surgery ($63.52 compared with $20.50, P < .0001). To treat diabetes, the annual medication cost was reduced by 88% at 1 year after gastric bypass surgery ($532.06 compared with $64.58, P < .0001). In the subset of patients with persistent hypertension or diabetes after surgery, the annual cost reduction for antihypertensive medications was 58% ($87.14 versus $36.82, P < .002). The annual cost reduction for diabetic medications was 69% ($1036.60 versus $322.90, P < .02).

Gastric bypass surgery resulted in a significant reduction in the cost of medications to treat hypertension and diabetes in the morbidly obese at 1 year after surgery. These cost savings were also significant in the subset of patients who had persistent hypertension and diabetes after surgery.

This paper is the first to conduct cost-effectiveness analyses of bariatric surgery comparing obese patients with obesity-related diseases to obese people without comorbidities across different BMI categories, using the meta-analysis results of surgery outcomes for our effectiveness inputs. We find that surgery treatment is in general cost-effective for people whose BMI is greater than 35 kg/m(2) with or without obesity-related comorbidities, and it is even cost-saving for super obese (BMI ≥ 50 kg/m(2)) with obesity-related comorbidities. Our results also suggest that surgery can be cost-effective for the mildly obese (BMI ≥ 30 kg/m(2)). The bottom line is that bariatric surgery should be universally available to all classes of obese people.

Morbidly obese individuals are major consumers of healthcare services, with high associated costs. Bariatric surgery is an alternative for improving these individuals' comorbidities. There are no studies comparing costs before and after bariatric surgery in Brazil. The aim here was to analyze results relating to healthcare usage and direct costs among morbidly obese patients undergoing bariatric surgery.

Historical cohort study on patients receiving healthcare through a private health plan in Belo Horizonte, Minas Gerais.

All healthcare services and their associated costs were included in the analysis: hospitalization, hospital stay, elective outpatient consultations, emergency service usage and examinations. The analyses were treated as total when including the whole years before and after surgery, or partial when excluding the three-month periods adjacent to the operation.

For 382 obese patients who underwent open bariatric operations, there were 53 hospitalizations one year before and 95 one year after surgery (P = 0.013). Gastrointestinal complications were the main indications for post-procedure hospitalizations. The partial average cost almost doubled after the operation (US$ 391.96 versus US$ 678.31). In subgroup analysis, the costs from patients with gastrointestinal complications were almost four times greater after bariatric surgery. Even in the subgroup without complications, the partial average cost remained significantly higher.

Although bariatric surgery is the only path towards sustained weight loss for morbidly obese patients, the direct costs over the first year after the procedure are greater. Further studies, with longer follow-up, might elucidate whether long-term reversal of this trend would occur.

Bariatric surgery is effective on short- and medium-term weight loss, reduction of comorbidities, and overall mortality. A large and increasing portion of the population is eligible for bariatric surgery, which increases instant health care costs. A review of the literature identifies a series of ethical challenges: unjust distribution of bariatric surgery, autonomy and informed consent, classification of obesity and selecting assessment endpoints, prejudice among health professionals, intervention in people's life-world, and medicalization of appearance. Bariatric surgery is particularly interesting because it uses surgical methods to modify healthy organs, is not curative, but offers symptoms relief for a condition that it is considered to result from lack of self-control and is subject to significant prejudice. Taking the reviewed ethical issues into account is important when meeting persons eligible for bariatric surgery, as well as in the assessment of and decision making on surgery for obesity.

Interventional therapy for weight regain after gastric bypass surgery has been tempered by higher complications associated with revisional surgery. Endolumenal reduction of post-bypass stomal and pouch dilatation offers the promise of a safer approach. Questions still remain regarding safety and efficacy with these procedures. We report intra- and postoperative results to date utilizing an endolumenal suturing platform for this patient subset.

Patients who had regained significant weight 2+ years after Roux-en-Y gastric bypass (RYGB) after losing ≥ 50% of excess body weight (EBW) post RYGB underwent endolumenal stomal and pouch reduction if they endoscopically displayed post-bypass stomal and/or pouch dilatation. The platform was utilized to endolumenally reduce stoma size by creating circumferential folds with a tissue anchoring system. Anchors were also utilized to approximate gastric pouch tissue. Information regarding patient baseline status and data on procedural safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date with use of this system.

In 20/21 subjects we were able to successfully place anchors (one patient had occult G-G fistula which impaired visualization). Weight regain post RYGB averaged 59 lbs (N = 20). Stomal diameter was reduced on average by 53%, with pouch reduction averaging 41%. The number of anchors placed on average per case was 5.3. Operating room (OR) time averaged 91 min. There were no significant complications. Three- and 12-month esophagogastroduodenoscopy (EGD) results revealed preservation of most of the intraoperative stoma and pouch reduction, and presence of fibrotic tissue folds with continued presence of anchors at their original locations. Mean percentage excess weight loss (%EWL) at 6 months was 18% to date (N = 18). Mean weight loss at 6 months was 17.3 ± 15 lbs.

Clinical study of this endolumenal tissue approximation system has shown intraoperative safety and efficacy in reducing stoma and pouch dilatation post RYGB. Follow-up anchor durability to date is encouraging. Continuing weight loss is being tracked through ongoing endoscopic and clinical follow-up.

The objective of this study was to use nationally representative data to compare outcomes of open gastric bypass (OGB) versus laparoscopic gastric bypass (LGB) surgery.

The number of bariatric procedures continues to grow. Increasingly, these surgeries are being performed laparoscopically. However, few population-based studies have examined differences in outcomes between LGB and OGB surgeries. Population-based studies can provide further insight into differences in outcomes between open and laparoscopic bariatric procedures.

Using the Nationwide Inpatient Sample, we identified adults undergoing LGB or OGB surgery during 2005 (n = 19,156). Following preliminary descriptive statistics, multiple logistic and linear regressions were used to obtain risk-adjusted outcomes, including postoperative in-hospital complications, reoperation, length of stay, and total charges.

The majority of patients in the study sample (74.5%) underwent laparoscopic bypass surgery in 2005. After adjusting for patient and hospital level factors, patients undergoing OGB surgery were more likely to experience reoperation as well as the following complications: pulmonary (odds ratio [OR] = 1.92 (1.54-2.38), P < 0.001); cardiovascular (OR = 1.54 [1.07-2.23], P = 0.02); procedural (OR = 1.29 [1.06-1.57], P < 0.01); sepsis (OR = 2.18 [1.50-3.16], P < 0.001); and anastomotic leak (OR = 1.32 [1.02-1.71], P = 0.03). After risk adjustment, LGB was associated with a shorter length of stay but higher total charges.

Overall, LGB patients are less likely to experience reoperation and postoperative complications in the hospital and have a shorter length of stay but incur higher total charges than OGB patients.

Given Medicare's recent national coverage decision on bariatric surgery, as well as potential coverage expansions for other obesity-related treatments, data on obesity in the Medicare population have great relevance. Using nationally representative data, we estimate that between 1997 and 2002, the prevalence of obesity in the Medicare population increased by 5.6 percentage points, or about 2.7 million beneficiaries. By 2002, 21.4 percent of aged beneficiaries and 39.3 percent of disabled beneficiaries were obese, compared with 16.4 percent and 32.5 percent, respectively, in 1997. Using 2002 data, we estimate that three million beneficiaries would be eligible for bariatric surgery coverage under current Medicare policy.

The aims of this study was to determine whether an active policy of cost curtailment would impact on the theater cost of laparoscopic surgery in a pediatric setting; to document the extent of cost changes over time and to identify factors that adversely influence expenditure; and to investigate whether the surgeon is a significant factor in the price of the procedure.

A prospective audit of laparoscopic procedures was performed in a single unit over a 36-month period. Detailed costs of theater inventory for all procedures were compiled on a case-by-case basis and recorded on a database. The cost of six index procedures were collated and changes over the period of the study analyzed. The factors responsible for increased expenditure were flagged and appraised to enable the implementation of cost-saving measures. The prices of the laparoscopic equipment were based on invoiced figures provided by hospital managers, and no long-term outcome measures were taken into account.

A total of 179 cases were performed by six surgeons over a 3-year period between January 1, 2003 and December 31, 2005, with no adverse intraoperative events. The procedures studied in further detail were appendicectomy (n = 50), fundoplication (n = 25), cholecystectomy (n = 12), nephrectomy (n = 10), Fowler Stevens for undescended testes (n = 10), and modified Palomo operations for varicocoele (n = 7). The mean cost of these procedures fell year by year over the period of study but was significant only in appendicectomy (P = 0.017). For this procedure, there was a significant difference in costs between the various surgeons (P = 0.007), but this trend was not noted with the other procedures. There were no major intraoperative events, although 2 patients required conversion owing to technical difficulties posed by the cases. Among the factors that influenced costs were the use of disposables, particularly for hemostasis and suctioning, and an inability to procure reuseable instruments.

The costs of commonly performed laparoscopic procedures are falling year by year. The surgeon is a factor in the costs of some procedures. A cost-saving strategy has not been compromised of patient safety; however, some cost-saving measures, though attractive, are labor intensive and are not practical. An overall commitment to the sensible use of health care resources translates into savings for hospitals, thereby strengthening the case for laparoscopic surgery.

Rational decision-making regarding health care spending for weight management requires an understanding of the cost of care provided to obese patients and the potential cost-effectiveness or cost savings of interventions. The purpose of this review is to assist health plans and disease management leaders in making informed decisions for weight management services. Among the review's findings, obesity and severe obesity are strongly and consistently associated with increased health care costs. The cost-effectiveness of obesity-related interventions is highly dependent on the risk status of the treated population, as well as the length, cost, and effectiveness of the intervention. Bariatric surgery offers high initial costs and uncertain long-term cost savings. From the perspective of a payor, obesity management services are as cost-effective as other commonly offered health services, though not likely to offer cost savings. Behavioral health promotion interventions in the worksite setting provide cost savings from the employer's perspective, if decreased rates of absenteeism are included in the analysis.

Obesity constitutes a major health problem with serious social and economic consequences worldwide. In North America, nearly one third of the population is obese, and this figure includes children and adolescents who are likely to become obese adults. Obesity carries a great financial impact on society; consequently, treating morbidly obese patients with surgery may offer substantial economic savings. This article summarizes the financial burdens of obesity and the economics of treating obesity in North America. It addresses the medical effectiveness and cost-effectiveness of bariatric surgery and the new regulations and accreditations for bariatric surgery programs.

With the increasing number of bariatric surgical procedures being performed, outcome assessment is of even greater importance. Few randomized, controlled prospective trials have compared bariatric surgery to nonsurgical weight-loss treatments, and the quality of current outcome data is suboptimal. However, the available evidence suggests that bariatric surgery, and particularly gastric bypass, is the most effective weight-loss treatment for people with extreme (class III) obesity. In addition to reduced energy intake and to a lesser extent malabsorption, numerous other potential mechanisms related to bariatric surgery may play a role in promoting weight loss and improving comorbidities. After bariatric surgery, clinical improvement or resolution has been reported in 64% to 100% of patients with diabetes mellitus, 62% to 69% of patients with hypertension, 85% of patients with obstructive sleep apnea, 60% to 100% of patients with dyslipidemia, and up to 90% of patients with nonalcoholic fatty liver disease. A wide range of other weight-related conditions also appear to improve, and limited data suggest that overall mortality may decrease in patients undergoing bariatric surgery. Although not conclusive, evidence from available studies indicates that bariatric surgery is cost-effective. Further research with improved methodology is needed to define the mechanisms of action of bariatric surgery; to document its effect on long-term weight loss, comorbid conditions, and overall mortality; and to determine its cost-effectiveness.

The incidence of children in the United States who are overweight or obese is increasing at an alarming rate, and many obesity-related complications are now being described in children. There appears to be no current pharmacologic treatment or surgical procedure that is both safe and effective for millions of obese children. Bariatric surgery may be useful, however, in carefully selected obese children with associated serious comorbidities unresponsive to medical or dietary interventions. The complications of pediatric obesity are discussed, as well as current medical and surgical management of this disorder.