Dr. John Morton is Chief of Bariatric and Minimally Invasive Surgery, Clinic Chief for the Bariatric and Metabolic Inter-Disciplinary Clinic, and heads the Bariatric and Minimally Invasive Surgery Fellowship. Dr. Morton received BS, MPH, and MD Degrees from Tulane University and a Masters in Health Administration from University of Washington. He was the first surgical resident to receive a Robert Wood Johnson Clinical Scholar Fellowship in the program’s history at University of Washington and also completed an advanced laparoscopic fellowship at University of North Carolina, Chapel Hill. He served on Capitol Hill as Senator Bill Frist’s Health Policy Intern. He is a Diplomate of both the American Board of Surgery and American Board of Obesity Medicine and certified in Medical Quality by the American College of Medical Quality.
He has published over 140 articles and 18 book chapters with over 300 national and international presentations. His research has focused on quality improvement and bariatric surgery. He led 5 site FDA Pivotal Trials and has received funding from NIH and Gordon and Betty Moore Foundation. He serves as editor of four books and on 11 editorial boards. His research efforts have been recognized by 26 research awards from 5 different surgical societies including the Society for Advanced Gastrointestinal Endoscopic Surgeons (SAGES) Golden Laparoscope Award as 2008 Young Investigator of the Year. As a teacher, Dr. Morton has received five teaching awards at Stanford University in 8 years including the 2008 Arthur Bloomfield Clinical Teacher of the Year and 2011 Henry J. Kaiser Teaching Award.
As Director of Surgical Quality at Stanford University Medical Center from 2007-2013, Dr. Morton led efforts to improve the Department of Surgery’s University Health Consortium’s annual ranking from 24/98 to 1/98 and their Annual NSQIP mortality ranking from Average to Exemplary. He has been an invited speaker on surgical quality by the American College of Surgeons, Agency for Healthcare Research and Quality, National Patient Safety Foundation, and American Society for Metabolic and Bariatric Surgery and served on the National Quality Forum’s Surgical and GI/GU Steering Committees. Currently, he is the national Chair of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), a collaboration for 800 hospitals between the American Society of Metabolic and Bariatric Surgery and the American College of Surgeons. From 2014-16, the Stanford Bariatric Surgery program was noted to be Exemplary in five different categories by MBSAQIP.
From 2014-5, he served as elected President of the American Society of Metabolic and Bariatric Surgery composed of over 4000 members from 52 countries. With over 2000 bariatric surgeries performed, he has been recognized as a bariatric surgery leader by Agency for Healthcare Research and Quality, RAND, American College of Surgeons, Who’s Who and America’s Top Surgeons. His clinical skills have resulted in being named Castle Connolly’s Physician of the Year for Clinical Excellence in 2012. Dr. Morton also founded the first obesity related Political Action Committee, Obesity PAC on behalf of the American Society for Metabolic and Bariatric Surgery and Chair of the National Obesity Collaborative Care Summit for 35 Different Medical Societies. He was selected as Chair for Obesity Week 2018, which is the largest worldwide meeting devoted to obesity. Dr. Morton has been featured on the Today Show, Good Morning America, NY Times, National Public Radio, CNN, Fox, MSNBC, BBC, Newsweek, Time, Medscape, Washington Post, LA Times, San Francisco Chronicle, USA Today, International Herald Tribune, Reuters, United Press International, Wall Street Journal, and Associated Press.

Clinical Focus

  • Bariatric Surgery
  • Surgical Procedures, Minimally Invasive
  • Gastric Bypass
  • gastric banding
  • sleeve gastrectomy
  • General Surgery
  • Gastrointestinal Surgical Procedure
  • GERD
  • Esophageal Achalasia
  • Paraesophageal Hiatal Hernia
  • Hernia, Abdominal
  • Splenectomy
  • Cholecystectomy, Laparoscopic
  • natural orifice surgery
  • nissen fundoplication

Academic Appointments

Administrative Appointments

  • Medical Advisor, Centers of Excellence for Bariatric Surgery, California Blue Shield (2004 - Present)
  • Member, Program, Research Committee, American Society of Bariatric Surgery (2004 - Present)
  • Chairman, Outcomes Committee, SAGES (2004 - Present)
  • Expert Reviewer for Bariatric Surgery(only two MDs Chosen), California Medical Board (2006 - Present)
  • Surgery Sub-Internship Director, Stanford School of Medicine (2003 - 2007)
  • Minimally Invasive Surgery Fellowship Director, Stanford School of Medicine (2004 - Present)
  • Associate Editor, Obesity Surgery (2007 - Present)
  • Associate Editor, Surgery for Obesity and Related Diseases, SOARD Journal for ASBS (2005 - Present)
  • Director, Surgical Quality, Stanford University Medical Center (2007 - 2013)
  • Director, (SCORE) Stanford Center for Outcomes Research and Evaluation (2007 - Present)
  • Section Chief, Minimally Invasive Surgery, Stanford School of Medicine (2009 - Present)
  • Elected Faculty Senator at Large, Stanford Faculty Senate (2009 - Present)
  • Editorial Board, World Journal of Gastroenterology (2009 - Present)
  • Co-Director, Digestive Health Center (2009 - Present)
  • Associate, NIH Digestive Disease Center (2009 - Present)
  • Chairman, Access to Care, ASMBS (2010 - Present)
  • Publications Board, The Obesity Society (2010 - Present)
  • Member, International Nutrition Council (2011 - Present)
  • Editorial Board, Journal of Surgical Case Reports (2011 - Present)
  • Advisory Board Member, American College of Surgeons Bariatric Surgery Network (2011 - Present)
  • Executive Council, American Society of Metabolic and Bariatric Surgery (2011 - Present)
  • Editorial Board, Bariatric Times (2011 - Present)
  • Editorial Board, Cureus (2012 - Present)
  • Member, GI/GU Steering Committee, National Quality Forum (2012 - Present)
  • National Secretary-Treasurer, American Society of Metabolic and Bariatric Surgery (2012 - 2014)
  • Chair, National Committee on Metabolic and Bariatric Surgery, American Society of Metabolic and Bariatric Surgery and American College of Surgeons (2013 - 2015)
  • President, American Society for Metabolic and Bariatric Surgeons (2014 - 2016)

Honors & Awards

  • Expert Panel on Bariatric Surgery Quality Indicators, RAND (May 2004)
  • Excellence in Teaching, Stanford School of Medicine (2005)
  • Ronald H.Fegelman Memorial Lecturer, Jewish Hospital, Cincinnati, OH (2006)
  • Best Poster Award (170 posters presented), International Federation of Surgery for Obesity, Sydney, Australia (2006)
  • Poster of Distinction, SAGES, Las Vegas, NV (2006)
  • Gastric Bypass and Cardiac Risk Factors: Is the Way to Heart Through the Stomach?, Inaugural Conference on Obesity Diabetes and Hypertension, Berlin, Germany (2006)
  • Expert Panel on Birth Outcomes after Bariatric Surgery, RAND (2007)
  • Best Fellow Presentation, SAGES, Las Vegas, NV (2007)
  • Visiting Professor, Henry Ford Hospitals (2007)
  • Young Investigator of the Year, SAGES (2008)
  • Visiting Professor, Vanderbilt (2008)
  • Arthur L. Bloomfield Award for Excellence in the Teaching of Clinical Medicine, Stanford University School of Medicine (2008)
  • Best Student Research Poster, Stanford University School of Medicine (2008)
  • President-Elect, California Chapter of the American Society of Bariatric and Metabolic Surgeons (2008)
  • Magisterial Address, 2009 Annual Meeting, Asociación Mexicana de Cirugía General y el Colegio Americano de Cirujanos (2009)
  • Expert Panel on Bariatric Surgery for BMI< 35, RAND (2009)
  • Best Student Poster, Stanford School of Medicine Research Symposium (2009)
  • Excellence in Teaching, Stanford School of Medicine (2009)
  • Ethan Sims Young Investigator Finalist Award, Obesity Society (2009)
  • Invited Address, The Role of the Surgical Champion, NSQIP, American College of Surgeons (2009)
  • Invited Address, Utilizing Patient Safety Indicators in Quality Improvement, Agency for Healthcare Research and Quality (2009)
  • Outstanding Abstract, Improvement in Adolescent Cardiac Risk Factors after Gastric Bypass, International Federation of Surgery for Obesity (August 2009)
  • Invited Address, Weighing in on Improving Bariatric Surgery, UK Bariatric Surgery Annual Meeting, Chichester, England (2009)
  • America's Top Doctors, Castle Connolly (2009)
  • Chair, NSQIP Surgical Champions Forum, American College of Surgeons (2009)
  • Invited Address, Implementing Surgical Quality Innovation at the Bedside, American College for Medical Quality (2010)
  • Metric Magic: Creating Synergy between Indicators, Priorities and Mandates, National Patient safety Foundation (2010)
  • Elected Member, Society for University Surgeons (2010)
  • Excellence in Teaching, Stanford School of Medicine Student Body (2010)
  • Invited Address, Bariatric Surgery: Which Procedure Do You Recommend, The Obesity Society (2010)
  • Invited Address, NSQIP Town Hall, American College of Surgeons (2010)
  • ACS Delegate, Surgical Steering Committee, National Quality Forum (2011)
  • Invited Address, Translating Data into Results, Florida Surgical Care Initiative (Feb 2011)
  • Keynote Address, 2011 Annual Meeting of the Taiwan Surgical Association (2011)
  • Invited Address, Drugs, Behavior or Surgery: Place Your Bets…”, The Obesity Society (2011)
  • ACS Delegate, Consensus Standards Approval Committee, National Quality Forum (2011)
  • Advisory Panel, Campaign for Effective Patient Care (2011)
  • Henry J. Kaiser Clinical Teaching Award, Stanford University School of Medicine (2011)
  • Healthcare-Associated Infection Expert Panel, Agency for Healthcare Research and Quality (2011)
  • America's Top Doctors, Castle Connolly (2011)
  • America's Top Doctors, Castle Connolly (2012)
  • Excellence in Teaching, Stanford School of Medicine (2012)
  • National Physician of the Year for Clinical Excellence, Castle Connolly Top Doctors (2012)
  • Expert Panel, Citizens Panel of Community Forum Project, AHRQ (2012)
  • Poster of Distinction: National Bariatric Surgery Outcomes for Age>65: BOLD Database, ASMBS (2012)
  • Top 5 Poster: Are There Differences in Outcomes Based On Insurance Status, ASMBS (2012)
  • Top 5 Paper: National Comparisions of Bariatric Surgery Outcomes: FIndings from the BOLD Database, ASMBS (2012)
  • Appointed Secretary-Treasurer and Elected Executive Council, ASMBS (2012)
  • America's Top Doctors, Castle-Connolly (2013)
  • GI Advisory Board, United HealthCare (2013)
  • Poster of Distinction, Digestive Diseases Week (2013)
  • Poster of Distinction, American Society of Metabolic and Bariatric Surgery/Obesity Week (2013)
  • President-Elect, American Society of Metabolic and Bariatric Surgery (2013)

Professional Education

  • Board Certification: Obesity Medicine, American Board of Obesity Medicine (2013)
  • Residency:Tulane Medical Center (1999) LA
  • Internship:Tulane Medical Center (1994) LA
  • Fellowship:University of North Carolina (2003) NC
  • Board Certification: General Surgery, American Board of Surgery (2002)
  • Residency:Swedish Medical Center on Broadway (2001) WA
  • Medical Education:Tulane University School of Medicine (1993) LA
  • MD, Tulane (1993)
  • MPH, Tulane (1993)
  • MHA, University of Washington (1997)

Research & Scholarship

Current Research and Scholarly Interests

Bariatric Surgery
Morbid obesity represents the second leading cause of preventable death in the US, scheduled to surpass tobacco as the leading cause of preventable death due to obesity’s epidemic rate of growth. Despite this clear and present danger to the nation’s health, only bariatric surgery extends hope to the morbidly obese. Laparoscopy, as in previous clinical iterations, has widened the potential pool of patients seeking surgical management of disease. Accompanying this increase in procedures should be a concurrent rise in bariatric research. Morbid obesity represents for me a compelling juncture of my laparoscopic, public health, and outcomes training that I hope to employ in examining the following questions.

Evidence-Based Surgery
The clinical science of surgery has made spectacular gains in the past century and the new century will no doubt see more advances perhaps with the aid of evidence-based medicine. Surgery has been a recent convert to the philosophy of evidence- based medicine. Surgery results have often been in the form of case series or expert opinion, which are ranked lowly in evidence grading. Given market changes and the consumer revolution reaching medicine, the ability to perform physician-oriented research will be limited. The powerful statistical and epidemiological tools that evidence- based medicine employs can help answer questions that may have no other recourse. Surgery, unlike other clinical sciences, does not lend itself to randomization. Patients, particularly in the laparoscopic experience, will demand only one arm of any randomized study. As a result, widespread dissemination of technology may take place prior to any assessment of the technology. Given these circumstances, well-designed observational studies are often the best approach. In addition, population-based studies provide a “real-world” assessment of clinical practices and avoid any study bias by examining the entire population of interest. In this manner, surgeons can provide evidence for their patients, colleagues, and payers. Evidence-based surgery can provide the ability to assess technology, improve quality of care, and maintain patient safety as noted in the below research questions.

Surgical Education
There has been much discussion regarding quality in medicine and reducing medical error. Concern regarding patient safety in teaching hospitals has focused on resident work hours, particularly call nights. A potential for system improvement lies within our surgical educational system. Given impending constraints on resident work hours, it is important to optimize teaching opportunities. Further argument for improvement of our educational system lies in part with recent unfilled surgery match positions. Resident surgeons are changing in their demographics and life experiences requiring a change in century-old Halsteadian techniques and more emphasis on adult learning. This emphasis on adult learning has further import on continued education for more experienced surgeons, critically important in the setting of new technology and emphasis on competence.

Clinical Trials

  • An Investigation of the EndoStim® Lower Esophageal Sphincter (LES) Stimulation System for the Treatment of Reflux Recruiting

    The purpose of this investigation is to demonstrate the safety and effectiveness of Lower Esophageal Sphincter (LES) Stimulation System in treating gastroesophageal reflux disease (GERD). This investigation is a multicenter, randomized, double-blind, sham-controlled study. After the implant procedure, subjects will be randomized to either the Treatment Group (immediate stimulation) or Control Group (delayed stimulation) for six months followed by an additional open-label phase in which all subjects will receive electrical stimulation. Subjects continue on stimulation treatment in an extended open-label follow-up phase through 5 years post-stimulation.

    View full details

  • EMPOWER Clinical Trial: Vagal Blocking for Obesity Control Not Recruiting

    This is a randomized multi-center study being done to measure the ability of a new medical device, Maestro System, to safely reduce body weight over five years in people who are considered obese.

    Stanford is currently not accepting patients for this trial. For more information, please contact Marilyn Florero, (866) 356 - 3506.

    View full details

  • Surgical Weight-Loss to Improve Functional Status Trajectories Following Total Knee Arthroplasty (SWIFT Trial) Recruiting

    The purpose of the SWIFT Trial is to answer two research questions. 1. Does bariatric surgery before total knee arthroplasty (TKA) improve both perioperative and long-term outcomes of TKA in extreme obesity? 2. Does bariatric surgery before TKA delay or possibly negate the need for arthroplasty?

    View full details

  • Safety and Efficacy of EndoBarrier in Subjects With Type 2 Diabetes Who Are Obese Recruiting

    To determine if the EndoBarrier safely and effectively improves glycemic control in obese subjects with type 2 diabetes

    View full details


2017-18 Courses

Stanford Advisees

Graduate and Fellowship Programs


All Publications

  • Halo Effect for Bariatric Surgery Collateral Weight Loss in Patients' Family Members ARCHIVES OF SURGERY Woodard, G. A., Encarnacion, B., Peraza, J., Hernandez-Boussard, T., Morton, J. 2011; 146 (10): 1185-1190


    Bariatric surgery is an effective treatment for morbid obesity, which is increasingly recognized as a familial disease. Healthy behavior transmission may be enhanced by family relationships.To determine changes in weight and healthy behavior in patients who underwent Roux-en-Y gastric bypass surgery and their family members.Prospective, longitudinal, and multidimensional health assessment before and 1 year after index Roux-en-Y gastric bypass surgery.An academic bariatric center of excellence, from January 1, 2007, through December 31, 2009.Eighty-five participants (35 patients, 35 adult family members, and 15 children <18 years old).Roux-en-Y gastric bypass surgery and associated dietary and lifestyle counseling.Weight and expected body mass index (calculated as weight in kilograms divided by height in meters squared). Secondary outcomes were waist circumference, quality of life (36-Item Short Form or Pediatric Quality of Life Inventory), healthy behaviors, eating behaviors, and activity levels.Participants were grouped by relationship to patient for analysis with paired 2-sample t tests. Before the operation, 60% of adult family members and 73% of children of patients undergoing Roux-en-Y gastric bypass surgery were obese. At 12 months after the operation, significant weight loss was observed in obese adult family members (from 234 to 226 lb; P = .01). There was a trend for obese children to have a lower body mass index than expected for their growth curve (31.2 expected vs 29.6 observed; P = .07). Family members increased their daily activity levels (adults, from 8 to 17 metabolic equivalent task-hours, P = .005; and children, from 13 to 22, P = .04). Adult family members also had improved eating habits with less uncontrollable eating (from 35 to 28; P = .01), emotional eating (from 36 to 28; P = .04), and alcohol consumption (from 11 drinks per month to 1 drink per month; P = .009).Gastric bypass surgery may render an additional benefit of weight loss and improved healthy behavior for bariatric patients' family members.

    View details for Web of Science ID 000295942300018

    View details for PubMedID 22006878

  • Quality of Life After Bariatric Surgery. Current obesity reports Mazer, L. M., Azagury, D. E., Morton, J. M. 2017; 6 (2): 204-210


    The purpose of this review is to provide an introduction to quality of life (QOL) outcomes after bariatric surgery and a summary of the current evidence.QOL has been emphasized in bariatric surgery since the NIH Consensus Conference statement in 1991. Initial studies were limited to 1- and 2-year follow-up. More recent findings have expanded the follow-up period up to 12 years, providing a better description of the impact on long-term QOL. Overall, there is little to no consensus regarding the definition of QOL or the ideal survey. Bariatric surgery has the greatest impact on physical QOL, and the impact on mental health remains unclear. There are some specific and less frequently reported threats to quality of life after bariatric surgery that are also discussed. Obesity has a definite impact on quality of life, even without other comorbidities, and surgery for obesity results in significant and lasting improvements in patient-reported quality of life outcomes. This conclusion is limited by a wide variety of survey instruments and absence of consensus on the definition of QOL after bariatric surgery.

    View details for DOI 10.1007/s13679-017-0266-7

    View details for PubMedID 28527103

  • Mammography before and after bariatric surgery SURGERY FOR OBESITY AND RELATED DISEASES Mokhtari, T. E., Rosas, U. S., Downey, J. R., Miyake, K. K., Ikeda, D. M., Morton, J. M. 2017; 13 (3): 451-456
  • Constructing a competency-based bariatric surgery fellowship training curriculum SURGERY FOR OBESITY AND RELATED DISEASES McBride, C. L., Rosenthal, R. J., Brethauer, S., DeMaria, E., Kelly, J. J., Morton, J. M., Lo Menzo, E., Moore, R., Pomp, A., Nguyen, N. T. 2017; 13 (3): 437-441
  • Assessing national provision of care: variability in bariatric clinical care pathways SURGERY FOR OBESITY AND RELATED DISEASES Telem, D. A., Majid, S. F., Powers, K., DeMaria, E., Morton, J., Jones, D. B. 2017; 13 (2): 281-284


    The American Society for Metabolic and Bariatric Surgery (ASMBS) Quality Improvement and Patient Safety (QIPS) Committee hypothesized that collecting and sharing clinical pathways could provide a valuable resource to new and existing bariatric programs.To shed light on the variability in practice patterns across the country by analyzing pathways.United States Centers of Excellence METHODS: From June 2014 to April 2015, clinical pathways pertaining to preoperative, intraoperative, and postoperative management of bariatric patients were solicited from the ASMBS executive council (EC), QIPS committee members, and state chapter presidents. Pathways were de-identified and then analyzed based on predetermined metrics pertaining to preoperative, intraoperative, and postoperative care. Concordance and discordance were then analyzed.In total, 31 pathways were collected; response rate was 80% from the EC, 77% from the QIPS committee, and 21% from state chapter presidents. The number of pathways sent in ranged from 1 to 10 with a median of 3 pathways per individual or institution. The majority of pathways centered on perioperative care (80%). Binary assessment (presence or absence) of variables found a high concordance (defined by greater than 65% of pathways accounting for that parameter) in only 6 variables: nutritional evaluation, psychological evaluation, intraoperative venous thromboembolism (VTE) prophylaxis, utilization of antiemetics in the postoperative period, a dedicated pain pathway, and postoperative laboratory evaluation.There is considerable national variation in clinical pathways among practicing bariatric surgeons. Most pathways center on Metabolic and Bariatric Surgery Accredited Quality Improvement Program (MBSAQIP) accreditation parameters, patient satisfaction, or Surgical Care Improvement Protocol (SCIP) measures. These pathways provide a path toward standardization of improved care.

    View details for DOI 10.1016/j.soard.2016.08.002

    View details for Web of Science ID 000396802900025

    View details for PubMedID 27887932

  • Comparative effectiveness of primary bariatric operations in the United States. Surgery for obesity and related diseases Sudan, R., Maciejewski, M. L., Wilk, A. R., Nguyen, N. T., Ponce, J., Morton, J. M. 2017


    Four current bariatric operations were compared after matching patients for differences at baseline. Operations with greater weight loss and resolution of co-morbidities also incurred more adverse events. Reflux was best treated by gastric bypass and type 2 diabetes with duodenal switch. These results can guide decision making regarding choice of bariatric operation. Relative outcomes of common primary bariatric operations have not been compared previously in a large multisite cohort from surgeons in multiple surgical centers.Compare outcomes of primary bariatric operations in a matched national sample.Bariatric Surgery Centers of Excellence in the United States of America METHODS: Data from Bariatric Surgery Center of Excellence Data File was queried from June 2007 to September 2011 for 30-day and 1-year adverse events, 1-year weight loss and comorbidity resolution. Inverse probability weighting accounted for covariate imbalances in multivariable linear/logistic regressions estimates of differences/odds ratios for each pairwise surgical procedure comparison. A Bonferroni correction was applied to account for multiple pairwise comparisons.Among 130,796 patients, 57,094 patients underwent AGB, 5942 patients underwent SG, 66,324 patients underwent RYGB and 1436 patients underwent BPD/DS. Compared with AGB, change in body mass index units at 1 year for BPD/DS was 10.6 (standard error [SE]: .15), RYGB 9.3 (SE: .03), and SG 5.7 (SE: .06). Resolution of GERD was best for RYGB (odds ratio [OD] = 1.5, 95% confidence interval [CI]: 1.48-1.58) and lowest for SG (OR = 0.87, 95% CI: .79-.95). Hypertension and T2D resolution were better after the BPD/DS (OR = 3.82, 95% CI: 3.21-4.55, and OR = 5.62, 95% CI: 4.60-6.88, respectively) or after RYGB (OR = 3.08, 95% CI: 2.98-3.18 and OR = 3.5, 95% CI: 3.39-3.64, respectively). Odds of serious adverse events at 1 year were: SG, OR = 3.22, 95% CI: 2.64-3.92; RYGB, OR = 4.92, 95% CI: 4.38-5.54; BPD/DS, OR = 17.47, 95% CI: 14.19-21.52.Odds of adverse events and co-morbidity resolution were determined after matching for baseline characteristics. RYGB was associated with highest resolution of GERD, whereas BPD/DS was associated with highest resolution of T2D. These findings can guide decision making regarding choice of bariatric operation.

    View details for DOI 10.1016/j.soard.2017.01.021

    View details for PubMedID 28236529

  • Buttressing of the EEA stapler during gastrojejunal anastomosis decreases rate of bleeding-related complications for laparoscopic gastric bypass. Surgery for obesity and related diseases Ichter, Z. A., Voeller, L., Rivas, H., Khoury, H., Azagury, D., Morton, J. M. 2017


    Bariatric surgery is a well-tolerated and effective treatment for severe obesity. Newer surgical techniques and equipment have improved safety standards surrounding bariatric surgery. In particular, buttressing of the staple line in sleeve gastrectomy has decreased rates of clinically significant postoperative bleeding. The present study investigates the effectiveness of buttressing the circular stapled anastomosis during laparoscopic Roux-en-Y gastric bypass (LRYGB).Academic, accredited hospital.A total of 253 patients undergoing LRYGB at a single academic institution were included in this retrospective study between 2014 and 2015. Buttressing material was used in 125 of these cases. Demographic information was collected from both groups preoperatively. Surgical characteristics were also obtained analyzed using unpaired t or χ(2) tests.Patients in both buttressing and nonbuttressing groups were on average 46 years old and predominantly female (79.2% versus 74.2% female, respectively), with a body mass index of approximately 48 kg/m(2). Postoperative weight loss did not significantly differ between groups at any time point (buttressing versus nonbuttressing percentage of excess weight loss: 39.5% versus 41.5% at 3 mo, P = .3860; 56.4% versus 56.7% at 6 mo, P = .9341). There were no significant differences for operating time, length of stay, readmissions, or reoperations. Complications due to strictures were found to be lower for the buttressing group (0% buttressing versus 2.3% nonbuttressing, P = .0851). Specific rates of bleeding-related complications were significantly lower for the group in which buttressing was used (0% buttressing versus 3.1% nonbuttressing, P = .0463).Buttressing of the gastrojejunal anastomosis during LRYGB significantly reduces bleeding-related complications and increases tolerability of the procedure.

    View details for DOI 10.1016/j.soard.2017.01.019

    View details for PubMedID 28325504

  • Obesity and the role of bariatric surgery in the surgical management of osteoarthritis of the hip and knee: a review of the literature. Surgery for obesity and related diseases Springer, B. D., Carter, J. T., McLawhorn, A. S., Scharf, K., Roslin, M., Kallies, K. J., Morton, J. M., Kothari, S. N. 2017; 13 (1): 111-118


    Obesity accelerates the development of osteoarthritis of the knee and hip by exerting deleterious effects on joints through both biomechanical and also systemic inflammatory changes. The objective of this review was to evaluate the impact of obesity on lower limb biomechanics and total joint arthroplasty outcomes, as well as weight changes after joint arthroplasty and the role of bariatric surgery among patients requiring joint arthroplasty. The currently published data indicate that weight loss increases swing time, stride length, gait speed, and lower extremity range of motion. Total joint arthroplasty improves pain and joint function, but does not induce significant weight loss in the majority of patients. Bariatric surgery improves gait biomechanics, and in the severely obese patient with osteoarthritis improves pain and joint function. The evidence for supporting bariatric surgery before total joint arthroplasty is limited to retrospective reports with conflicting results. Fundamental clinical questions remain regarding the optimal management of morbid obesity and lower extremity arthritis, which should be the focus of future collaborations across disciplines providing care to patients with both conditions.

    View details for DOI 10.1016/j.soard.2016.09.011

    View details for PubMedID 27865814

  • Adipose tissue macrophages impair preadipocyte differentiation in humans. PloS one Liu, L. F., Craig, C. M., Tolentino, L. L., Choi, O., Morton, J., Rivas, H., Cushman, S. W., Engleman, E. G., McLaughlin, T. 2017; 12 (2)


    The physiologic mechanisms underlying the relationship between obesity and insulin resistance are not fully understood. Impaired adipocyte differentiation and localized inflammation characterize adipose tissue from obese, insulin-resistant humans. The directionality of this relationship is not known, however. The aim of the current study was to investigate whether adipose tissue inflammation is causally-related to impaired adipocyte differentiation.Abdominal subcutaneous(SAT) and visceral(VAT) adipose tissue was obtained from 20 human participants undergoing bariatric surgery. Preadipocytes were isolated, and cultured in the presence or absence of CD14+ macrophages obtained from the same adipose tissue sample. Adipocyte differentiation was quantified after 14 days via immunofluorescence, Oil-Red O, and adipogenic gene expression. Cytokine secretion by mature adipocytes cultured with or without CD14+macrophages was quantified.Adipocyte differentiation was significantly lower in VAT than SAT by all measures (p<0.001). With macrophage removal, SAT preadipocyte differentiation increased significantly as measured by immunofluorescence and gene expression, whereas VAT preadipocyte differentiation was unchanged. Adipocyte-secreted proinflammatory cytokines were higher and adiponectin lower in media from VAT vs SAT: macrophage removal reduced inflammatory cytokine and increased adiponectin secretion from both SAT and VAT adipocytes. Differentiation of preadipocytes from SAT but not VAT correlated inversely with systemic insulin resistance.The current results reveal that proinflammatory immune cells in human SAT are causally-related to impaired preadipocyte differentiation, which in turn is associated with systemic insulin resistance. In VAT, preadipocyte differentiation is poor even in the absence of tissue macrophages, pointing to inherent differences in fat storage potential between the two depots.

    View details for DOI 10.1371/journal.pone.0170728

    View details for PubMedID 28151993

    View details for PubMedCentralID PMC5289462

  • Prevalence and Risk Factors for Bariatric Surgery Readmissions: Findings From 130,007 Admissions in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Annals of surgery Berger, E. R., Huffman, K. M., Fraker, T., Petrick, A. T., Brethauer, S. A., Hall, B. L., Ko, C. Y., Morton, J. M. 2016: -?


    To evaluate readmissions following laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB).Few studies have evaluated national readmission rates for primary bariatric surgery with national, bariatric-specific data.Patients undergoing primary LAGB, LSG, or LRYGB from January 1, 2014 to December 31, 2014, at 698 centers were identified based upon Current Procedural Terminology codes. The primary outcome was 30-day readmission from date of initial operation.A total of 130,007 patients who underwent primary bariatric surgery were identified: 7378 LAGB (5.7%), 80,646 LSG (62.0%), and 41,983 LRYGB (32.3%). A total of 5663 (4.4%) patients were readmitted within 30 days for all causes. Patients undergoing LAGB had the lowest related readmission rate of 1.4%, followed by LSG (2.8%), and LRYGB (4.9%). Of patients who had a complication, 17.9% (n = 785) were readmitted, whereas those without readmission had a complication 1.9% of the time (P < 0.001). The most common cause of a related readmission was nausea, vomiting, fluid, electrolyte, and nutritional depletion (35.4%), followed by abdominal pain (13.5%), anastomotic leak (6.4%), and bleeding (5.8%), accounting for more than 61% of readmissions. When compared with LAGB, LSG, and LRYGB had significantly higher rates of readmission (LSG: odds ratio 1.89; 95% confidence interval 1.52-2.33; LRYGB: odds ratio 3.06; 95% confidence interval 2.46-3.81).National bariatric readmissions after primary procedures were closely associated with complications, varied based on the type of procedure, and were most commonly due to nausea, vomiting, electrolyte, and nutritional depletion.

    View details for PubMedID 27849660

  • John Morton, MD, MPH. Obesity surgery Morton, J., Shikora, S. 2016; 26 (11): 2553-2554

    View details for PubMedID 27730466

  • Characterizing Readmissions After Bariatric Surgery. Journal of gastrointestinal surgery Garg, T., Rosas, U., Rogan, D., Hines, H., Rivas, H., Morton, J. M., Azagury, D. 2016; 20 (11): 1797-1801


    Readmissions are an important quality metric for surgery. Here, we compare characteristics of readmissions across laparoscopic Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG), and adjustable gastric band (LAGB).Demographic, intraoperative, anthropometric, and laboratory data were prospectively obtained for 1775 patients at a single academic institution. All instances of readmissions within 1 year were recorded. Data were analyzed using STATA, release 12.For the 1775 patients, 113 (6.37 %) were readmitted. Mean time to readmission was 52.1 days. Of all the readmissions, 64.6 % were within 30 days, 22.1 % from 30 to 90 days, 1.77 % from 90 to 180 days, and 11.5 % from 180 to 365 days. Incidence of 30-day readmissions varied across surgeries (LRYGB: 7.17 %; LAGB: 3.05 %; LSG: 4.25 %, p = 0.04). Time to readmission varied as well, with 90.0 % of LSG and 80.0 % of LABG patients within the first 30 days, versus 60.8 % of LRYGB (p = 0.02). The most common causes of readmissions were gastrointestinal issues related to index procedure (34.5 %) and did not vary across surgeries. In multivariable logistic regression, index hospital length of stay (LOS) was associated with readmission (OR = 1.07, 95 % CI 1.02-1.13, p = 0.01).Readmissions after bariatric surgery are associated with high index hospital LOS, and a measureable proportion of procedure-related readmissions can occur up to 1 year, especially for LRYGB.

    View details for PubMedID 27613733

  • Mammography before and after bariatric surgery. Surgery for obesity and related diseases Mokhtari, T. E., Rosas, U. S., Downey, J. R., Miyake, K. K., Ikeda, D. M., Morton, J. M. 2016


    Morbidly obese women are at increased risk for breast cancer, and the majority of surgical weight-loss patients are older than 40 years old.The purpose of the present study was to determine the technical and interpretive changes in mammography following bariatric surgery.Accredited Academic Hospital.Two breast-imaging radiologists reviewed screening mammograms performed on 10 morbidly obese women undergoing bariatric surgery both pre- and postoperatively. American College of Radiology Breast Imaging Reporting and Data System (ACR BI-RADS) density, imaging quality measurements, compression force, breast thickness, pectoral nipple line (PNL) length, and x-ray beam kilovoltage (kVp) and miliamperes per second (mAs) were recorded.The average patient age was 56 years old, with mean age at menarche of 13 years old; 70% of patients were postmenopausal (average age 49 years at menopause) and 50% had a family history of breast cancer. There was a significant reduction in both BMI (-13.2 kg/m(2), P<.01) and waist circumference (-32.0 cm, P<.01) following bariatric surgery. There was a significant reduction in breast thickness (-23.8 mm), reduction in PNL length (-1.9 cm), reduction in kVp (-1.2), and reduction in mAs (-16.7) even though there was no compression force change in pre- and postoperative mammograms detected. All breast densities were fatty or scattered though there were more scattered and fewer fatty images after surgery (P = .002).Morbidly obese women can undergo quality mammograms before and after bariatric surgery; however, weight loss after bariatric surgery leads to only slightly denser mammograms. Furthermore, weight loss reduces mammographic radiation doses.

    View details for DOI 10.1016/j.soard.2016.10.021

    View details for PubMedID 27986574

  • Influence of Weight Loss Attempts on Bariatric Surgery Outcomes. American surgeon Deb, S., Voller, L., Palisch, C., Ceja, O., Turner, W., Rivas, H., Morton, J. M. 2016; 82 (10): 916-920


    Many payors require an additional attempt at nonsurgical weight loss before approval of bariatric procedures. This study evaluates this requirement by characterizing the prior weight loss attempts (WLAs) undergone by bariatric surgery patients and correlating those attempts to postoperative weight loss outcomes. Number and duration of WLAs were obtained from a preoperative clinic assessment. Body mass index (BMI) and percentage of excess weight loss (%EWL) were used to assess weight loss. Kruskal-Wallis and Spearman Correlation tests were performed to analyze data using GraphPad Prism 6. Mean number of WLAs before surgery was 3.5 ± 0.2 attempts, with an average duration of 15.2 ± 1.1 years. There was a significant negative correlation between duration of WLAs and preoperative BMI (r = -0.2637, P = 0.0025). No significant difference was found for preoperative BMI or mean 12-month %EWL among any WLA groups. The number and duration of dietary attempts before surgery do not significantly affect long-term weight loss outcomes after bariatric surgery. Given these data, an additional preoperative WLA may not be efficacious in improving patients' chances at weight loss.

    View details for PubMedID 27779973

  • Bariatric Surgery Outcomes in US Accredited vs Non-Accredited Centers: A Systematic Review. Journal of the American College of Surgeons Azagury, D., Morton, J. M. 2016; 223 (3): 469-477


    Accreditation for bariatric surgery has been scrutinized recently for its impact on surgical outcomes. This study aimed to systematically examine the medical literature to examine the impact of bariatric accreditation on surgical outcomes.The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and checklist were used. The MEDLINE database was searched for the following terms (2000 through September 2014): gastric bypass or bariatric surgery or sleeve gastrectomy or vertical banded gastroplasty or biliopancreatic diversion or duodenal switch or adjustable gastric band or weight loss surgery and accreditation or center of excellence or credentialing or national coverage decision or CMS or Medicare. Only studies in English and articles comparing accredited with non-accredited centers were included. Quality was assessed using the Newcastle-Ottawa scale for evaluation of all studies.Thirteen studies were published in a very short time frame and covered >1.5 million patients. Ten of the 13 studies identified a substantial benefit of Center of Excellence accreditation for risk-adjusted outcomes. Six of the 8 studies reported a considerable reduction in mortality in patients operated on in Centers of Excellence, with odds ratios ranging from 2.26 to 3.57 for non-accredited centers; 2 studies showed no significant difference. Similarly, morbidity was reduced in 8 of 11 studies, although more discreetly, with odds ratios ranging from 1.09 to 1.39.This study found that the preponderance of medical evidence supports accreditation for bariatric surgery.

    View details for DOI 10.1016/j.jamcollsurg.2016.06.014

    View details for PubMedID 27423398

  • The Impact of Different Surgical Techniques on Outcomes in Laparoscopic Sleeve Gastrectomies: The First Report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Annals of surgery Berger, E. R., Clements, R. H., Morton, J. M., Huffman, K. M., Wolfe, B. M., Nguyen, N. T., Ko, C. Y., Hutter, M. M. 2016; 264 (3): 464-473


    Questions remain regarding best surgical techniques to use for a laparoscopic sleeve gastrectomy (LSG) including the use of staple line reinforcement (SLR), bougie size (BS), and distance from the pylorus (DP) where the staple line is initiated. Our objectives were to assess the impact of these techniques on 30-day outcomes and to evaluate the impact of these techniques on weight loss and comorbidities at 1 year.Using the MBSAQIP data registry, univariate analyses and hierarchical logistical regression models were developed to analyze outcomes for techniques of LSG at patient and surgeon-level.A total of 189,477 LSG operations were performed by 1634 surgeons at 720 centers from 2012 to 2014. Eighty percent of surgeons used SLR, 20% did not. SLR cases were associated with higher leak rates (0.96% vs 0.65%, odds ratio [OR] 1.20 95% confidence interval [CI] 1.00-1.43) and lower bleed rates (0.75% vs 1.00%, OR 0.74 95% CI 0.63-0.86) compared to no SLR at patient level. At the surgeon level, leak rates remained significant, but bleeding events became nonsignificant. BS ≥38 was associated with significantly lower leak rates compared to BS <38 at patient and surgeon level (patient level: 0.80% vs 0.96%, OR 0.72, 95% CI 0.62-0.94; surgeon level: 0.84% vs 0.95%, OR 0.90, 95% CI 0.80-0.99). BS ≥40 was associated with increased weight loss. DP had no impact on leaks or bleeds but showed an increase in weight loss with increasing DP.LSG is a safe procedure with a low morbidity rate. SLR is associated with increased leak rates. A surgeon should consider risks, benefits, and costs of these surgical techniques when performing a LSG and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.

    View details for DOI 10.1097/SLA.0000000000001851

    View details for PubMedID 27433904

  • Bariatric Surgery: Overview of Procedures and Outcomes. Endocrinology and metabolism clinics of North America Azagury, D. E., Morton, J. M. 2016; 45 (3): 647-656


    Bariatric surgery is the most efficient and long-lasting weight loss therapy available. Its safety has improved over tenfold over the last decade. With the advent of laparoscopy, mortality rates of are now under 1 per 1400 cases in accredited centers. Gastric bypass reduces diabetes-related mortality by 92% over 7 years and long lasting remission has been demonstrated in observational studies covering >10,000 patients and multiple randomized control trials. The benefit of bariatric surgery on diabetes is so substantial that these procedures should be considered in all type 2 diabetic patients with a BMI > 35 kg/m(2).

    View details for DOI 10.1016/j.ecl.2016.04.013

    View details for PubMedID 27519136

  • Geographic Variation in Surgical Outcomes and Cost Between the United States and Japan AMERICAN JOURNAL OF MANAGED CARE Hurley, M. P., Schoemaker, L., Morton, J. M., Wren, S. M., Vogt, W. B., Watanabe, S., Yoshikawa, A., Bhattacharya, J. 2016; 22 (9): 600-?


    Unwarranted geographic variation in spending has received intense scrutiny in the United States. However, few studies have compared variation in spending and surgical outcomes between the United States healthcare system and those of other nations. In this study, we compare the geographic variation in postsurgical outcomes and cost between the United States and Japan.This retrospective cohort study uses Medicare Part A data from the United States (2010-2011) and similar inpatient data from Japan (2012). Patients 65 years or older undergoing 1 of 5 surgeries (coronary artery bypass graft, abdominal aortic aneurysm repair, colectomy, pancreatectomy, or gastrectomy) were selected in the United States and Japan.Reliability- and case-mix-adjusted coefficient of variation (COV) values were calculated using hierarchical modeling and empirical Bayes techniques for the following 5 outcomes: postoperative mortality, the development of a complication, death after complication (failure to rescue), length of stay, and the cost of the hospitalization. Sensitivity analyses were also performed by calculating patient demographic-and case-mix-adjusted COV values for each outcome using weighted age- and sex-standardized values.The variability of the postsurgical outcomes was uniformly lower in the United States compared with Japan. Cost variation was consistently higher in the United States for all surgeries.Although the US healthcare system may be more inefficient regarding costs, the presence of higher geographic variation in postoperative care in Japan, relative to the United States, suggests that the observed geographic variation in the United States-both for health expenditures and outcomes-is not a unique manifestation of its structural shortcomings.

    View details for Web of Science ID 000384740300009

    View details for PubMedID 27662222

  • American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. Surgery for obesity and related diseases Ponce, J., DeMaria, E. J., Nguyen, N. T., Hutter, M., Sudan, R., Morton, J. M. 2016

    View details for DOI 10.1016/j.soard.2016.08.488

    View details for PubMedID 27692915

  • Patient Safety and Quality Improvement Initiatives in Contemporary Metabolic and Bariatric Surgical Practice. Surgical clinics of North America Azagury, D. E., Morton, J. M. 2016; 96 (4): 733-742


    Patient safety and quality improvement have been part of bariatric surgery since its inception, and there have been significant improvements in outcomes of bariatric surgery over the past 2 decades. A strong accreditation program exists. This program defines 2 tiers of accredited centers: low-acuity and comprehensive centers similar to the trauma systems. Accreditation has been shown to have a favorable impact on outcomes of bariatric surgery. Bariatric surgery lends itself well to improvements in processes and use of perioperative protocols, such as ulcer and thromboembolic prophylaxis prevention or gallstone prevention and management.

    View details for DOI 10.1016/j.suc.2016.03.014

    View details for PubMedID 27473798

  • National prevalence, causes, and risk factors for bariatric surgery readmissions AMERICAN JOURNAL OF SURGERY Garg, T., Rosas, U., Rivas, H., Azagury, D., Morton, J. M. 2016; 212 (1): 76-80


    Readmissions are often used as a quality metric particularly in bariatric surgery.Laparoscopic Roux en Y gastric bypass, laparoscopic adjustable gastric banding, and laparoscopic sleeve gastrectomy were identified using Current Procedure Terminology codes in the 2012 National Surgical Quality Improvement Program public use file.A total of 18,296 patients were included, 10,080 (55.1%) were laparoscopic Roux en Y gastric bypass, 1,829 (10.0%) were laparoscopic adjustable gastric banding, and 6,387 (34.9%) were laparoscopic sleeve gastrectomy. Among all patients, 955 (5.22%) were readmitted. Patients with readmissions had a higher proportion of body mass index greater than 50 (30.2% vs 24.6%, P < .001), higher index operative time (132 minutes vs 115, P < .001) and greater proportion with length of stay greater than 4 days (9.57% vs 3.36%, P < .001). Readmitted patients were more likely to have diabetes (31.1% vs 27.7%, P = .02), chronic obstructive pulmonary disease (2.63% vs 1.72%, P = .04), and hypertension (54.5% vs 50.8%, P = .03). Overall, 40.6% of readmitted patients had a complication. Common readmissions were gastrointestinal-related (45.0%), dietary (33.5%), and bleeding (6.57%). Readmission was independently associated with African-American race (odds ratio [OR] = 1.53, P = .02), complication (OR = 11.3, 95%, P < .001), and resident involvement (OR = .53, P = .04).A 30-day readmission after bariatric surgery is prevalent and closely associated with complications.

    View details for DOI 10.1016/j.amjsurg.2016.01.023

    View details for Web of Science ID 000378063100011

    View details for PubMedID 27133197

  • Ethnic Considerations for Metabolic Surgery DIABETES CARE Morton, J. M. 2016; 39 (6): 949-953


    Obesity and diabetes represent twin health concerns in the developed world. Metabolic surgery has emerged as an established and enduring treatment for both obesity and diabetes. As the burden of obesity and diabetes varies upon the basis of ethnicity, it is also apparent that there may be differences for indications and outcomes for different ethnic groups after metabolic surgery. Whereas there appears to be evidence for variation in weight loss and complications for different ethnic groups, comorbidity remission particularly for diabetes appears to be free of ethnic disparity after metabolic surgery. The impacts of access, biology, culture, genetics, procedure, and socioeconomic status upon metabolic surgery outcomes are examined. Further refinement of the influence of ethnicity upon metabolic surgery outcomes is likely imminent.

    View details for DOI 10.2337/dc16-0413

    View details for Web of Science ID 000376980500020

    View details for PubMedID 27222553

  • Covering bariatric surgery has minimal effect on insurance premium costs within the Affordable Care Act SURGERY FOR OBESITY AND RELATED DISEASES English, W., Williams, B., Scott, J., Morton, J. 2016; 12 (5): 1045-1050


    Currently, of the 51 state health exchanges operating under the Affordable Care Act, only 23 include benchmark plans that cover bariatric surgery coverage. Bariatric surgery coverage is not considered an essential health benefit in 28 state exchanges, and this lack of coverage has a discriminatory and detrimental impact on millions of Americans participating in state exchanges that do not provide bariatric surgery coverage.We examined 3 state exchanges in which a portion of their plans provided coverage for bariatric surgery to determine if bariatric surgery coverage is correlated with premium costs.State health exchanges; United States.Data from the 2015 state exchange plans were analyzed using information from the Centers for Medicare & Medicaid Services' Individual Market Landscape file and Benefits and Cost Sharing public use files.Only 3 states (Oklahoma, Oregon, and Virginia) in the analysis have 1 or more rating regions in which a portion of the plans cover bariatric surgery. In Oklahoma and Oregon, the average monthly premiums for all bronze, silver, and gold coverage levels are higher for plans covering bariatric surgery. Only 1 of these states included platinum plans that cover bariatric surgery. The average difference in premiums was between $1 to $45 higher in Oklahoma, and $18 to $32 higher in Oregon. Conversely, in Virginia, the average monthly premiums are between $2 and $21 lower for each level for plans covering bariatric surgery. Monthly premiums for plans covering versus not covering bariatric surgery ranged from 6% lower to 15% higher in the same geographic rating region.Across all 3 states in the sample, the average monthly premiums do not differ consistently on the basis of whether the state exchange plans cover bariatric surgery.

    View details for DOI 10.1016/j.soard.2016.03.011

    View details for Web of Science ID 000381840000019

    View details for PubMedID 27260649

  • A postoperative nutritional consult improves bariatric surgery outcomes. Surgery for obesity and related diseases Garg, T., Birge, K., Ulysses Rosas, Azagury, D., Rivas, H., Morton, J. M. 2016; 12 (5): 1052-1056


    Bariatric surgery is the most effective treatment for obesity. Guidelines for optimizing postoperative care are emerging, and roles of the surgeon and registered dietician (RD) have opportunities for coordination.The study objective was to better define the appropriate guidelines for postoperative care by investigating whether a combined surgeon and RD follow-up for the initial postoperative visit within 2 to 6 weeks after surgery improves patient outcomes.The setting was an accredited bariatric hospital in an academic setting.A retrospective analysis of a prospective database was performed on patients who underwent bariatric surgery and were followed up by either a surgeon alone or by a surgeon and RD for initial postoperative visit.There were 302 patients in the surgeon follow-up group and 268 in the RD follow-up. Patients in the RD follow-up group had significantly fewer readmissions due to dietary-related problems (9 versus 0; P = .004), more favorable 3-month change in serum thiamine (-30.5 versus-4.04; P = .002), high-density lipoprotein (-3.42 versus-1.67; P = .053), and triglycerides (-17.5 versus-31.5; P = .03), and trended lower number of minor complications (16 versus 6; P = .08). No significant differences in percent excess weight loss were observed at all time points after surgery. Multivariate logistic models controlling for demographic features found that RD follow-up predicted 3-month increase in thiamine (odds ratio = 2.49; P<.000) and high-density lipoprotein cholesterol (OR = 1.73; P = .01), and decrease in total cholesterol (OR = 1.58; P = .03) and triglycerides (OR = 1.55; P = .03).Follow-up with a surgeon and RD for the initial postoperative visit may help improve patient outcomes.

    View details for DOI 10.1016/j.soard.2016.01.008

    View details for PubMedID 27220825

  • Tracheal Stenosis Because of Wegener Granulomatosis Misdiagnosed as Asthma. A & A case reports O'Hear, K. E., Ingrande, J., Brodsky, J. B., Morton, J. M., Sung, C. 2016; 6 (10): 311-312


    We describe a patient with Wegener granulomatosis whose complaint of wheezing was incorrectly attributed to asthma. Anesthesiologists must recognize that tracheal stenosis is extremely common in Wegener granulomatosis and can mimic other causes of wheezing.

    View details for DOI 10.1213/XAA.0000000000000307

    View details for PubMedID 27075424

  • Effect of Vagal Nerve Blockade on Moderate Obesity with an Obesity-Related Comorbid Condition: the ReCharge Study. Obesity surgery Morton, J. M., Shah, S. N., Wolfe, B. M., Apovian, C. M., Miller, C. J., Tweden, K. S., Billington, C. J., Shikora, S. A. 2016; 26 (5): 983-989


    Vagal nerve blockade (vBloc) therapy was shown to be a safe and effective treatment for moderate to severe obesity. This report summarizes the safety and efficacy of vBloc therapy in the prespecified subgroup of patients with moderate obesity.The ReCharge Trial is a double-blind, randomized controlled clinical trial of participants with body mass index (BMI) of 40-45 or 35-40 kg/m(2) with at least one obesity-related comorbid condition. Participants were randomized 2:1 to implantation with either a vBloc or sham device with weight management counseling. Eighty-four subjects had moderate obesity (BMI 35-40 kg/m(2)) at randomization.Fifty-three participants were randomized to vBloc and 31 to sham. Qualifying obesity-related comorbidities included dyslipidemia (73 %), hypertension (58 %), sleep apnea (33 %), and type 2 diabetes (8 %). The vBloc group achieved a percentage excess weight loss (%EWL) of 33 % (11 % total weight loss (%TWL)) compared to 19 % EWL (6 % TWL) with sham at 12 months (treatment difference 14 percentage points, 95 % CI, 7-22; p < 0.0001). Common adverse events of vBloc through 12 months were heartburn/dyspepsia and implant site pain; the majority of events were reported as mild or moderate.vBloc therapy resulted in significantly greater weight loss than the sham control among participants with moderate obesity and comorbidities with a well-tolerated safety profile.

    View details for DOI 10.1007/s11695-016-2143-y

    View details for PubMedID 27048437

  • Lipids and bariatric procedures Part 2 of 2: scientific statement from the American Society for Metabolic and Bariatric Surgery (ASMBS), the National Lipid Association (NLA), and Obesity Medicine Association (OMA) SURGERY FOR OBESITY AND RELATED DISEASES Bays, H., Kothari, S. N., Azagury, D. E., Morton, J. M., Nguyen, N. T., Jones, P. H., Jacobson, T. A., Cohen, D. E., Orringer, C., Westman, E. C., Horn, D. B., Scinta, W., Primack, C. 2016; 12 (3): 468-495


    Bariatric procedures generally improve dyslipidemia, sometimes substantially so. Bariatric procedures also improve other major cardiovascular risk factors. This 2-part Scientific Statement examines the lipid effects of bariatric procedures and reflects contributions from authors representing the American Society for Metabolic and Bariatric Surgery (ASMBS), the National Lipid Association (NLA), and the Obesity Medicine Association (OMA). Part 1 was published in the Journal of Clinical Lipidology, and reviewed the impact of bariatric procedures upon adipose tissue endocrine and immune factors, adipose tissue lipid metabolism, as well as the lipid effects of bariatric procedures relative to bile acids and intestinal microbiota. This Part 2 reviews: (1) the importance of nutrients (fats, carbohydrates, and proteins) and their absorption on lipid levels; (2) the effects of bariatric procedures on gut hormones and lipid levels; (3) the effects of bariatric procedures on nonlipid cardiovascular disease (CVD) risk factors; (4) the effects of bariatric procedures on lipid levels; (5) effects of bariatric procedures on CVD; and finally, (6) the potential lipid effects of vitamin, mineral, and trace element deficiencies, that may occur after bariatric procedures.

    View details for DOI 10.1016/j.soard.2016.01.007

    View details for Web of Science ID 000376223300004

    View details for PubMedID 27050404

  • High-dimensional immune profiling of total and rotavirus VP6-specific intestinal and circulating B cells by mass cytometry MUCOSAL IMMUNOLOGY Nair, N., Newell, E. W., Vollmers, C., Quake, S. R., Morton, J. M., DAVIS, M. M., He, X. S., Greenberg, H. B. 2016; 9 (1): 68-82


    In-depth phenotyping of human intestinal antibody secreting cells (ASCs) and their precursors is important for developing improved mucosal vaccines. We used single-cell mass cytometry to simultaneously analyze 34 differentiation and trafficking markers on intestinal and circulating B cells. In addition, we labeled rotavirus (RV) double-layered particles with a metal isotope and characterized B cells specific to the RV VP6 major structural protein. We describe the heterogeneity of the intestinal B-cell compartment, dominated by ASCs with some phenotypic and transcriptional characteristics of long-lived plasma cells. Using principal component analysis, we visualized the phenotypic relationships between major B-cell subsets in the intestine and blood, and revealed that IgM(+) memory B cells (MBCs) and naive B cells were phenotypically related as were CD27(-) MBCs and switched MBCs. ASCs in the intestine and blood were highly clonally related, but associated with distinct trajectories of phenotypic development. VP6-specific B cells were present among diverse B-cell subsets in immune donors, including naive B cells, with phenotypes representative of the overall B-cell pool. These data provide a high dimensional view of intestinal B cells and the determinants regulating humoral memory to a ubiquitous, mucosal pathogen at steady-state.Mucosal Immunology advance online publication, 22 April 2015; doi:10.1038/mi.2015.36.

    View details for DOI 10.1038/mi.2015.36

    View details for Web of Science ID 000367653800006

  • Lipids and bariatric procedures part 1 of 2: Scientific statement from the National Lipid Association, American Society for Metabolic and Bariatric Surgery, and Obesity Medicine Association: EXECUTIVE SUMMARY. Journal of clinical lipidology Bays, H. E., Jones, P. H., Jacobson, T. A., Cohen, D. E., Orringer, C. E., Kothari, S., Azagury, D. E., Morton, J., Nguyen, N. T., Westman, E. C., Horn, D. B., Scinta, W., Primack, C. 2016; 10 (1): 15-32


    Bariatric procedures often improve lipid levels in patients with obesity. This 2-part scientific statement examines the potential lipid benefits of bariatric procedures and represents contributions from authors representing the National Lipid Association, American Society for Metabolic and Bariatric Surgery, and the Obesity Medicine Association. The foundation for this scientific statement was based on data published through June 2015. Part 1 of this 2-part scientific statement provides an overview of: (1) adipose tissue, cholesterol metabolism, and lipids; (2) bariatric procedures, cholesterol metabolism, and lipids; (3) endocrine factors relevant to lipid influx, synthesis, metabolism, and efflux; (4) immune factors relevant to lipid influx, synthesis, metabolism, and efflux; (5) bariatric procedures, bile acid metabolism, and lipids; and (6) bariatric procedures, intestinal microbiota, and lipids, with specific emphasis on how the alterations in the microbiome by bariatric procedures influence obesity, bile acids, and inflammation, which in turn, may all affect lipid levels. Included in part 2 of this comprehensive scientific statement will be a review of: (1) the importance of nutrients (fats, carbohydrates, and proteins) and their absorption on lipid levels; (2) the effects of bariatric procedures on gut hormones and lipid levels; (3) the effects of bariatric procedures on nonlipid cardiovascular disease risk factors; (4) the effects of bariatric procedures on lipid levels; (5) effects of bariatric procedures on cardiovascular disease; and finally (6) the potential lipid effects of vitamin, mineral, and trace element deficiencies that may occur after bariatric procedures. This document represents the executive summary of part 1.

    View details for DOI 10.1016/j.jacl.2015.12.003

    View details for PubMedID 26892119

  • Lipids and bariatric procedures part 1 of 2: Scientific statement from the National Lipid Association, American Society for Metabolic and Bariatric Surgery, and Obesity Medicine Association: FULL REPORT. Journal of clinical lipidology Bays, H. E., Jones, P. H., Jacobson, T. A., Cohen, D. E., Orringer, C. E., Kothari, S., Azagury, D. E., Morton, J., Nguyen, N. T., Westman, E. C., Horn, D. B., Scinta, W., Primack, C. 2016; 10 (1): 33-57


    Bariatric procedures often improve lipid levels in patients with obesity. This 2 part scientific statement examines the potential lipid benefits of bariatric procedures and represents the contributions from authors representing the National Lipid Association, American Society for Metabolic and Bariatric Surgery, and the Obesity Medicine Association. The foundation for this scientific statement was based on published data through June 2015. Part 1 of this 2 part scientific statement provides an overview of: (1) adipose tissue, cholesterol metabolism, and lipids; (2) bariatric procedures, cholesterol metabolism, and lipids; (3) endocrine factors relevant to lipid influx, synthesis, metabolism, and efflux; (4) immune factors relevant to lipid influx, synthesis, metabolism, and efflux; (5) bariatric procedures, bile acid metabolism, and lipids; and (6) bariatric procedures, intestinal microbiota, and lipids, with specific emphasis on how the alterations in the microbiome by bariatric procedures influence obesity, bile acids, and inflammation, which in turn, may all affect lipid levels. Included in part 2 of this comprehensive scientific statement will be a review of (1) the importance of nutrients (fats, carbohydrates, and proteins) and their absorption on lipid levels; (2) the effects of bariatric procedures on gut hormones and lipid levels; (3) the effects of bariatric procedures on nonlipid cardiovascular disease (CVD) risk factors; (4) the effects of bariatric procedures on lipid levels; (5) effects of bariatric procedures on CVD; and finally, (6) the potential lipid effects of vitamin, mineral, and trace element deficiencies that may occur after bariatric procedures. This document represents the full report of part 1.

    View details for DOI 10.1016/j.jacl.2015.12.002

    View details for PubMedID 26892120

  • The Influence of Resected Gastric Weight upon Weight Loss after Sleeve Gastrectomy AMERICAN SURGEON Rosas, U., Hines, H., Rogan, D., Rivas, H., Morton, J. 2015; 81 (12): 1240-1243
  • American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in the United States, 2011-2014 SURGERY FOR OBESITY AND RELATED DISEASES Ponce, J., Nguyen, N. T., Hutter, M., Sudan, R., Morton, J. M. 2015; 11 (6): 1199-1200
  • Mesenteric defect closure in laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial. Surgical endoscopy Rosas, U., Ahmed, S., Leva, N., Garg, T., Rivas, H., Lau, J., Russo, M., Morton, J. M. 2015; 29 (9): 2486-2490


    Internal herniation is a potential complication following laparoscopic Roux-en-Y gastric bypass (LRYGB). Previous studies have shown that closure of mesenteric defects after LRYGB may reduce the incidence of internal herniation. However, controversy remains as to whether mesenteric defect closure is necessary to decrease the incidence of internal hernias after LRYGB. This study aims to determine if jejeunal mesenteric defect closure reduces incidence of internal hernias and other complications in patients undergoing LRYGB.105 patients undergoing laparoscopic antecolic RYGB were randomized into two groups: closed mesenteric defect (n = 50) or open mesenteric defect (n = 55). Complication rates were obtained from the medical record. Patients were followed up to 3 years post-operatively. Patients also completed the gastrointestinal quality of life index (GI QoL) pre-operatively and 12 months post-operatively. Outcome measures included: incidence of internal hernias, complications, readmissions, reoperations, GI QoL scores, and percent excess weight loss (%EWL).Pre-operatively, there were no significant differences between the two groups. The closed group had a longer operative time (closed-153 min, open-138 min, p = 0.073). There was one internal hernia in the open group. There was no significant difference at 12 months for decrease in BMI (closed-15.9, open-16.3 kg/m(2), p = 0.288) or %EWL (closed-75.3%, open-69.0%, p = 0.134). There was no significant difference between the groups in incidence of internal hernias and general complications post-operatively. Both groups showed significantly improved GI QoL index scores from baseline to 12 months post-surgery, but there were no significant differences at 12 months between groups in total GI QoL (closed-108, open-112, p = 0.440).In this study, closure or non-closure of the jejeunal mesenteric defect following LRYGB appears to result in equivalent internal hernia and complication rates. High index of suspicion should be maintained whenever internal hernia is expected after LRYGB.

    View details for DOI 10.1007/s00464-014-3970-3

    View details for PubMedID 25480607

  • Mesenteric defect closure in laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Rosas, U., Ahmed, S., Leva, N., Garg, T., Rivas, H., Lau, J., Russo, M., Morton, J. M. 2015; 29 (9): 2486-2490
  • Response to "Ensuring Excellence in Centers of Excellence Programs". Annals of surgery Kothari, S. N., Brethauer, S. A., Rosenthal, R. J., Nguyen, N. T., Morton, J. M. 2015: -?

    View details for PubMedID 26079915

  • Do adverse childhood experiences affect surgical weight loss outcomes? Journal of gastrointestinal surgery Lodhia, N. A., Rosas, U. S., Moore, M., Glaseroff, A., Azagury, D., Rivas, H., Morton, J. M. 2015; 19 (6): 993-998


    Bariatric surgery is an effective and enduring treatment for obesity; however, variation in weight loss may occur following surgery. Many factors beyond technical considerations may influence postoperative outcomes. A better understanding of the influence of adverse childhood experiences (ACE) on surgical weight loss may improve preoperative care. Demographic and preoperative and postoperative data were prospectively obtained for 223 patients undergoing bariatric surgery. All cases were completed laparoscopically without serious complication. Patients completed the ACE questionnaire, which assesses childhood maltreatment. Patients had an average age of 48 years and 77 % were female. There was a significant reduction from preoperative to 12-month postoperative BMI (45 to 31 kg/m(2), p ≤ 0.01). The average ACE score was 2.9 and these patients were more likely than population norms to have an ACE score ≥4 (35.9 vs. 12.5 %, p < 0.001). There was a positive correlation between the number of preoperative comorbidities and preoperative ACE score (R = 0.112, p = 0.09). Patients with a high ACE score (≥6) vs. patients low ACE scores had a higher postoperative BMI at 6-months (36.9 vs. 33.4 kg/m(2), p = 0.03) and 12-months postoperatively (34.5 vs. 30.5 kg/m(2), p = 0.07). High ACE patients had higher total cholesterol (191 vs. 169 mg/dL, p = 0.02) and LDL cholesterol (116 vs. 94 mg/dL, p = 0.02) than low ACE patients 12-months postoperatively. A high preoperative ACE score decreases weight loss following bariatric surgery and may warrant an increased preoperative counseling.

    View details for DOI 10.1007/s11605-015-2810-7

    View details for PubMedID 25832488

  • The TRANSFORM Patient Safety Project: A Microsystem Approach to Improving Outcomes on Inpatient Units JOURNAL OF GENERAL INTERNAL MEDICINE Braddock, C. H., Szaflarski, N., Forsey, L., Abel, L., Hernandez-Boussard, T., Morton, J. 2015; 30 (4): 425-433


    Improvements in hospital patient safety have been made, but innovative approaches are needed to accelerate progress. Evidence is emerging that microsystem approaches to quality and safety improvement in hospital care are effective.We aimed to evaluate the effects of a multifaceted, microsystem-level patient safety program on clinical outcomes and safety culture on inpatient units.A 1-year prospective interventional study was conducted, followed by a 6-month sustainability phase.Four medical and surgical inpatient units within an academic university medical center were included, with registered nurses and residents representing study participants.In situ simulation training; debriefing of medical emergencies; monthly patient safety team meetings; patient safety champion role; interdisciplinary patient safety conferences; recognition program for exemplary teamwork.Hospital-acquired severe sepsis/septic shock and acute respiratory failure; unplanned transfers to higher level of care (HLOC); weighted risk-adjusted mortality. Safety culture was measured using a widely accepted, validated survey.Rates of hospital-acquired severe sepsis/septic shock and acute respiratory failure decreased on study units, from 1.78 to 0.64 (p = 0.04) and 2.44 to 0.43 per 1,000 unit discharges (p = 0.03), respectively. The mean number of days between cases of severe sepsis/septic shock increased from baseline to the intervention period (p = 0.03). Unplanned transfers to HLOC increased from 715 to 764 per 1,000 unit transfers (p = 0.08). The weighted risk-adjusted observed-to-expected mortality ratio on all study units decreased from 0.50 to 0.40 (p < 0.001). Overall scores of safety culture on study units improved after the 1-year intervention, significantly for nurses (p < 0.001), but not for residents (p = 0.06). Scores significantly improved in nine of twelve survey dimensions for nurses, compared to in four dimensions for residents.A multifaceted patient safety program suggested an association with improved hospital-acquired complications and weighted, risk-adjusted mortality, and improved nurses' perceptions of safety culture on inpatient study units.

    View details for DOI 10.1007/s11606-014-3067-7

    View details for Web of Science ID 000351664000014

    View details for PubMedID 25348342

  • Morbidity, Mortality, and Weight Loss Outcomes After Reoperative Bariatric Surgery in the USA JOURNAL OF GASTROINTESTINAL SURGERY Sudan, R., Nguyen, N. T., Hutter, M. M., Brethauer, S. A., Ponce, J., Morton, J. M. 2015; 19 (1): 171-179


    Obesity is successfully treated by bariatric operations, but some patients need reoperations. No large national studies are available to evaluate the safety and efficacy after reoperative bariatric surgery.Data from June 2007 through March 2012 from the Bariatric Outcomes Longitudinal Database were queried for safety and efficacy of reoperations and compared to those who had initial bariatric operations but did not undergo reoperations. Reoperations were subdivided into corrective operations and conversions.Out of 449,753 bariatric operations, 28,720 (6.3%) underwent reoperations of which 19,970 (69.5%) were corrective and 8,750 (30.5%) were conversions. The conversion group compared to primary operations was older (47.63 ± 10.8 vs. 45.5 ± 11.8 years), had less males (13.5 vs. 21.3%), and had more African Americans (14.6 vs. 12%). Comparing primary operations to corrective and conversions operations, respectively, the following were observed: length of stay (1.78 ± 4.95 vs. 2.04 ± 6.44 and 2.86 ± 4.58 days), severe adverse events at 30 days (1.6 vs. 1.7 and 3.3%), severe adverse events at 1 year (2.15 vs. 1.9 and 3.61%), percent excess weight loss at 1 year (43.2 vs. 35.9 ± 92.4 and 39.3 ± 39.9%), 30-day mortality rate (0.1 vs. 0.12 and 0.21%), and 1-year mortality rate (0.17 vs. 0.24 and 0.31%). Comorbidities were resolved after both primary operations and reoperations.Most bariatric surgery patients do not need reoperations. Among those who do, the complication rate is low and outcomes are clinically comparable to primary procedures.

    View details for DOI 10.1007/s11605-014-2639-5

    View details for Web of Science ID 000347684100021

    View details for PubMedID 25186073

  • Hospital Accreditation and Bariatric Surgery: Is It Important? Advances in surgery Blondet, J. J., Morton, J. M., Nguyen, N. T. 2015; 49 (1): 123-129

    View details for DOI 10.1016/j.yasu.2015.03.012

    View details for PubMedID 26299494

  • T-Cell Profile in Adipose Tissue Is Associated With Insulin Resistance and Systemic Inflammation in Humans ARTERIOSCLEROSIS THROMBOSIS AND VASCULAR BIOLOGY McLaughlin, T., Liu, L., Lamendola, C., Shen, L., Morton, J., Rivas, H., Winer, D., Tolentino, L., Choi, O., Zhang, H., Chng, M. H., Engleman, E. 2014; 34 (12): 2637-2643
  • Effect of reversible intermittent intra-abdominal vagal nerve blockade on morbid obesity: the ReCharge randomized clinical trial. JAMA-the journal of the American Medical Association Ikramuddin, S., Blackstone, R. P., Brancatisano, A., Toouli, J., Shah, S. N., Wolfe, B. M., Fujioka, K., Maher, J. W., Swain, J., Que, F. G., Morton, J. M., Leslie, D. B., Brancatisano, R., Kow, L., O'Rourke, R. W., Deveney, C., Takata, M., Miller, C. J., Knudson, M. B., Tweden, K. S., Shikora, S. A., Sarr, M. G., Billington, C. J. 2014; 312 (9): 915-922


    Although conventional bariatric surgery results in weight loss, it does so with potential short-term and long-term morbidity.To evaluate the effectiveness and safety of intermittent, reversible vagal nerve blockade therapy for obesity treatment.A randomized, double-blind, sham-controlled clinical trial involving 239 participants who had a body mass index of 40 to 45 or 35 to 40 and 1 or more obesity-related condition was conducted at 10 sites in the United States and Australia between May and December 2011. The 12-month blinded portion of the 5-year study was completed in January 2013.One hundred sixty-two patients received an active vagal nerve block device and 77 received a sham device. All participants received weight management education.The coprimary efficacy objectives were to determine whether the vagal nerve block was superior in mean percentage excess weight loss to sham by a 10-point margin with at least 55% of patients in the vagal block group achieving a 20% loss and 45% achieving a 25% loss. The primary safety objective was to determine whether the rate of serious adverse events related to device, procedure, or therapy in the vagal block group was less than 15%.In the intent-to-treat analysis, the vagal nerve block group had a mean 24.4% excess weight loss (9.2% of their initial body weight loss) vs 15.9% excess weight loss (6.0% initial body weight loss) in the sham group. The mean difference in the percentage of the excess weight loss between groups was 8.5 percentage points (95% CI, 3.1-13.9), which did not meet the 10-point target (P = .71), although weight loss was statistically greater in the vagal nerve block group (P = .002 for treatment difference in a post hoc analysis). At 12 months, 52% of patients in the vagal nerve block group achieved 20% or more excess weight loss and 38% achieved 25% or more excess weight loss vs 32% in the sham group who achieved 20% or more loss and 23% who achieved 25% or more loss. The device, procedure, or therapy-related serious adverse event rate in the vagal nerve block group was 3.7% (95% CI, 1.4%-7.9%), significantly lower than the 15% goal. The adverse events more frequent in the vagal nerve block group were heartburn or dyspepsia and abdominal pain attributed to therapy; all were reported as mild or moderate in severity.Among patients with morbid obesity, the use of vagal nerve block therapy compared with a sham control device did not meet either of the prespecified coprimary efficacy objectives, although weight loss in the vagal block group was statistically greater than in the sham device group. The treatment was well tolerated, having met the primary safety Identifier: NCT01327976.

    View details for DOI 10.1001/jama.2014.10540

    View details for PubMedID 25182100

  • Does hospital accreditation impact bariatric surgery safety? Annals of surgery Morton, J. M., Garg, T., Nguyen, N. 2014; 260 (3): 504-509


    To evaluate the impact of hospital accreditation upon bariatric surgery outcomes.Since 2004, the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery have accredited bariatric hospitals. Few studies have evaluated the impact of hospital accreditation on all bariatric surgery outcomes.Bariatric surgery hospitalizations were identified using International Classification of Diseases, Ninth Revision (ICD9) codes in the 2010 Nationwide Inpatient Sample (NIS). Hospital names and American Hospital Association (AHA) codes were used to identify accredited bariatric centers. Relevant ICD9 codes were used for identifying demographics, length of stay (LOS), total charges, mortality, complications, and failure to rescue (FTR) events.There were 117,478 weighted bariatric patient discharges corresponding to 235 unique hospitals in the 2010 NIS data set. A total of 72,615 (61.8%) weighted discharges, corresponding to 145 (61.7%) named or AHA-identifiable hospitals were included. Among the 145 hospitals, 66 (45.5%) were unaccredited and 79 (54.5%) accredited. Compared with accredited centers, unaccredited centers had a higher mean LOS (2.25 vs 1.99 days, P < 0.0001), as well as total charges ($51,189 vs $42,212, P < 0.0001). Incidence of any complication was higher at unaccredited centers than at accredited centers (12.3% vs 11.3%, P = 0.001), as was mortality (0.13% vs 0.07%, P = 0.019) and FTR (0.97% vs 0.55%, P = 0.046). Multivariable logistic regression analysis identified unaccredited status as a positive predictor of incidence of complication [odds ratio (OR) = 1.08, P < 0.0001], as well as mortality (OR = 2.13, P = 0.013).Hospital accreditation status is associated with safer outcomes, shorter LOS, and lower total charges after bariatric surgery.

    View details for DOI 10.1097/SLA.0000000000000891

    View details for PubMedID 25115426

  • Systematic review on reoperative bariatric surgery American Society for Metabolic and Bariatric Surgery Revision Task Force SURGERY FOR OBESITY AND RELATED DISEASES Brethauer, S. A., Kothari, S., Sudan, R., Williams, B., English, W. J., Brengman, M., Kurian, M., Hutter, M., Stegemann, L., Kallies, K., Nguyen, N. T., Ponce, J., Morton, J. M. 2014; 10 (5): 952-972


    Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures.Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies.A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery.The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.

    View details for DOI 10.1016/j.soard.2014.02.014

    View details for Web of Science ID 000344719200040

    View details for PubMedID 24776071

  • Increasing Access to Specialty Surgical Care Application of a New Resource Allocation Model to Bariatric Surgery ANNALS OF SURGERY Leroux, E. J., Morton, J. M., Rivas, H. 2014; 260 (2): 274-278
  • COMPARATIVE EFFECTIVENESS OF BARIATRIC SURGERY AMONG THE SUPER OBESE 19th World Congress of the International-Federation-for-the-Surgery-of-Obesity-and-Metabolic-Disorders (IFSO) Morton, J. M., Rosas, U., Rivas, H., Garg, T., Rogan, D. SPRINGER. 2014: 1215–16
  • Metabolic surgery: action via hormonal milieu changes, changes in bile acids or gut microbiota? A summary of the literature. Best practice & research. Clinical gastroenterology Sweeney, T. E., Morton, J. M. 2014; 28 (4): 727-740


    Obesity and type 2 diabetes remain epidemic problems. Different bariatric surgical techniques causes weight loss and diabetes remission to varying degrees. The underlying mechanisms of the beneficial effects of bariatric surgery are complex, and include changes in diet and behaviour, as well as changes in hormones, bile acid flow, and gut bacteria. We summarized the effects of multiple different bariatric procedures, and their resulting effects on several hormones (leptin, ghrelin, adiponectin, glucagon-like peptide 1 (GLP-1), peptide YY, and glucagon), bile acid changes in the gut and the serum, and resulting changes to the gut microbiome. As much as possible, we have tried to incorporate multiple studies to try to explain underlying mechanistic changes. What emerges from the data is a picture of clear differences between restrictive and metabolic procedures. The latter, in particular the roux-en-Y gastric bypass, induces large and distinctive changes in most measured fat and gut hormones, including early and sustained increase in GLP-1, possible through intestinal bile acid signalling. The changes in bile flow and the gut microbiome are causally inseparable so far, but new studies show that each contributes to the effects of weight loss and diabetes resolution.

    View details for DOI 10.1016/j.bpg.2014.07.016

    View details for PubMedID 25194186

  • Metabolic surgery: Action via hormonal milieu changes, changes in bile acids or gut microbiota ? A summary of the literature BEST PRACTICE & RESEARCH IN CLINICAL GASTROENTEROLOGY Sweeney, T. E., Morton, J. M. 2014; 28 (4): 727-740
  • What variables are associated with successful weight loss outcomes for bariatric surgery after 1 year? SURGERY FOR OBESITY AND RELATED DISEASES Robinson, A. H., Adler, S., Stevens, H. B., Darcy, A. M., Morton, J. M., Safer, D. L. 2014; 10 (4): 697-704
  • What variables are associated with successful weight loss outcomes for bariatric surgery after 1 year? Surgery for obesity and related diseases Robinson, A. H., Adler, S., Stevens, H. B., Darcy, A. M., Morton, J. M., Safer, D. L. 2014; 10 (4): 697-704


    Prior evidence indicates that predictors of weight loss outcomes after gastric bypass surgery fall within 5 domains: 1) presurgical factors, 2) postsurgical psychosocial variables (e.g., support group attendance), 3) postsurgical eating patterns, 4) postsurgical physical activity, and 5) follow-up at postsurgical clinic. However, little data exist on which specific behavioral predictors are most associated with successful outcomes (e.g.,≥50% excess weight loss) when considering the 5 domains simultaneously. The objective of this study was to specify the behavioral variables, and their respective cutoff points, most associated with successful weight loss outcomes.Signal detection analysis evaluated associations between 84 pre- and postsurgical behavioral variables (within the 5 domains) and successful weight loss at≥1 year in 274 postgastric bypass surgery patients.Successful weight loss was highest (92.6%) among those reporting dietary adherence of>3 on a 9-point scale (median = 5) who grazed no more than once-per-day. Among participants reporting dietary adherence<3 and grazing daily or less, success rates more than doubled when highest lifetime body mass index was<53.7 kg/m(2). Success rates also doubled for participants with dietary adherence = 3 if attending support groups. No variables from the physical activity or postsurgical follow-up domains were significant, nor were years since surgery. The overall model's sensitivity = .62, specificity = .92.To our knowledge, this is the first study to simultaneously consider the relative contribution of behavioral variables within 5 domains and offer clinicians an assessment algorithm identifying cut-off points for behaviors most associated with successful postsurgical weight loss. Such data may inform prospective study designs and postsurgical interventions.

    View details for DOI 10.1016/j.soard.2014.01.030

    View details for PubMedID 24913590

  • The first metabolic and bariatric surgery accreditation and quality improvement program quality initiative: Decreasing readmissions through opportunities provided Annual Meeting of the American-Society-for-Metabolic-and-Bariatric-Surgery (ASMBS) Morton, J. ELSEVIER SCIENCE INC. 2014: 377–78
  • Does chronic kidney disease affect outcomes after major abdominal surgery? Results from the national surgical quality improvement program. Journal of gastrointestinal surgery Cloyd, J. M., Ma, Y., Morton, J. M., Kurella Tamura, M., Poultsides, G. A., Visser, B. C. 2014; 18 (3): 605-612


    The impact of chronic kidney disease (CKD) and end-stage renal disease on outcomes following major abdominal surgery is not well defined.The 2008 NSQIP database was queried to identify adult patients undergoing complex abdominal surgery (major colorectal, hepatobiliary, pancreatic, gastric, and esophageal operations). Thirty-day morbidity and mortality in patients on hemodialysis (HD) versus patients not on HD were compared. The impact of preoperative renal insufficiency, measured by glomerular filtration rate (GFR), on morbidity and mortality was then assessed in non-dialysis patients.Of 24,572 patients who underwent major abdominal operations, excluding emergency cases, only 149 (0.6 %) were on HD preoperatively. Thirty-day mortality in the HD group was 12.8 % compared to 1.8 % for those not on HD (p < 0.0001). Overall complication rate was 23.5 versus 12.3 % (p < 0.0001). In particular, rates of pneumonia (6.7 vs 3.0 %, p < 0.05) and sepsis (12.8 vs 5.3 %, p < 0.001) were higher in patients on HD. In patients not on HD, GFR was significantly predictive of postoperative mortality after controlling for age, gender, race, emergency status, and comorbidities. Compared to patients with normal preoperative kidney function (GFR, 75-90 ml/min/1.73 m(2)), even modest CKD (GFR, 45-60 ml/min/1.73 m(2)) was associated with increased postoperative mortality (odds ratio (OR), 1.62). With greater impairment in kidney function, postoperative mortality was even more marked (GFR, 30-45 ml/min/1.73 m(2) and OR, 2.84; GFR, 15-30 ml/min/1.73 m(2) and OR, 5.56). In addition, CKD was independently associated with increased postoperative complications.Any degree of preoperative kidney impairment, even mild asymptomatic disease, is associated with clinically significant increases in 30-day postoperative morbidity and mortality following major abdominal surgery.

    View details for DOI 10.1007/s11605-013-2390-3

    View details for PubMedID 24241964

  • Is ambulatory laparoscopic roux-en-y gastric bypass associated with higher adverse events? Annals of surgery Morton, J. M., Winegar, D., Blackstone, R., Wolfe, B. 2014; 259 (2): 286-292


    To determine the impact of length of stay upon 30-day outcomes.It has been recommended the goal length of stay (LOS) after laparoscopic Roux-en-Y gastric bypass (LRYGB) should be 1 day to improve resource utilization. This study's aim was to assess LRYGB outcomes by LOS.Data were obtained from the BOLD (Bariatric Outcomes Longitudinal Database) for 51,788 laparoscopic gastric bypass (LRYGB) procedures performed between 2007 and 2010. Logistic regression models were used to evaluate age, sex, race, body mass index, insurance status, comorbidities, and LOS as predictors for 30-day mortality, serious complications, and readmissions.Overall patient demographics were as follows: median age, 45 years; median body mass index, 46.3 kg/m; % female, 78.6; % white, 77.8; % private insurance, 86.2; and % comorbidities more than 5 (39.1%). Overall, 30-day outcomes included mortality, 0.1%; serious complications, 0.5%; and readmissions, 3.8%. median LOS was 2 days, and the distribution of LOS was as follows [n (%)]: 0 (1.0), 1 (18.4), 2 (59.0), 3 (17.5), and 4 (4.1). Using the median LOS 2 days as reference, the logistic regression analysis revealed that ambulatory LOS of was significantly associated with increased risk of 30-day mortality (odds ratio: 13.02; P < 0.0001) as was LOS 1 day (odds ratio: 2.02; P < 0.0552). For LOS of 0 day, there was a trend toward an increase in the rate of 30-day serious complications (odds ratio: 1.9; P < 0.16). There was no significant trend between LOS status and 30-day readmission rates.In this large, prospective, clinical database, LOS of 1 day or less for LRYGB patients was significantly associated with an increased risk of 30-day mortality and a trend toward increased risk of 30-day serious complications.

    View details for DOI 10.1097/SLA.0000000000000227

    View details for PubMedID 24169190

  • Influence of Ethnicity on the Efficacy and Utilization of Bariatric Surgery in the USA 54th Annual Meeting of the Society-for-Surgery-of-the-Alimentary-Tract (SSAT) / Digestive Disease Week (DDW) / Annual Meeting of the Pancrease-Club Sudan, R., Winegar, D., Thomas, S., Morton, J. SPRINGER. 2014: 130–36


    Ethnic disparities in patterns of utilization and outcomes after Roux-en-Y gastric bypass surgery (RYGB) were examined from Bariatric Outcomes Longitudinal Database.Descriptive statistics were used for demographics of Whites, Blacks, or Hispanics undergoing RYGB with 1 year of follow-up, between June 2007 and October 2011. Multivariate logistic and normal regression models, controlling for baseline characteristics, examined relationships between race and outcomes. T tests were used for continuous variables and Pearson chi-square test for categorical variables.Study patients (108,333) were79 % White, 12 % Black, and 9 % Hispanic. Fewer Black males underwent surgery (15 %) compared to Whites or Hispanics (∼22 %). Blacks compared to Whites were younger (42.7 ± 10.6 vs. 46.4 ± 11.6 years), heavier BMI (50 ± 9.1 vs. 47.4 ± 8.0 kg/m(2)), and more often hypertensive (57 vs. 52 %). Other comorbidities were higher in Whites. Thirty-day mortality rate was equivalent (0.23-0.26 %), but serious adverse events were higher for Blacks (3.65 %) versus Whites (3.19 %) and Hispanics (2.01 %). At 1 year, weight and comorbidity burden declined significantly but less in Blacks despite adjustment for baseline characteristics.Fewer Black males underwent RYGB. Despite a smaller percent decline in BMI and comorbidities in Blacks, all races benefitted significantly from RYGB. Influence of other factors such as diet, culture, and genetics needs to be investigated further.

    View details for DOI 10.1007/s11605-013-2368-1

    View details for Web of Science ID 000329405400032

    View details for PubMedID 24101449

  • Letter to the editor. Surgery for obesity and related diseases Morton, J. M., Wolfe, B. 2013; 9 (5): 831-832

    View details for DOI 10.1016/j.soard.2013.06.001

    View details for PubMedID 23911346

  • Comparative effectiveness of bariatric surgery for cardiac risk factor improvement 99th Annual Clinical Congress of the American-College-of-Surgeons / 68th Annual Sessions of the Owen H Wangensteen Surgical Forum on Fundamental Surgical Problems Morton, J. M., Crowe, C., Leva, N., Rivas, H. ELSEVIER SCIENCE INC. 2013: S15–S16
  • Letter to the editor: Response to JAMA article which did not accept these letters delineating numerous problems with the published study. Surgery for obesity and related diseases Morton, J. M., Nguyen, N. 2013; 9 (5): 831-?

    View details for DOI 10.1016/j.soard.2013.06.002

    View details for PubMedID 24079903

  • Kidney failure in a transplant from an identical twin. American journal of kidney diseases Lum, E. L., Morton, J. M., Melcher, M. L. 2013; 62 (2): xxi-xxiii

    View details for DOI 10.1053/j.ajkd.2013.03.046

    View details for PubMedID 23883662

  • The Human Gut Microbiome A Review of the Effect of Obesity and Surgically Induced Weight Loss JAMA SURGERY Sweeney, T. E., Morton, J. M. 2013; 148 (6): 563-569


    Recent advances in parallel genomic processing and computational mapping have been applied to the native human microbial environment to provide a new understanding of the role of the microbiome in health and disease. In particular, studies of the distal gut microbiome have proposed that changes in gut microbiota are related to obesity, the metabolic syndrome, and Western diet. We examined the changes in the distal gut microbiome composition as it relates to the lean and obese phenotypes, particularly after surgical weight loss. A PubMed search of publications from January 1, 2005, through December 31, 2012, used the search terms weight, obesity, microbiome, and bariatric surgery. We included studies that provided information on subjects' weight and/or body mass index and a formal assessment of the microbiome. Certain bacteria, specifically the archaeon Methanobrevibacter smithii, have enhanced ability to metabolize dietary substrate, thereby increasing host energy intake and weight gain. With weight loss, there is a decrease in the ratio of Firmicutes to Bacteroidetes phyla. One major finding from microbial sequencing analyses after Roux-en-Y gastric bypass is the comparative overabundance of Proteobacteria in the distal gut microbiome, which is distinct from the changes seen in weight loss without Roux-en-Y gastric bypass. This review provides the practicing surgeon with (1) an update on the state of a rapidly innovating branch of clinical bioinformatics, specifically, the microbiome; (2) a new understanding of the microbiome changes after Roux-en-Y gastric bypass and weight loss; and (3) a basis for understanding further clinical applications of studies of the distal gut microbiome, such as in Crohn disease, ulcerative colitis, and infectious colitis.

    View details for DOI 10.1001/jamasurg.2013.5

    View details for Web of Science ID 000321981600021

    View details for PubMedID 23571517

  • COMPARATIVE EFFECTIVENESS FOR BARIATRIC SURGERY: CARDIAC RISK FACTOR REDUCTION 62nd Annual Scientific Session of the American-College-of-Cardiology Morton, J., Crowe, C., Leva, N., Garg, T. ELSEVIER SCIENCE INC. 2013: E1425–E1425
  • Hospital readmission after a pancreaticoduodenectomy: an emerging quality metric? HPB Kastenberg, Z. J., Morton, J. M., Visser, B. C., Norton, J. A., Poultsides, G. A. 2013; 15 (2): 142-148


    Hospital readmission has attracted attention from policymakers as a measure of quality and a target for cost reduction. The aim of the study was to evaluate the frequency and patterns of rehospitalization after a pancreaticoduodenectomy (PD).The records of all patients undergoing a PD at an academic medical centre for malignant or benign diagnoses between January 2006 and September 2011 were retrospectively reviewed. The incidence, aetiology and predictors of subsequent readmission(s) were analysed.Of 257 consecutive patients who underwent a PD, 50 (19.7%) were readmitted within 30 days from discharge. Both the presence of any post-operative complication (P = 0.049) and discharge to a nursing/rehabilitation facility or to home with health care services (P = 0.018) were associated with readmission. The most common reasons for readmission were diet intolerance (36.0%), pancreatic fistula/abscess (26.0%) and superficial wound infection (8.0%). Nine (18.0%) readmissions had lengths of stay of 2 days or less and in four of those (8.0%) diagnostic evaluation was eventually negative.Approximately one-fifth of patients require hospital readmission within 30 days of discharge after a PD. A small fraction of these readmissions are short (2 days or less) and may be preventable or manageable in the outpatient setting.

    View details for DOI 10.1111/j.1477-2574.2012.00563.x

    View details for Web of Science ID 000313548400009

    View details for PubMedID 23297725

  • Comment on: Outcomes of bariatric surgery in patients with BMI less than 35 kg/m². Surgery for obesity and related diseases Morton, J. 2013; 9 (1): 150-?

    View details for DOI 10.1016/j.soard.2011.12.005

    View details for PubMedID 22266277

  • Severe worsening of diabetic retinopathy following bariatric surgery. Ophthalmic surgery, lasers & imaging retina Silva, R. A., Morton, J. M., Moshfeghi, D. M. 2013; 44 (6): E11-4


    Intensive glycemic control results in long-term reduction of diabetic retinopathy, although initial short-term worsening of retinopathy is not uncommon. The authors report a patient with a history of stable diabetic retinopathy who, despite achieving abrupt glycemic control following laparoscopic Roux-en-Y gastric bypass surgery, suffered rapid worsening of her retinopathy within 1 month of surgery. Hemoglobin A1c levels were 8.8 preoperatively and declined to 7.2 at 3.5 months postoperatively. Although visual function in the left eye was spared, useful visual acuity was lost in the right eye. Retinal evaluation is recommended in all patients with diabetes mellitus who are considering bariatric surgery, with close follow-up as warranted.

    View details for DOI 10.3928/23258160-20131009-01

    View details for PubMedID 24131131

  • The EMPOWER Study: Randomized, Prospective, Double-Blind, Multicenter Trial of Vagal Blockade to Induce Weight Loss in Morbid Obesity OBESITY SURGERY Sarr, M. G., Billington, C. J., Brancatisano, R., Brancatisano, A., Toouli, J., Kow, L., Nguyen, N. T., Blackstone, R., Maher, J. W., Shikora, S., Reeds, D. N., Eagon, J. C., Wolfe, B. M., O'Rourke, R. W., Fujioka, K., Takata, M., Swain, J. M., Morton, J. M., Ikramuddin, S., Schweitzer, M., Chand, B., Rosenthal, R. 2012; 22 (11): 1771-1782


    Intermittent, reversible intraabdominal vagal blockade (VBLOC® Therapy) demonstrated clinically important weight loss in feasibility trials. EMPOWER, a randomized, double-blind, prospective, controlled trial was conducted in USA and Australia.Five hundred three subjects were enrolled at 15 centers. After informed consent, 294 subjects were implanted with the vagal blocking system and randomized to the treated (n = 192) or control (n = 102) group. Main outcome measures were percent excess weight loss (percent EWL) at 12 months and serious adverse events. Subjects controlled duration of therapy using an external power source; therapy involved a programmed algorithm of electrical energy delivered to the subdiaphragmatic vagal nerves to inhibit afferent/efferent vagal transmission. Devices in both groups performed regular, low-energy safety checks. Data are mean ± SEM.Study subjects consisted of 90 % females, body mass index of 41 ± 1 kg/m(2), and age of 46 ± 1 years. Device-related complications occurred in 3 % of subjects. There was no mortality. 12-month percent EWL was 17 ± 2 % for the treated and 16 ± 2 % for the control group. Weight loss was related linearly to hours of device use; treated and controls with ≥ 12 h/day use achieved 30 ± 4 and 22 ± 8 % EWL, respectively.VBLOC® therapy to treat morbid obesity was safe, but weight loss was not greater in treated compared to controls; clinically important weight loss, however, was related to hours of device use. Post-study analysis suggested that the system electrical safety checks (low charge delivered via the system for electrical impedance, safety, and diagnostic checks) may have contributed to weight loss in the control group.

    View details for DOI 10.1007/s11695-012-0751-8

    View details for Web of Science ID 000309876800018

    View details for PubMedID 22956251

  • The Effect of Positive and Negative Verbal Feedback on Surgical Skills Performance and Motivation Annual Spring Meeting of the Association-for-Program-Directors-in-Surgery (APDS) Kannappan, A., Yip, D. T., Lodhia, N. A., Morton, J., Lau, J. N. ELSEVIER SCIENCE INC. 2012: 798–801


    There is considerable effort and time invested in providing feedback to medical students and residents during their time in training. However, little effort has been made to measure the effects of positive and negative verbal feedback on skills performance and motivation to learn and practice. To probe these questions, first-year medical students (n = 25) were recruited to perform a peg transfer task on Fundamentals of Laparoscopic Surgery box trainers. Time to completion and number of errors were recorded. The students were then randomized to receive either positive or negative verbal feedback from an expert in the field of laparoscopic surgery. After this delivery of feedback, the students repeated the peg transfer task. Differences in performance pre- and post-feedback and also between the groups who received positive feedback (PF) vs negative feedback (NF) were analyzed. A survey was then completed by all the participants. Baseline task times were similar between groups (PF 209.3 seconds; NF 203 seconds, p = 0.58). The PF group averaged 1.83 first-time errors while the NF group 1 (p = 0.84). Post-feedback task times were significantly decreased for both groups (PF 159.75 seconds, p = 0.05; NF 132.08 seconds, p = 0.002). While the NF group demonstrated a greater improvement in mean time than the PF group, this was not statistically significant. Both groups also made fewer errors (PF 0.33 errors, p = 0.04; NF 0.38 errors, p = 0.23). When surveyed about their responses to standardized feedback scenarios, the students stated that both positive and negative verbal feedback could be potent stimulants for improved performance and motivation. Further research is required to better understand the effects of feedback on learner motivation and the interpersonal dynamic between mentors and their trainees.

    View details for DOI 10.1016/j.jsurg.2012.05.012

    View details for Web of Science ID 000311024100021

    View details for PubMedID 23111049

  • Normal Alcohol Metabolism after Gastric Banding and Sleeve Gastrectomy: A Case-Cross-Over Trial JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Changchien, E. M., Woodard, G. A., Hernandez-Boussard, T., Morton, J. M. 2012; 215 (4): 475-479


    Severe obesity remains the leading public health concern of the industrialized world, with bariatric surgery as the only current effective enduring treatment. In addition to gastric bypass, gastric banding and sleeve gastrectomy have emerged as viable treatment options for the severely obese. Occasionally, poor postoperative psychological adjustment has been reported. It has been previously demonstrated that breath alcohol content (BAC) levels and time to sober were increased in postoperative gastric bypass patients. The aim of this study was to examine whether alcohol metabolism in patients undergoing restrictive-type bariatric procedures is also altered.Nine patients undergoing laparoscopic adjustable gastric banding (LAGB) and 7 patients undergoing laparoscopic sleeve gastrectomy (LSG) were recruited. Preoperatively, 3-month and 6-month BAC and time to sober were measured after administration of 5 ounces of red wine. In addition, participants were asked to complete a questionnaire of drinking habits.The 16 total participants achieved a mean 44.7% 6-month excess weight loss. There were no significant changes in peak BAC or time to sober from preoperative levels (0.033%, 67.8 min, respectively) to 3 months (0.032%, 77.1 min, respectively, p = 0.421) or 6 months (0.035%, 81.2 min, respectively, p = 0.198).Patients undergoing LAGB and LSG do not share the same altered alcohol metabolism as seen in gastric bypass patients. However, all bariatric surgery patients should be counseled regarding alcohol use.

    View details for DOI 10.1016/j.jamcollsurg.2012.06.008

    View details for Web of Science ID 000308910300003

    View details for PubMedID 22770864

  • Obesity Disparities in Preventive Care: Findings From the National Ambulatory Medical Care Survey, 2005-2007 OBESITY Hernandez-Boussard, T., Ahmed, S. M., Morton, J. M. 2012; 20 (8): 1639-1644


    Obesity and its consequences are a major health concern. There are conflicting reports regarding utilization of preventive health-care services among obese patients. Our objective was to determine whether obese patients receive the same preventive care as normal weight patients. Weighted patient clinic visit data from the National Ambulatory Medical Care Survey (NAMCS) were analyzed for all adult patient visits with height/weight data (N = 866,415,856) from 2005 to 2007. Preventive care practice patterns were compared among different weight groups of normal, obese, and morbidly obese. Obese patients received the least number of preventive exams with a clear gradient present by weight. Obese patients were significantly less likely to receive cancer screening including breast examination (normal weight, reference, obese, odds ratio (OR), 0.8), mammogram (obese OR, 0.7), pap smear (obese OR, 0.7), pelvic exam (obese OR, 0.8), and rectal exam (obese OR, 0.7). The obese population also received less tobacco (obese OR, 0.7) and injury prevention education (obese OR, 0.7), yet significantly more diet, exercise, and weight reduction education. Significant differences in clinic practice patterns relative to normal weight patients were also evident with more physician referral (obese OR, 1.2) and less likely to see physician at the index clinic visit (obese OR, 0.8) and less likely to receive psychotherapy referral (obese OR, 0.6). Significant gaps in preventive care exist for the obese including cancer screening, tobacco cessation and injury prevention counseling, and psychological referral. Although obese patients received more weight-related education, this emphasis may have the consequence of de-emphasizing other needed preventive health measures.

    View details for DOI 10.1038/oby.2011.258

    View details for Web of Science ID 000306920900013

    View details for PubMedID 21818146

  • Weighing in on bariatric surgery: who and when? International journal of obesity supplements Lodhia, N. A., Morton, J. M. 2012; 2: S47-S50


    Over two-thirds of the United States is overweight or obese, and over 5% of the country is morbidly obese. Numerous public health preventative measures have been established to help battle this public health epidemic. Surgical obesity treatment, although now gaining popularity, has been an underutilized treatment option for obesity. Patients with a body mass index (BMI) of >40 or >35 kg m(-2) with two or more comorbid conditions are eligible for bariatric surgery. Currently, the three most popular bariatric surgeries are Roux-en-y gastric bypass, sleeve gastrectomy and gastric banding procedures, all overwhelmingly performed laparoscopically. The purpose of this article is to discuss the heterogeneity of bariatric surgery. In our practice, among 834 patients operated over a 4-year period (2006-2010), patients were of an average age of 45 years (16-73 years), 80.4% were female patients, 82.5% had private insurance, 61% were White, 17% were Hispanic and 9% were Black. Patients had an average BMI of 46.2 kg m(-2) (30.1-75.3 kg m(-2)), waist circumference of 133.6 cm (68.6-207.8 cm) and four preoperative comorbidities (0-11 comorbidities). Variation exists in surgeon practice patterns for preoperative weight-loss recommendations and complication rates based on surgery case volume. Despite variation in patient, surgeon and hospital characteristics, bariatric surgery outcomes are generally highly safe and effective.

    View details for PubMedID 25018871

  • Laparoscopic vs Open Gastric Bypass Surgery Differences in Patient Demographics, Safety, and Outcomes ARCHIVES OF SURGERY Banka, G., Woodard, G., Hernandez-Boussard, T., Morton, J. M. 2012; 147 (6): 550-556


    To determine national outcome differences between laparoscopic Roux-en-Y gastric bypass (LRYGB) and open Roux-en-Y gastric bypass (ORYGB).Retrospective cohort study.The Nationwide Inpatient Sample.Patients undergoing ORYGB and LRYGB.Outcome measures were number of procedures performed, patient and hospital characteristics, patient complications, mortality, length of stay, resource use, and Agency for Healthcare Research and Quality Patient Safety Indicators. Both demographic and outcomes variables were compared by either t test or χ2 analysis, with regression analysis adjusting for confounding variables.The ORYGB and LRYGB cohorts consisted of 41 094 and 115 177 cases, respectively. From 2005 to 2007, LRYGB was more commonly performed than ORYGB (72% vs 28%; P < .001) and at high-volume hospitals (69% vs 61%; P < .001). A higher percentage of ORYGB compared with LRYGB patients were Medicare (9.3% vs 7.1%) and Medicaid (10.4% vs 5.9%; P < .01) beneficiaries. More ORYGB patients compared with LRYGB patients were discharged with nonroutine dispositions (7.7% vs 2.4%; P = .005), died (0.2% vs 0.1%; P < .001), and had 1 or more complications (18.7% vs 12.3%; P < .001). All Patient Safety Indicator rates were higher for ORYGB. Patients who had ORYGB compared with LRYGB also had longer median lengths of stay (3.5 vs 2.4 days; P < .001) and higher total charges ($35 018 vs $32 671; P < .001). Patients who had LRYGB had a lower odds ratio than patients who had ORYGB for both mortality (odds ratio, 0.54; P < .001) and having 1 or more complications (odds ratio, 0.66; P < .001) even after adjusting for confounding variables.In this population-based study, LRYGB provided greater safety than ORYGB even after adjusting for patient-level socioeconomic and comorbidity differences.

    View details for Web of Science ID 000305428500014

    View details for PubMedID 22786543

  • Effect of Roux-en-Y gastric bypass on testosterone and prostate-specific antigen BRITISH JOURNAL OF SURGERY Woodard, G., Ahmed, S., Podelski, V., Hernandez-Boussard, T., Presti, J., Morton, J. M. 2012; 99 (5): 693-698


    Obese men have lower serum levels of testosterone, dehydroepiandrosterone (DHEA) and prostate-specific antigen (PSA), but an increased risk of dying from prostate cancer. The aim of this study was to examine the effect of surgically induced weight loss on serum testosterone, DHEA and PSA levels in obese men.Consecutive men undergoing Roux-en-Y gastric bypass (RYGB) participated in a prospective, longitudinal study. Main outcomes were changes were body mass index (BMI), percentage excess weight loss, serum levels of testosterone, DHEA and PSA, PSA mass and plasma volume, measured before operation and 3, 6 and 12 months later.In 64 patients, mean BMI fell from 48.2 kg/m(2) before operation to 39.2, 35.6 and 32.4 kg/m(2) at 3, 6 and 12 months after RYGB. Testosterone levels rose significantly from 259 ng/dl to 386, 452 and 520 ng/dl respectively. Serum PSA levels increased significantly from 0.51 ng/ml to 0.67 ng/ml at 12 months. There were no significant changes in DHEA or PSA mass.RYGB normalizes the serum testosterone level. PSA levels increase with weight loss and may be inversely correlated with changes in plasma volume, indicating that PSA levels may be artificially low in obese men owing to haemodilution.

    View details for DOI 10.1002/bjs.8693

    View details for Web of Science ID 000303150700016

    View details for PubMedID 22302466

  • Short-term medication cost savings for treating hypertension and diabetes after gastric bypass SURGERY FOR OBESITY AND RELATED DISEASES Ghiassi, S., Morton, J., Bellatorre, N., Eisenberg, D. 2012; 8 (3): 269-274


    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.

    View details for DOI 10.1016/j.soard.2011.05.009

    View details for Web of Science ID 000304520900005

    View details for PubMedID 21723203

  • Determinants of Adverse Events in Vascular Surgery JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Hernandez-Boussard, T., McDonald, K. M., Morton, J. M., Dalman, R. L., Bech, F. R. 2012; 214 (5): 788-797


    Patient safety is a national priority. Patient Safety Indicators (PSIs) monitor potential adverse events during hospital stays. Surgical specialty PSI benchmarks do not exist, and are needed to account for differences in the range of procedures performed, reasons for the procedure, and differences in patient characteristics. A comprehensive profile of adverse events in vascular surgery was created.The Nationwide Inpatient Sample was queried for 8 vascular procedures using ICD-9-CM codes from 2005 to 2009. Factors associated with PSI development were evaluated in univariate and multivariate analyses.A total of 1,412,703 patients underwent a vascular procedure and a PSI developed in 5.2%. PSIs were more frequent in female, nonwhite patients with public payers (p < 0.01). Patients at mid and low-volume hospitals had greater odds of developing a PSI (odds ratio [OR] = 1.17; 95% CI, 1.10-1.23 and OR = 1.69; 95% CI, 1.53-1.87). Amputations had highest PSI risk-adjusted rate and carotid endarterectomy and endovascular abdominal aortic aneurysm repair had lower risk-adjusted rate (p < 0.0001). PSI risk-adjusted rate increased linearly by severity of patient indication: claudicants (OR = 0.40; 95% CI, 0.35-0.46), rest pain patients (OR = 0.78; 95% CI, 0.69-0.90), ulcer (OR = 1.20; 95% CI, 1.07-1.34), and gangrene patients (OR = 1.85; 95% CI, 1.66-2.06).Patient safety events in vascular surgery were high and varied by procedure, with amputations and open abdominal aortic aneurysm repair having considerably more potential adverse events. PSIs were associated with black race, public payer, and procedure indication. It is important to note the overall higher rates of PSIs occurring in vascular patients and to adjust benchmarks for this surgical specialty appropriately.

    View details for DOI 10.1016/j.jamcollsurg.2012.01.045

    View details for Web of Science ID 000303724200009

    View details for PubMedID 22425449

  • Relationship between Patient Safety and Hospital Surgical Volume HEALTH SERVICES RESEARCH Hernandez-Boussard, T., Downey, J. R., McDonald, K., Morton, J. M. 2012; 47 (2): 756-769


    To examine the relationship between hospital volume and in-hospital adverse events.Patient safety indicator (PSI) was used to identify hospital-acquired adverse events in the Nationwide Inpatient Sample database in abdominal aortic aneurysm, coronary artery bypass graft, and Roux-en-Y gastric bypass from 2005 to 2008.In this observational study, volume thresholds were defined by mean year-specific terciles. PSI risk-adjusted rates were analyzed by volume tercile for each procedure.Overall, hospital volume was inversely related to preventable adverse events. High-volume hospitals had significantly lower risk-adjusted PSI rates compared to lower volume hospitals (p < .05).These data support the relationship between hospital volume and quality health care delivery in select surgical cases. This study highlights differences between hospital volume and risk-adjusted PSI rates for three common surgical procedures and highlights areas of focus for future studies to identify pathways to reduce hospital-acquired events.

    View details for DOI 10.1111/j.1475-6773.2011.01310.x

    View details for Web of Science ID 000301229300012

    View details for PubMedID 22091561

  • Postoperative vitamin deficiencies in patients undergoing laparoscopic roux-en-y gastric bypass Experimental Biology Meeting 2012 Lodhia, N. A., Almario, L. V., Eltorai, A., Kattan, J., Nkansah, M. M., Kerolus, M., Kiely, K., Morton, J. FEDERATION AMER SOC EXP BIOL. 2012
  • Is Patient Safety Improving? National Trends in Patient Safety Indicators: 1998-2007 HEALTH SERVICES RESEARCH Downey, J. R., Hernandez-Boussard, T., Banka, G., Morton, J. M. 2012; 47 (1): 414-430


    Emphasis has been placed on quality and patient safety in medicine; however, little is known about whether quality over time has actually improved in areas such as patient safety indicators (PSIs).To determine whether national trends for hospital PSIs have improved from 1998 to 2007.Using PSI criteria from the Agency for Healthcare Research and Quality, PSIs were identified in the Nationwide Inpatient Sample (NIS) for all eligible inpatient admissions between 1998 and 2007. Joinpoint regression was used to estimate annual percentage changes (APCs) for PSIs.Annual percent change for PSIs.From 1998 to 2007, 7.6 million PSI events occurred for over 69 million hospitalizations. A total of 14 PSIs showed statistically significant trends. Seven PSIs had increasing APC: postoperative pulmonary embolism or deep vein thrombosis (8.94), postoperative physiological or metabolic derangement (7.67), postoperative sepsis (7.17), selected infections due to medical care (4.05), decubitus ulcer (3.05), accidental puncture or laceration (2.64), and postoperative respiratory failure (1.46). Seven PSIs showed decreasing APCs: birth trauma injury to neonate (-17.79), failure to rescue (-6.05), postoperative hip fracture (-5.86), obstetric trauma-vaginal without instrument (-5.69), obstetric trauma-vaginal with instrument (-4.11), iatrogenic pneumothorax (-2.5), and postoperative wound dehiscence (-1.8).This is the first study to establish national trends of PSIs during the past decade indicating areas for potential quality improvement prioritization. While many factors influence these trends, the results indicate opportunities for either emulation or elimination of current patient safety trends.

    View details for DOI 10.1111/j.1475-6773.2011.01361.x

    View details for Web of Science ID 000299041600007

    View details for PubMedID 22150789

  • B-type natriuretic peptide increases after gastric bypass surgery and correlates with weight loss 12th World Congress of Endoscopic Surgery (WCES) Changchien, E. M., Ahmed, S., Betti, F., Higa, J., Kiely, K., Hernandez-Boussard, T., Morton, J. SPRINGER. 2011: 2338–43


    Coronary artery disease is the primary cause of death in the United States, with obesity as a leading preventable risk factor. Previous studies have established the beneficial effect of Roux-en-Y gastric bypass on both weight and cardiac risk factors. Further assessment of cardiac function may be accomplished using B-type natriuretic peptide (BNP), which has demonstrated clinical utility in diagnosing congestive heart failure. This study aimed to assess changes in BNP after intentional weight loss through gastric bypass surgery.Plasma volume, weight, and BNP were measured preoperatively and at 3, 6, and 12 months postoperatively for 101 consecutive patients undergoing laparoscopic gastric bypass surgery by a single surgeon in an academic medical setting. Outcomes were compared by matched t-test. Multivariable linear regression and Pearson's correlation were used to examine predictors of pro-B-type natriuretic peptide (NT-proBNP) concentration.The concentration of BNP increased significantly from a mean preoperative level of 50.5 ng/l to postoperative levels of 73.9 ng/l at 3 months (P=0.013), 74.3 ng/l at 6 months (P<0.001), and 156.3 ng/l at 12 months (P<0.001). In addition, excess weight loss was the only statistically significant predictor of increased BNP concentration (odds ratio, 1.483; P<0.05).Gastric bypass leads to significant excess weight loss and surprisingly increased BNP concentrations. Correlation of BNP increase with weight loss suggests an additional novel mechanism for surgically induced weight loss.

    View details for DOI 10.1007/s00464-010-1565-1

    View details for Web of Science ID 000291690100039

    View details for PubMedID 21424205

  • The Role of Surgical Champions in the American College of Surgeons National Surgical Quality Improvement Program - A National Survey JOURNAL OF SURGICAL RESEARCH Raval, M. V., Bentrem, D. J., Eskandari, M. K., Ingraham, A. M., Hall, B. L., Randolph, B., Ko, C. Y., Morton, J. M. 2011; 166 (1): E15-E25


    The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) empowers surgeons and medical centers to reliably collect, analyze, and act on clinically collected outcomes data. How individual ACS NSQIP leaders designated as Surgeon Champions (SC) utilize the ACS NSQIP at the hospital level and the obstacles they encounter are not well studied.All SC representing the 236 hospitals participating in the ACS NSIQP were invited to complete a survey designed to assess the role of the SC, data use, continuous quality improvement (CQI) efforts, CQI culture, and financial implications.We received responses from 109 (46.2%) SC. The majority (72.5%) of SC were not compensated for their CQI efforts. Factors associated with demonstrable CQI efforts included longer duration of participation in the program, frequent meetings with clinical reviewers, frequent presentation of data to administration, compensation for Surgical Champion efforts and providing individual surgeons with feedback (all P < 0.05). Almost all SC stated ACS NSQIP data improved the quality of care that patients received at the hospital level (92.4%) and that the ACS NSQIP provided data that could not be obtained by other sources (95.2%). All SCs considered future funding for participation in the ACS NSQIP secure.Active use of ACS NSQIP data provide SC with demonstrable CQI by regularly reviewing data, having frequent interaction with clinical reviewers, and frequently sharing data with hospital administration and colleagues. SC thus play a key role in successful quality improvement at the hospital level.

    View details for DOI 10.1016/j.jss.2010.10.036

    View details for Web of Science ID 000288167300002

    View details for PubMedID 21176914

  • Determination of the Relationship Between Gastric Wall Thickness and Body Mass Index with Endoscopic Ultrasound OBESITY SURGERY Larsen, M. C., Yan, B. M., Morton, J., Van Dam, J. 2011; 21 (3): 300-304


    The aim of this study was to determine the relationship between gastric wall thickness and BMI.Bariatric surgery patients undergoing a pre-operative screening EGD and patients undergoing endoscopic ultrasound for non-gastric pathology were prospectively enrolled in the study. Patients underwent endoscopic ultrasound evaluation with measurements of gastric wall thickness at six areas of the stomach. The primary outcome was the correlation of BMI and mean gastric wall thickness.Twenty-four patients were enrolled in the study. Eight patients were excluded due to endoscopic abnormalities of the stomach (five) or intolerance to the procedure (three). Ten patients with a normal BMI and six obese patients were included in the analysis. BMI in the non-obese group was 23.8 ± 2.5 kg/m(2) compared to 54.7 ± 14.6 kg/m(2) in the obese population. The average gastric wall thickness amongst all subjects was 3.27 ± 0.42 mm. Mean gastric thickness in the non-obese group was 3.25 ± 0.45 mm compared to 3.30 ± 0.39 mm in the obese group (p = 0.41). When both groups were combined, there did not appear to be a linear relationship between mean thickness and BMI (R (2) = 0.005). There was no linear relationship between gastric wall thickness and waist circumference (R (2) = 0.02).There was no significant correlation between gastric wall thickness and BMI. Mean gastric wall thickness of endoscopically normal stomachs was in the range of 3-4 mm.

    View details for DOI 10.1007/s11695-009-9839-1

    View details for Web of Science ID 000287523200006

    View details for PubMedID 19381738

  • Impaired Alcohol Metabolism after Gastric Bypass Surgery: A Case-Crossover Trial JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Woodard, G. A., Downey, J., Hernandez-Boussard, T., Morton, J. M. 2011; 212 (2): 209-214


    Severe obesity remains the leading public health crisis of the industrialized world, with bariatric surgery the only effective and enduring treatment. Poor psychological adjustment has been occasionally reported postoperatively. In addition, evidence suggests that patients can metabolize alcohol differently after gastric bypass.Preoperatively and at 3 and 6 months postoperatively, 19 Roux-en-Y gastric bypass (RYGB) patients' breath alcohol content (BAC) was measured every 5 minutes after drinking 5 oz red wine to determine peak BAC and time until sober in a case-crossover design preoperatively and at 6 months postoperatively.Patients reported symptoms experienced when intoxicated and answered a questionnaire of drinking habits. The peak BAC in patients after RYGB was considerably higher at 3 months (0.059%) and 6 months (0.088%) postoperatively than matched preoperative levels (0.024%). Patients also took considerably more time to return to sober at 3 months (61 minutes) and 6 months (88 minutes) than preoperatively (49 minutes). Postoperative intoxication was associated with lower levels of diaphoresis, flushing, and hyperactivity and higher levels of dizziness, warmth, and double vision. Postoperative patients reported drinking considerably less alcohol, fewer preferred beer, and more preferred wine than before surgery.This is the first study to match preoperative and postoperative alcohol metabolism in gastric bypass patients. Post-RYGB patients have much higher peak BAC after ingesting alcohol and require more time to become sober. Patients who drink alcohol after gastric bypass surgery should exercise caution.

    View details for DOI 10.1016/j.jamcollsurg.2010.09.020

    View details for Web of Science ID 000287466200010

    View details for PubMedID 21183366

  • Cardiac Arrest During Laparoscopic Roux-en-Y Gastric Bypass in a Bariatric Patient with Drug-Associated Long QT Syndrome OBESITY SURGERY Woodard, G., Brodsky, J. B., Morton, J. M. 2011; 21 (1): 134-137


    Obese patients often may demonstrate an acquired prolonged QTc interval due to alteration in cardiac physiology, electrolyte disturbances, and/or medication use. Intraoperatively, bariatric surgery may further contribute additional cardiac stressors to obese patients with long QT syndrome (LQTS). We present a case report of an obese woman with LQTS who underwent laparoscopic Roux-en-Y gastric bypass surgery and sustained an intraoperative cardiac arrest. We discuss identification, prevention, and treatment strategies for LQTS in the bariatric surgery patient.

    View details for DOI 10.1007/s11695-010-0137-8

    View details for Web of Science ID 000286423600020

    View details for PubMedID 20383601

  • Declining Incidence of Neonatal Endophthalmitis in the United States AMERICAN JOURNAL OF OPHTHALMOLOGY Moshfeghi, A. A., Charalel, R. A., Hernandez-Boussard, T., Morton, J. M., Moshfeghi, D. M. 2011; 151 (1): 59-65


    To determine the incidence of neonatal endogenous endophthalmitis in the United States between 1998 and 2006 and to identify associated risk factors.Retrospective cohort study.We used the Nationwide Inpatient Sample database, a 20% representative sample of all hospital discharges in the United States, to help refine our understanding of this condition. International Classification of Diseases, ninth edition, codes for endophthalmitis, sepsis, and suspected endophthalmitis risk factors in hospitalized infants and neonates were searched in the database and were tracked over time. The main outcome measure was incidence of neonatal endophthalmitis over the study period.Of 3.64 million live births in 1998, 317 newborns were identified with endophthalmitis (8.71 cases per 100 000 live births). Of 4.14 million live births in 2006, only 183 newborns were identified with endophthalmitis (4.42 cases per 100 000 live births) by comparison. The incidence of endophthalmitis decreased at a rate of 6% per year (P = .01130) between 1998 and 2006. Neonates with endophthalmitis were more likely to have systemic bacteremia (odds ratio, 21.114; P < .0001), Candidemia (odds ratio, 2.356; P < .0001), a birth weight of less than 1500 g (odds ratio, 1.215; P < .0001), and retinopathy of prematurity (odds ratio, 2.052; P < .0001).We objectively validated the commonly held belief that Candidemia, bacteremia, retinopathy of prematurity, and low birth weight are significant risk factors for endophthalmitis development in infants, which seems to have had a decreasing incidence in recent years.

    View details for DOI 10.1016/j.ajo.2010.07.008

    View details for Web of Science ID 000286081200011

    View details for PubMedID 20970776

  • Perioperative considerations when operating on the very obese: tricks of the trade MINERVA CHIRURGICA Ahmed, S., Morrow, E., Morton, J. 2010; 65 (6): 667-676


    Obesity is the leading public health concern in the industrialized world with the advent of the very obese or "super obese" increasing exponentially. Bariatric surgery remains the only effective and enduring treatment for morbid obesity and can be safely accomplished in experienced centers. Surgery in the very obese may be considered high-risk: however, this risk may be managed with an experienced bariatric surgery team, appropriate anesthetic consideration, preoperative risk assessment, employment of venothrombotic event prevention, preoperative weight loss, and understanding of particular anatomic considerations. With appropriate preparation, the very obese surgical patient can achieve safe and effective surgical outcomes.

    View details for Web of Science ID 000286914600008

    View details for PubMedID 21224800

  • Laparoscopic diaphragmatic pacer placement - a potential new treatment for ALS patients: a brief description of the device and anesthetic issues JOURNAL OF CLINICAL ANESTHESIA Schmiesing, C. A., Lee, J., Morton, J. M., Brock-Utne, J. G. 2010; 22 (7): 549-552


    The Diaphragm Pacing Stimulator (DPS) has been used to treat ventilatory insufficiency in quadriplegic patients. The FDA approved a trial using the DPS in patients with amyotrophic lateral sclerosis (ALS). Three patients with advanced ALS, who underwent laparoscopic diaphragmatic pacer placement, and their general anesthetic management, are presented.

    View details for DOI 10.1016/j.jclinane.2009.09.010

    View details for Web of Science ID 000284791000011

    View details for PubMedID 21056813

  • Do Preventive Care Disparities Exist For the Obese? 28th Annual Scientific Meeting on the Obesity-Society Morton, J., Hernandez-Boussard, T. NATURE PUBLISHING GROUP. 2010: S196–S196
  • Cost Consciousness and Medical Education NEW ENGLAND JOURNAL OF MEDICINE Rivas, H., Morton, J. M., Krummel, T. M. 2010; 363 (9): 888-889

    View details for Web of Science ID 000281196600019

    View details for PubMedID 20738193

  • Frequency and Outcomes of Blood Products Transfusion Across Procedures and Clinical Conditions Warranting Inpatient Care: An Analysis of the 2004 Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database AMERICAN JOURNAL OF MEDICAL QUALITY Morton, J., Anastassopoulos, K. P., Patel, S. T., Lerner, J. H., Ryan, K. J., Goss, T. F., Dodd, S. L. 2010; 25 (4): 289-296


    The objective of this retrospective cohort study was to assess frequency and outcomes associated with blood products transfusion. Data from the 2004 Nationwide Inpatient Sample database were used. Length of stay (LOS), postoperative infections, noninfectious transfusion-related complications, in-hospital mortality, and total charges were evaluated for transfused and nontransfused cohorts. Of the estimated 38.66 million discharges in the United States in 2004, 5.8% (2.33 million) were associated with blood products transfusion. Average LOS was 2.5 days longer, and charges were $17 194 higher for the transfused cohort (P < .0001). Odds of death were 1.7 times higher (P < .0001) and odds of infection 1.9 times higher (P < .0001) for the transfused cohort. Increased provider awareness and recognition of the frequency and potential negative outcomes of blood products transfusion may encourage the adoption of novel approaches to minimize intraoperative and early postoperative bleeding, reduce transfusion requirements, and most important, improve patient-level postoperative outcomes and health-related quality of life.

    View details for DOI 10.1177/1062860610366159

    View details for Web of Science ID 000279552300008

    View details for PubMedID 20530223

  • Intraoperative Fluid Replacement and Postoperative Creatine Phosphokinase Levels in Laparoscopic Bariatric Patients OBESITY SURGERY Wool, D. B., Lemmens, H. J., Brodsky, J. B., Solomon, H., Chong, K. P., Morton, J. M. 2010; 20 (6): 698-701


    Morbid obesity and bariatric surgery are both risk factors for the development of postoperative rhabdomyolysis (RML). RML results from injury to skeletal muscle, and a serum creatine phosphokinase (CK) level >1,000 IU/L is considered diagnostic of RML. The aim of this study was to determine if intraoperative intravenous fluid (IVF) volume affects postoperative CK levels following laparoscopic bariatric operations.Prospective, single blinded, and randomized trial was conducted.Patients scheduled to undergo laparoscopic sleeve gastrectomy, adjustable gastric band, or Roux-en-Y gastric bypass operations were randomized into two groups. Subjects in Group A received 15 ml/kg total body weight (TBW) of IV crystalloid solution during surgery, while subjects in Group B received 40 ml/kg TBW. Preoperative and postoperative CK and creatinine levels and intra- and postoperative urine output were monitored and recorded.Forty-seven patients were assigned to Group A and 53 patients to Group B. Group B patients had significantly higher urine output in the operating room, in the post-anesthesia care unit (PACU), and on postoperative days 0 and 1. Group B patients also had significantly lower serum creatinine level in the PACU and a trend towards lower creatinine levels on postoperative days 0, 1, and 2. There were no statistical differences in CK levels at any time between the two groups. Four patients in Group A and three patients in Group B developed postoperative RML.Conservative (15 ml/kg) versus liberal (40 ml/kg) intraoperative IVF administration did not change the incidence of RML in patients undergoing laparoscopic bariatric operations. Since the occurrence of RML in this patient population is relatively high, postoperative CK levels should be routinely obtained in patients at special risk.

    View details for DOI 10.1007/s11695-010-0092-4

    View details for Web of Science ID 000278289500004

    View details for PubMedID 20198451

  • Rotavirus Differentially Infects and Polyclonally Stimulates Human B Cells Depending on Their Differentiation State and Tissue of Origin JOURNAL OF VIROLOGY Narvaez, C. F., Franco, M. A., Angel, J., Morton, J. M., Greenberg, H. B. 2010; 84 (9): 4543-4555


    We have shown previously that rotavirus (RV) can infect murine intestinal B220(+) cells in vivo (M. Fenaux, M. A. Cuadras, N. Feng, M. Jaimes, and H. B. Greenberg, J. Virol. 80:5219-5232, 2006) and human blood B cells in vitro (M. C. Mesa, L. S. Rodriguez, M. A. Franco, and J. Angel, Virology 366:174-184, 2007). However, the effect of RV on B cells, especially those present in the human intestine, the primary site of RV infection, is unknown. Here, we compared the effects of the in vitro RV infection of human circulating (CBC) and intestinal B cells (IBC). RV infected four times more IBC than CBC, and in both types of B cells the viral replication was highly restricted to the memory subset. RV induced cell death in 30 and 3% of infected CBC and IBC, respectively. Moreover, RV induced activation and differentiation into antibody-secreting cells (ASC) of CBC but not IBC when the B cells were present with other mononuclear cells. However, RV did not induce these effects in purified CBC or IBC, suggesting the participation of other cells in activating and differentiating CBC. RV infection was associated with enhanced interleukin-6 (IL-6) production by CBC independent of viral replication. The infection of the anti-B-cell receptor, lipopolysaccharide, or CpG-stimulated CBC reduced the secretion of IL-6 and IL-8 and decreased the number of ASC. These inhibitory effects were associated with an increase in viral replication and cell death and were observed in polyclonally stimulated CBC but not in IBC. Thus, RV differentially interacts with primary human B cells depending on their tissue of origin and differentiation stage, and it affects their capacity to modulate the local and systemic immune responses.

    View details for DOI 10.1128/JVI.02550-09

    View details for Web of Science ID 000276358000040

    View details for PubMedID 20164228

  • One Year Improvements in Cardiovascular Risk Factors: a Comparative Trial of Laparoscopic Roux-en-Y Gastric Bypass vs. Adjustable Gastric Banding OBESITY SURGERY Woodard, G. A., Peraza, J., Bravo, S., Toplosky, L., Hernandez-Boussard, T., Morton, J. M. 2010; 20 (5): 578-582


    Coronary artery disease (CAD) is the leading cause of death in the industrialized world with obesity as a leading preventable risk factor. Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) have been shown to improve certain biochemical cardiovascular risk factors (BCRFs) at 1 year post-op, however no study has directly compared the 12-month BCRF improvements of RYGB vs. LAGB.At a single academic institution (2004-2009), we measured BCRF in 838 consecutive bariatric patients (765 RYGB, 73 LAGB) pre-operatively and at 12 months post-operatively. BCRF included total cholesterol (TC), low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides (Trig), Trig/HDL ratio, lipoprotein(a) (Lp(a)), homocysteine (HmC), high sensitivity C-reactive protein (hs-CRP), fasting insulin (FI), and hemoglobin A1C (Hgb A1C). Pre-op and 12-month post-op values were compared by a paired t test of equal variance.At 12 months post-op, RYGB patients had lost 77% of their excess weight and had significant improvements in TC, LDL, HDL, Trig, Trig/HDL, HmC, hs-CRP, FI, and Hgb A1C. LAGB patients lost 47.6% of their excess weight and had significant improvements in Trig, Trig/HDL, HmC, hs-CRP, and Hgb A1C. Having RYGB instead of LAGB was predictive of significantly greater improvements in TC at 12 months post-operatively.In this study, both RYGB and LAGB demonstrated significant weight loss and improvements in BCRF at 12 months post-op. RYGB produced significant improvements in a greater number of BCRFs and in some instances the 12-month post-op BCRF values were significantly lower risk in RYGB vs. LAGB patients.

    View details for DOI 10.1007/s11695-010-0088-0

    View details for Web of Science ID 000276470700007

    View details for PubMedID 20186576

  • Endoscopic removal of dysfunctioning rings or bands after restrictive bariatric procedures GASTROINTESTINAL ENDOSCOPY Morton, J. M. 2010; 71 (3): 475-476

    View details for DOI 10.1016/j.gie.2009.11.014

    View details for Web of Science ID 000275897900006

    View details for PubMedID 20189505

  • Plasma Glucose and Insulin Regulation Is Abnormal Following Gastric Bypass Surgery with or Without Neuroglycopenia OBESITY SURGERY Kim, S. H., Liu, T. C., Abbasi, F., Lamendola, C., Morton, J. M., Reaven, G. M., McLaughlin, T. L. 2009; 19 (11): 1550-1556


    Enhanced insulin sensitivity is commonly seen following Roux-en-Y gastric bypass surgery (RYGB) whereas symptomatic hypoglycemia post-RYGB seems to occur infrequently. It is unclear how different plasma glucose and insulin responses are in patients with symptomatic hypoglycemia (SX-RYGB) versus those who remain asymptomatic (ASX-RYGB), nor when compared with non-surgical controls with varying degrees of insulin sensitivity.Plasma glucose and insulin concentrations were determined following a 75-g oral glucose challenge in five groups: symptomatic and asymptomatic patients following RYGB (n = 9 each) and overweight/obese controls, divided into three subgroups (n = 30 each) on the basis of degree of insulin sensitivity measured by the insulin suppression test.SX-RYGB group had higher 30-min glucose after oral glucose compared with the ASX-RYGB group (p = 0.04). The two groups did not differ in peak glucose and insulin concentrations, nadir glucose concentration, or insulin-to-glucose ratio 30 min after oral glucose. These values were significantly different from the three control groups, and peak insulin concentrations post-RYGB were increased at every degree of insulin sensitivity as compared with the control groups.Plasma glucose and insulin responses to oral glucose in patients with symptomatic hypoglycemia post-RYGB are minimally different when compared to individuals who remain asymptomatic, and both groups demonstrate hyperinsulinemia out of proportion to their degree of insulin sensitivity.

    View details for DOI 10.1007/s11695-009-9893-8

    View details for Web of Science ID 000271282900014

    View details for PubMedID 19557485

  • The Halo Effect of Bariatric Surgery: Weight Loss in Patients Family Members 27th Annual Scientific Meeting of the Obesity-Society Morton, J., Woodard, G., Encarnacion, B., Downey, J., Peraza, J., Hernandez-Boussard, T. NATURE PUBLISHING GROUP. 2009: S68–S69
  • Differential Intra-abdominal Adipose Tissue Profiling in Obese, Insulin-resistant Women OBESITY SURGERY Liu, A., McLaughlin, T., Liu, T., Sherman, A., Yee, G., Abbasi, F., Lamendola, C., Morton, J., Cushman, S. W., Reaven, G. M., Tsao, P. S. 2009; 19 (11): 1564-1573


    We recently identified differences in abdominal subcutaneous adipose tissue (SAT) from insulin-resistant (IR) as compared to obesity-matched insulin sensitive individuals, including accumulation of small adipose cells, decreased expression of cell differentiation markers, and increased inflammatory activity. This study was initiated to see if these changes in SAT of IR individuals were present in omental visceral adipose tissue (VAT); in this instance, individuals were chosen to be IR but varied in degree of adiposity. We compared cell size distribution and genetic markers in SAT and VAT of IR individuals undergoing bariatric surgery.Eleven obese/morbidly obese women were IR by the insulin suppression test. Adipose tissue surgical samples were fixed in osmium tetroxide for cell size analysis via Beckman Coulter Multisizer. Quantitative real-time polymerase chain reaction for genes related to adipocyte differentiation and inflammation was performed.While proportion of small cells and expression of adipocyte differentiation genes did not differ between depots, inflammatory genes were upregulated in VAT. Diameter of SAT large cells correlated highly with increasing proportion of small cells in both SAT and VAT (r = 0.85, p = 0.001; r = 0.72, p = 0.01, respectively). No associations were observed between VAT large cells and cell size variables in either depot. The effect of body mass index (BMI) on any variables in both depots was negligible.The major differential property of VAT of IR women is increased inflammatory activity, independent of BMI. The association of SAT adipocyte hypertrophy with hyperplasia in both depots suggests a primary role SAT may have in regulating regional fat storage.

    View details for DOI 10.1007/s11695-009-9949-9

    View details for Web of Science ID 000271282900016

    View details for PubMedID 19711137

  • Incidence of Retinopathy of Prematurity in the United States: 1997 through 2005 AMERICAN JOURNAL OF OPHTHALMOLOGY Lad, E. M., Hernandez-Boussard, T., Morton, J. M., Moshfeghi, D. M. 2009; 148 (3): 451-458


    To determine the incidence of retinopathy of prematurity (ROP) based on a national database and to identify baseline characteristics, demographic information, comorbidities, and surgical interventions.Retrospective study based on the National Inpatient Sample from 1997 through 2005.The National Inpatient Sample was queried for all newborn infants with and without ROP. Multivariate logistic regression was used to predict risk factors for ROP.Thirty-four million live births were recorded during the study period. The total ROP incidence was 0.17% overall and 15.58% for premature infants with length of stay of more than 28 days. Our results conclusively demonstrated the importance of low birth weight as a risk for ROP development in infants with length of stay of more than 28 days, as well as association with respiratory conditions, fetal hemorrhage, intraventricular hemorrhage, and blood transfer. An interesting finding was the protective effect conferred by hypoxia, necrotizing enterocolitis, and hemolytic disease of the newborn. Infants with ROP had a higher incidence of undergoing laser photocoagulation therapy, pars plana vitrectomy, and scleral buckle surgery.The current study represents a large, retrospective analysis of newborns with ROP. The multivariate analysis emphasizes the role of birth weight in extended-stay infants, as well as respiratory conditions, fetal hemorrhage, intraventricular hemorrhage, and blood transfer.

    View details for DOI 10.1016/j.ajo.2009.04.018

    View details for Web of Science ID 000269755400020

    View details for PubMedID 19541285

  • Probiotics Improve Outcomes After Roux-en-Y Gastric Bypass Surgery: A Prospective Randomized Trial JOURNAL OF GASTROINTESTINAL SURGERY Woodard, G. A., Encarnacion, B., Downey, J. R., Peraza, J., Chong, K., Hernandez-Boussard, T., Morton, J. M. 2009; 13 (7): 1198-1204


    Roux-en-Y gastric bypass (RNYGB) surgery offers an effective and enduring treatment for morbid obesity. Gastric bypass may alter gastrointestinal (GI) flora possibly resulting in bacterial overgrowth and dysmotility. Our hypothesis was that daily use of probiotics would improve GI outcomes after RNYGB.Forty-four patients undergoing RNYGB were randomized to either a probiotic or control group; 2.4 billion colonies of Lactobacillus were administered daily postoperatively to the probiotic group. The outcomes of H(2) levels indicative of bacterial overgrowth, GI-related quality of life (GIQoL), serologies, and weight loss were measured preoperatively and at 3 and 6 months postoperatively. Categorical variables were analyzed by chi(2) test and continuous variables were analyzed by t test with a p < 0.05 for significance.At 6 months, a statistically significant reduction in bacterial overgrowth was achieved in the probiotic group with a preoperative to postoperative change of sum H(2) part per million (probiotics = -32.13, controls = 0.80). Surprisingly, the probiotic group attained significantly greater percent excess weight loss than that of control group at 6 weeks (controls = 25.5%, probiotic = 29.9%) and 3 months (38.55%, 47.68%). This trend also continued but was not significant at 6 months (60.78%, 67.15%). The probiotic group had significantly higher postoperative vitamin B12 levels than the control group. Both probiotic and control groups significantly improved their GIQoL.In this novel study, probiotic administration improves bacterial overgrowth, vitamin B12 availability, and weight loss after RNYGB. These data may provide further evidence that altering the GI microbiota can influence weight loss.

    View details for DOI 10.1007/s11605-009-0891-x

    View details for Web of Science ID 000266821800008

    View details for PubMedID 19381735

  • Comparison of hospital charges between robotic, laparoscopic stapled, and laparoscopic handsewn Roux-en-Y gastric bypass. Journal of robotic surgery Curet, M. J., Curet, M., Solomon, H., Lui, G., Morton, J. M. 2009; 3 (2): 75-78


    The feasibility and safety of laparoscopic and robotic Roux-en-Y gastric bypass (RRYGB) have been established. To evaluate the cost-effectiveness of robotic surgery we compared the hospital charges for robotic, laparoscopic stapled (SRYGB), and laparoscopic handsewn Roux-en-Y gastric bypass (HRYGB) at our institution. One hundred thirty-five consecutive patients undergoing Roux-en-Y gastric bypass at Stanford University Medical Center by handsewn, stapled or robotic techniques from 1 July 2005 to 31 December 2005 were evaluated. Medical records of these patients were retrospectively reviewed and the following variables were collected and analyzed: age, gender, body mass index (BMI), number of preoperative comorbidities, length of stay (LOS), operating and anesthesia times, postoperative complications, mortality, professional fees, and hospital and total charges. Twenty-one RRYGB, 78 SRYGB, and 36 HRYGB were performed during the study period. Comparison of the above three groups demonstrated no statistically significant differences in age, gender, BMI, number of preoperative comorbidities, LOS, operating and anesthesia times, postoperative complications, mortality or professional fees. Total charges were higher for RRYGB (US $77,820) when compared with SRYGB (US $66,153) but not when compared with HRYGB (US $68,814). RRYGB higher hospital charges resulted in higher total charges when compared with SRYGB and HRYGB. These differences do not reflect actual cost to the hospital.

    View details for DOI 10.1007/s11701-009-0143-9

    View details for PubMedID 27638218

  • Bariatric Surgery Improves Musculoskeletal Quality of Life Independent of Weight Loss and Procedure Type Digestive Disease Week/110th Annual Meeting of the American-Gastroenterological-Association Bravo, S., Woodard, G., Hernandez-Boussard, T., Morton, J. W B SAUNDERS CO-ELSEVIER INC. 2009: A903–A903
  • Does Insurance Status Affect Gastric Bypass Surgery Outcomes? Digestive Disease Week/110th Annual Meeting of the American-Gastroenterological-Association Woodard, G., Hernandez-Boussard, T., Morton, J. W B SAUNDERS CO-ELSEVIER INC. 2009: A902–A902
  • Relationship Between Hospital Volume, System Clinical Resources, and Mortality in Pancreatic Resection JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Joseph, B., Morton, J. M., Hernandez-Boussard, T., Rubinfeld, I., Faraj, C., Velanovich, V. 2009; 208 (4): 520-527


    The relationship between hospital volume and perioperative mortality in pancreaticoduodenectomy has been well established. We studied whether associations exist between hospital volume and hospital clinical resources and between both of these factors to mortality to help explain this relationship.This two-part study reviewed publicly available hospital information from the Leapfrog Group, HealthGrades, and hospital Web sites. Hospitals were evaluated for Leapfrog ICU staffing criteria and Safe Practice Score; HealthGrades five-star rating for complex gastrointestinal procedures and operations; and presence of a general surgery residency, gastroenterology fellowship, and interventional radiology. Evaluation used trend analysis and multiple logistic regression analysis. The second part determined the mortality rate for pancreaticoduodenectomy using inpatient mortality data from the National Inpatient Sample and Leapfrog. Hospitals were categorized by low volume (< or = 10/year), high volume (> or = 11/year), strong clinical support (presence of all support factors), and weak clinical support (absence of any factor). Data were correlated by number of pancreatic resections per hospital, hospital system clinical resources, and operative mortality.As hospital volume increased, statistically significant increases occurred in the frequency of hospitals meeting Leapfrog ICU staffing criteria (p < 0.0001), Leapfrog Safe Practice Score (p = 0.0004), HealthGrades 5-star rating (p < 0.00001), general surgery residency (p < 0.00001), gastroenterology fellowship (p < 0.00001), and interventional radiology services (p < 0.00001). No significant relationships were found between resection volume and any one of the clinical support factors and perioperative death. Presence of strong clinical support was associated with lower mortality (odds ratio = 0.32; p = 0.001).System clinical resources were more influential in operative mortality for pancreatic resection. This might help explain why high-volume hospitals, low-volume surgeons in high-volume institutions, and some lower-volume hospitals with excellent clinical resources have lower perioperative mortality rates for pancreatic resection.

    View details for DOI 10.1016/j.jamcollsurg.2009.01.019

    View details for Web of Science ID 000270996800005

    View details for PubMedID 19476785

  • Succinylcholine: A Useful Drug in Bariatric Surgery OBESITY SURGERY Brodsky, J. B., Lemmens, H. J., Morton, J. M. 2009; 19 (4): 537-537

    View details for DOI 10.1007/s11695-008-9795-1

    View details for Web of Science ID 000264848100027

    View details for PubMedID 19089518

  • Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. American journal of gastroenterology Lee, J. K., Van Dam, J., Morton, J. M., Curet, M., Banerjee, S. 2009; 104 (3): 575-582


    Roux-en-Y gastric bypass (RYGB) is a common intervention for morbid obesity. Upper gastrointestinal (UGI) symptoms are frequent and difficult to interpret following RYGB. The aim of our study was to examine the role of endoscopy in evaluating UGI symptoms after RYGB and to assess the safety and efficacy of endoscopic therapy.Between 1998 and 2005, a total of 1,079 patients underwent RYGB for clinically severe obesity and were followed prospectively. Patients with UGI symptoms after RYGB who were referred for endoscopy were studied.Of 1,079 patients, 76 (7%) who underwent RYGB were referred for endoscopy to evaluate UGI symptoms. Endoscopic findings included normal surgical anatomy (n=24, 31.6%), anastomotic stricture (n=40, 52.6%), marginal ulcer (n=12, 15.8%), unraveled nonabsorbable sutures causing functional obstruction (n=3, 4%) and gastrogastric fistula (n=2, 2.6%). Patients with abnormal findings on endoscopy presented with UGI symptoms at a mean of 110.7 days from their RYGB, which was significantly shorter than the time of 347.5 days for patients with normal endoscopy (P<0.001). A total of 40 patients with anastomotic strictures underwent 86 endoscopic balloon dilations before complete symptomatic relief. In one patient, a needle knife was used to open a completely obstructed anastomotic stricture. Unraveled, nonabsorbable suture material was successfully removed using endoscopic scissors in three patients.Patients presenting with UGI symptoms less than 3 months after surgery are more likely to have an abnormal finding on endoscopy. Endoscopic balloon dilation is safe and effective in managing anastomotic strictures. Endoscopic scissors are safe and effective in removing unraveled, nonabsorbable sutures contributing to obstruction.

    View details for DOI 10.1038/ajg.2008.102

    View details for PubMedID 19262516

  • Benefits to Patients Choosing Preoperative Weight Loss in Gastric Bypass Surgery: New Results of a Randomized Trial JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Solomon, H., Liu, G. Y., Alami, R., Morton, J., Curet, M. J. 2009; 208 (2): 241-245


    Historically, preoperative weight loss has been encouraged for patients undergoing gastric bypass surgery to decrease liver mass, technically facilitating the procedure. In an earlier prospective randomized trial investigating effects of preoperative weight loss on patients' clinical outcomes, we reported no differences in postoperative complications or weight-loss profiles at 6-month followup. This article demonstrates results of the same study, with 1-year followup.One hundred consecutive patients in an 18-month period preparing to undergo gastric bypass surgery at Stanford University Medical Center were selected. Fifty patients were randomly assigned to lose 10% or more of their excess body weight preoperatively, and 50 patients were assigned to no preoperative weight-loss requirements. After 1 year, patient demographics and data on postoperative complications, cure or improvement of comorbidities, and differences in weight-loss profiles were collected.At 1 year, the 2 groups had similar preoperative demographics and body mass indexes (BMIs). Patients in the weight-loss group, on average, lost 8.2% of their excess body weight preoperatively compared with the nonweight-loss group, which gained 1.1% (p = 0.007). After a year, the patients in both arms of the study showed no difference in weight, BMI, excess weight-loss, and number of remaining comorbidites. But when patients were divided according to those who had lost at least 5% of their excess body weight preoperatively, the 1-year results for excess weight-loss, weight, and BMI were much lower for the weight-loss group.Preoperative weight loss in patients undergoing gastric bypass surgery is safe and feasible. It should be encouraged, because it will markedly improve longterm weight loss.

    View details for DOI 10.1016/j.jamcollsurg.2008.09.028

    View details for Web of Science ID 000263387500010

    View details for PubMedID 19228536

  • Pregnancy and Fertility Following Bariatric Surgery A Systematic Review JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Maggard, M. A., Yermilov, I., Li, Z., Maglione, M., Newberry, S., Suttorp, M., Hilton, L., Santry, H. P., Morton, J. M., Livingston, E. H., Shekelle, P. G. 2008; 300 (19): 2286-2296


    Use of bariatric surgery has increased dramatically during the past 10 years, particularly among women of reproductive age.To estimate bariatric surgery rates among women aged 18 to 45 years and to assess the published literature on pregnancy outcomes and fertility after surgery.Search of the Nationwide Inpatient Sample (1998-2005) and multiple electronic databases (Medline, EMBASE, Controlled Clinical Trials Register Database, and the Cochrane Database of Reviews of Effectiveness) to identify articles published between 1985 and February 2008 on bariatric surgery among women of reproductive age. Search terms included bariatric procedures, fertility, contraception, pregnancy, and nutritional deficiencies. Information was abstracted about study design, fertility, and nutritional, neonatal, and pregnancy outcomes after surgery.Of 260 screened articles, 75 were included. Women aged 18 to 45 years accounted for 49% of all patients undergoing bariatric surgery (>50,000 cases annually for the 3 most recent years). Three matched cohort studies showed lower maternal complication rates after bariatric surgery than in obese women without bariatric surgery, or rates approaching those of nonobese controls. In 1 matched cohort study that compared maternal complication rates in women after laparoscopic adjustable gastric band surgery with obese women without surgery, rates of gestational diabetes (0% vs 22.1%, P < .05) and preeclampsia (0% vs 3.1%, P < .05) were lower in the bariatric surgery group. Findings were supported by 13 other bariatric cohort studies. Neonatal outcomes were similar or better after surgery compared with obese women without laparoscopic adjustable gastric band surgery (7.7% vs 7.1% for premature delivery; 7.7% vs 10.6% for low birth weight, P < .05; 7.7% vs 14.6% for macrosomia, P < .05). No differences in neonatal outcomes were found after gastric bypass compared with nonobese controls (26.3%-26.9% vs 22.4%-20.2% for premature delivery, P = not reported [1 study] and P = .43 [1 study]; 7.7% vs 9.0% for low birth weight, P = not reported [1 study]; and 0% vs 2.6%-4.3% for macrosomia, P = not reported [1 study] and P = .28 [1 study]). Findings were supported by 10 other studies. Studies regarding nutrition, fertility, cesarean delivery, and contraception were limited.Rates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having had bariatric surgery compared with rates in pregnant women who are obese; however, further data are needed from rigorously designed studies.

    View details for Web of Science ID 000260965500029

    View details for PubMedID 19017915

  • Mechanical Bowel Preparation in Intestinal Surgery: A Meta-Analysis and Review of the Literature 49th Annual Meeting of the Society-for-Surgery-of-the-Alimentary-Tract/Digestive Disease Week Pineda, C. E., Shelton, A. A., Hernandez-Boussard, T., Morton, J. M., Welton, M. L. SPRINGER. 2008: 2037–44


    Despite several meta-analyses and randomized controlled trials showing no benefit to patients, mechanical bowel preparation (MBP) remains the standard of practice for patients undergoing elective colorectal surgery.We performed a systematic review of the literature of trials that prospectively compared MBP with no MBP for patients undergoing elective colorectal resection. We searched MEDLINE, LILACS, and SCISEARCH, abstracts of pertinent scientific meetings and reference lists for each article found. Experts in the field were queried as to knowledge of additional reports. Outcomes abstracted were anastomotic leaks and wound infections. Meta-analysis was performed using Peto Odds ratio.Of 4,601 patients (13 trials), 2,304 received MBP (Group 1) and 2,297 did not (Group 2). Anastomotic leaks occurred in 97(4.2%) patients in Group 1 and in 81(3.5%) patients in Group 2 (Peto OR = 1.214, CI 95%:0.899-1.64, P = 0.206). Wound infections occurred in 227(9.9%) patients in Group 1 and in 201(8.8%) patients in Group 2 (Peto OR = 1.156, CI 95%:0.946-1.413, P = 0.155).This meta-analysis demonstrates that MBP provides no benefit to patients undergoing elective colorectal surgery, thus, supporting elimination of routine MBP in elective colorectal surgery.In conclusion, MBP is of no benefit to patients undergoing elective colorectal resection and need not be recommended to meet "standard of care."

    View details for DOI 10.1007/s11605-008-0594-8

    View details for Web of Science ID 000260282200037

    View details for PubMedID 18622653

  • Gastric Bypass Surgery Improves Markers of Aging Annual Scientific Meeting of the Obesity-Society Downey, J., Woodard, G., Hernandez-Boussard, T., Morton, J. NATURE PUBLISHING GROUP. 2008: S144–S144
  • Disparity in Utilization, Demographics and Outcomes for Bariatric Surgeries Annual Scientific Meeting of the Obesity-Society Morton, J., Woodard, G., Downey, J., Hernandez-Boussard, T. NATURE PUBLISHING GROUP. 2008: S297–S297
  • Preoperative endoscopic screening for laparoscopic Roux-en-Y gastric bypass has a low yield for anatomic findings OBESITY SURGERY Mong, C., Van Dam, J., Morton, J., Gerson, L., Curet, M., Banerjee, S. 2008; 18 (9): 1067-1073


    Patients undergoing laparoscopic Roux-en-Y bariatric surgery undergo screening esophagoduodenoscopy (EGD) during preoperative evaluation. The hypothesis is to examine the utility of this examination. The purpose of this study was to evaluate the prevalence of clinically significant upper gastrointestinal (UGI) tract findings at screening EGD in patients undergoing laparoscopic Roux-en-Y bariatric surgery. A secondary aim was to determine whether preprocedure symptoms could predict findings at EGD.We evaluated records of patients undergoing EGD prior to bariatric surgery between 2000 and 2005 at the Stanford University Medical Center. Clinical, endoscopic, and pathological data were analyzed. The prevalence of endoscopic findings of clinical significance was determined.Two hundred seventy two complete patient records were identified and included in the study. Of these, 237 (87%) were female and 197 (72%) were Caucasian. The mean age was 43 +/- 9.68 years and mean body mass index was 48 +/- 7.95 kg/m(2). Of the 272 patients, 33 (12%) had EGD findings of clinical significance including erosive esophagitis (3.7%), Barrett's esophagus (3.7%), gastric ulcers (2.9%), erosive gastritis (1.8%), duodenal ulcers (0.7%), and gastric carcinoid (0.3%). No patients had malignancy. Of these 33 patients, 22 (67%) had UGI symptoms.Significant findings at screening EGD were found in 12% of patients. While EGD may be low-yield, the findings could be useful in guiding clinical decision making.

    View details for DOI 10.1007/s11695-008-9600-1

    View details for Web of Science ID 000258456400003

    View details for PubMedID 18574642

  • Profiling surgical staplers: effect of staple height, buttress, and overlap on staple line failure 24th Annual Meeting of the American-Society-for-Bariatric-Surgery Mery, C. M., Shafi, B. M., Binyamin, G., Morton, J. M., Gertner, M. ELSEVIER SCIENCE INC. 2008: 416–22


    Few studies have been designed to assess the performance of surgical staplers. In this study, we analyzed the effect of staple height, buttressing, and overlapping of staple lines on staple line failure.Staple lines created on fresh porcine small bowel segments ex vivo were tested for leak pressure by insufflating air into the bowel under water and recording pressure at failure. Three separate experiments were done and included staple height (white, 2.5 mm, n = 16; blue, 3.5 mm, n = 16; green, 4.1 mm, n = 16; one half of them buttressed); the absence (n = 12) or presence (n = 12) of an overlap in 3.5-mm staple lines; and the absence (n = 14) or presence (n = 11) of buttresses in 3.5-mm overlapping staple lines. Data are reported in median values and ranges; nonparametric tests were used for data analysis.In the porcine small bowel, leak pressure was related to staple height; green loads had the worst profile (35 mm Hg, range 19-105) compared with the blue (79 mm Hg, range 9-177), and white (108 mm Hg, range 28-280) loads (P = .006). Buttressing uniformly improved leak pressure for all staple loads (P <.0001). No significant difference was found between lines with overlapping (59 mm Hg, range 32-121) and those without (42 mm Hg, range 22-75; P = .162). Buttressing also improved the leak pressure of overlapping staple lines from 65 mm Hg (range 47-121) to 93 mm Hg (range 75-187; P = .0014).Great variability was found in the leak pressures among the different applications of the same stapler. Staple height is an important determinant of leak pressure. The presence of an overlap did not affect leak pressure; in fact, a trend toward improvement was seen with overlapping staple lines. Buttressing improved all types of staple lines.

    View details for DOI 10.1016/j.soard.2007.11.008

    View details for Web of Science ID 000261097800011

    View details for PubMedID 18226977

  • Meta-analysis of mechanical bowel preparation for elective colon and rectal resection Digestive Disease Week Meeting/109th Annual Meeting of the American-Gastroenterological-Association Pineda, C. E., Shelton, A. A., Hernandez-Boussard, T., Morton, J. M., Welton, M. L. W B SAUNDERS CO-ELSEVIER INC. 2008: A860–A860
  • Signal detection: A new statistical method to predict NASH in gastric bypass patients Digestive Disease Week Meeting/109th Annual Meeting of the American-Gastroenterological-Association Morton, J. M., Woodard, G. A., Hernandez-Boussard, T. W B SAUNDERS CO-ELSEVIER INC. 2008: A855–A855
  • Retinopathy of prematurity in the United States BRITISH JOURNAL OF OPHTHALMOLOGY Lad, E. M., Nguyen, T. C., Morton, J. M., Moshfeghi, D. M. 2008; 92 (3): 320-325


    To determine the incidence of retinopathy of prematurity (ROP) based upon a national database and to identify baseline characteristics, demographic information, comorbidities, and surgical interventions.The National Inpatient Sample, a representative sample of all US hospital discharges from 1997 to 2002, was queried for all newborn infants with and without ROP. Primary outcome variables included demographics, comorbidities, hospital length of stay (LOS), and hospital charges. Multivariate logistic regression was used to predict risk factors for ROP.4.67 million live births were recorded during the study period. The total incidence of ROP was 0.12% overall and 7.35% for premature infants with LOS greater than 14 days. Newborns with ROP were more likely to be born at a teaching hospital and to have higher LOS and hospitalisation charges. The odds ratios for the development of ROP were greatest in infants weighing less than 1250 grams. The multivariate regression model revealed that only respiratory distress and intraventricular haemorrhage were predictive of the development of ROP and Hispanic infants were 33% more likely to develop ROP.This study represents the largest cohort of newborns analysed for ROP. The multivariate analysis emphasised the role of birth weight in extended-stay infants, as well as Hispanic race, respiratory distress syndrome, and intraventricular haemorrhage.

    View details for DOI 10.1136/bjo.2007.126201

    View details for Web of Science ID 000253991800005

    View details for PubMedID 18303153

  • Use of flexible endoscopic scissors to cut obstructing suture material in gastric bypass patients OBESITY SURGERY Patel, C., Van Dam, J., Curet, M., Morton, J. M., Banerjee, S. 2008; 18 (3): 336-339


    With the epidemic increase in obesity in the USA and consequent increased demand for bariatric surgery, new complications of the surgery are being described. The most common surgery practiced is the Roux-en-Y gastric bypass (RYGBP). Unraveling of suture material at the gastrojejunal anastomosis may occur, which may be troublesome if nonabsorbable suture is employed. We describe, for the first time, two patients who developed obstructive symptoms as a consequence of food matter/bezoars entrapped within a mesh of unraveled nonabsorbable suture material at their anastomoses. One of these patients also developed ulceration, presumably as a result of pressure necrosis from the entrapped bezoar. We describe a third patient where the placement of nonabsorbable sutures led to obstructive symptoms by limiting distensibility at an otherwise satisfactory anastomosis. We also describe for the first time, the use of a new endoscopic scissors in cutting luminal suture material with subsequent resolution of the clinical problem.

    View details for DOI 10.1007/s11695-007-9283-z

    View details for Web of Science ID 000253627700017

    View details for PubMedID 18197458

  • Laparoscopic adjustable gastric banding in a morbidly obese 18-year-old with hypertrophic cardiomyopathy OBESITY SURGERY Waipa, J., Dutta, S., Albanese, C. T., Morton, J. M. 2008; 18 (3): 332-335


    In this case report, we present an 18-year-old morbidly obese male with complicating hypertensive cardiomyopathy who underwent laparoscopic adjustable gastric band surgery. The patient had multiple comorbidities associated with his obesity, including obstructive sleep apnea, systemic hypertension, asthma, and depression. Given the severity of his underlying cardiac pathology and multiple previously unsuccessful attempts at weight loss with conventional medical and behavioral therapy, the patient opted to proceed with surgical intervention. We present this laparoscopic adjustable gastric banding surgical case to demonstrate the impact of surgical weight reduction on cardiac risk factors in a morbidly obese adolescent, highlighting the viability of this surgery for patients with existing cardiac dysfunction.

    View details for DOI 10.1007/s11695-007-9330-9

    View details for Web of Science ID 000253627700016

    View details for PubMedID 18193180

  • Bariatric Surgery in Patients With Morbid Obesity and Type 2 Diabetes 1st Meeting on Controversies in Obesity, Diabetes and Hypertension Schernthaner, G., Morton, J. M. AMER DIABETES ASSOC. 2008: S297–S302

    View details for DOI 10.2337/dc08-s270

    View details for Web of Science ID 000264701200032

    View details for PubMedID 18227500

  • National trends in adolescent bariatric surgical procedures and implications for surgical centers of excellence JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Schilling, P. L., Davis, M. M., Albanese, C. T., Dutta, S., Morton, J. 2008; 206 (1): 1-12


    Bariatric surgery is indicated for severely obese adolescents who have failed nonsurgical treatment. Our objective was to examine national trends in the use of bariatric operations among adolescents.The Kids' Inpatient Database was used to identify bariatric surgery patients in the pediatric population (age younger than 18 years) for 1997, 2000, and 2003. Patients were identified by procedure codes for bariatric operations with confirmatory diagnosis codes for obesity. Nationally representative estimates of trends in bariatric procedures, patient characteristics, hospital characteristics, and in-hospital complication rates were calculated. We augmented our analysis with the 2003 Nationwide Inpatient Sample, to ascertain hospitals' overall bariatric surgical volume (adolescents and adults).From 1997 to 2003, the estimated number of adolescent bariatric procedures performed nationally increased 5-fold from 51 to 282 (p < 0.01). More than 100 hospitals performed bariatric procedures on adolescents in 2003, most of which (87%) performed 4 or fewer adolescent bariatric operations annually. Operations were predominantly performed in adult hospitals (85%). Although most hospitals had high overall bariatric operation volumes (> 200 bariatric procedures for patients of any age), 39% of adolescent bariatric procedures were performed at lower-volume centers. Patients were predominantly Caucasian (68%) and female (72%), with a mean age of 16 years (minimum age 12 years). In-hospital complications occurred in 6% of patients. There were no in-hospital deaths.Our findings indicate a recent, rapid increase in the frequency of adolescent bariatric procedures. Most hospitals that performed bariatric procedures on adolescents had limited experience with adolescent bariatric patients, although many of these hospitals appear to have been experienced adult centers with high overall bariatric volume (adolescents and adults). Future research must better clarify the institutional qualifications considered mandatory for treatment of eligible adolescents.

    View details for DOI 10.1016/j.jamcollsurg.2007.07.028

    View details for Web of Science ID 000252109200001

    View details for PubMedID 18155562

  • Are health related outcomes in acute pancreatitis improving? An analysis of national trends in the U.S. from 1997 to 2003. JOP : Journal of the pancreas Brown, A., Young, B., Morton, J., Behrns, K., Shaheen, N. 2008; 9 (4): 408-414


    Acute pancreatitis is a common inflammatory disorder of the pancreas. Within the past decade our ability to diagnose and treat complications of acute pancreatitis has improved. Despite advances in diagnostic and therapeutic technology it is unclear whether we have been able to impact health related outcomes of acute pancreatitis such as incidence and mortality.The aim of this study was to use a national database of U.S. hospitals to evaluate the trends in the incidence and mortality associated with acute pancreatitis. We also examined the impact that patient demographic and hospital characteristics have on health related outcomes in acute pancreatitis.We analyzed the National Inpatient Sample Database (NIS) for all subjects in which acute pancreatitis (ICD-9 code: 577.0) was the principal discharge diagnosis during the period from 1997-2003. All identified subjects were analyzed for demographic characteristics as well as hospital characteristics.The mean frequency of discharges for acute pancreatitis, percentage mortality and mean length of stay for acute pancreatitis were determined for all identified cases.The statistical significance of the difference in the discharge frequency, mortality and length of stay over the study period was determined by utilization of the chi-square test for trend and the linear regression.During the study period there were 1,476,498 admissions with a principal discharge diagnosis of acute pancreatitis. The frequency of discharges with acute pancreatitis increased by 30.2% (P<0.001) during the period from 1997-2003. The average mortality associated with acute pancreatitis decreased by 35.2% (P<0.001) and the median length of stay decreased by 9.4% (P=0.002). Most discharges with acute pancreatitis were in the Southern U.S. and were at large non-teaching hospitals located in urban areas.Possible explanations for the results of our study are the improvements in our ability to diagnose acute pancreatitis, an increase in the availability of medical ICU's and an increase in hospital admissions for gallstones and alcohol use during the study period.

    View details for PubMedID 18648131

  • Retrievable inferior vena cava filters may be safely applied in gastric bypass surgery SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Schuster, R., Hagedorn, J. C., Curet, M. J., Morton, J. M. 2007; 21 (12): 2277-2279


    Pulmonary embolus (PE) is a potentially devastating and fatal postoperative complication in morbidly obese patients. This study was undertaken to review the safety and efficacy of retrievable prophylactic inferior vena cava (IVC) filters in high-risk morbidly obese patients undergoing gastric bypass.Patients who underwent gastric bypass surgery and preoperative insertion of retrievable IVC filters had their records reviewed. Indications for IVC filter insertion were: history of deep venous thrombosis (DVT) or PE, long-standing sleep apnea, venous stasis disease, and/or weight > 400 pounds.24 patients underwent IVC filter placement before gastric bypass surgery. There were 10 women and 14 men with an average age of 50 +/- 6.3 years (range 39 to 59) and average body mass index (BMI) of 57 +/- 7.5 kg/m(2) (range 49 to 74). BMI greater then 50 kg/m(2) was present in 21 of 24 patients (88%). All patients had successful IVC filter placement. IVC filter retrieval postoperatively was performed in 20 of 24 patients (83%) with three left for clinical reasons and one (4%) left due to technical inability to retrieve. There was one complication directly attributable to IVC filter retrieval. There were no deaths. Five patients (21%) developed DVT or PE postoperatively. Follow-up was 16 +/- 7.6 months (range 8 to 33).Prophylactic IVC filter placement and retrieval can be safely undertaken in high-risk gastric bypass patients. We recommend preoperative IVC filter placement in selected patients.

    View details for DOI 10.1007/s00464-007-9370-1

    View details for Web of Science ID 000250923200033

    View details for PubMedID 17440780

  • Gastrointestinal complications after coronary artery bypass grafting: A national study of morbidity and mortality predictors JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Rodriguez, F., Nguyen, T. C., Galanko, J. A., Morton, J. 2007; 205 (6): 741-747


    Previous single-institution studies have documented a 0.6% to 2.4% incidence of gastrointestinal (GI) complications after coronary artery bypass grafting (CABG), with an associated 14% to 63% mortality rate. To better determine the incidence and impact of GI complications after CABG, national outcomes for CABG were examined from 1998 to 2002.The Nationwide Inpatient Sample was queried for all patients undergoing CABG (ICD9 procedure codes 36.10 to 36.16). Two cohorts were compared: CABGs with and without GI complications. Both demographic and outcomes variables were compared by either t-test or chi-square analysis. Logistic regression analyses indicated potential predictors of CABG inpatient mortality and GI complications after CABG.The incidence of GI complications among 2.7 million CABGs identified was 4.1%. Total hospital length of stay (19.3 versus 8.8 days) and inpatient mortality (12.0% versus 2.5%, both p < 0.0001) were increased in CABG patients having GI complications. Factors associated with increased risk of GI complications included: age greater than 65 years (odds ratio [OR], 2.1); hemodialysis (OR, 3.4); intraaortic balloon pump (OR, 1.6); concomitant valve procedure (OR, 1.5); and procedure urgency (OR, 1.22). Use of an internal mammary graft was protective (OR, 0.5), but GI complications increased inpatient mortality risk (OR, 2.6).This national population-based study indicates that GI complications after CABG occur at a higher rate than previously described, leading to increased hospital length of stay and mortality.

    View details for DOI 10.1016/j.jamcollsurg.2007.07.003

    View details for Web of Science ID 000251439800003

    View details for PubMedID 18035256

  • Does gastric bypass alter alcohol metabolism? SURGERY FOR OBESITY AND RELATED DISEASES Hagedorn, J. C., Encarnacion, B., Brat, G. A., Morton, J. M. 2007; 3 (5): 543-548


    Morbid obesity is the leading public health crisis in the United States, with bariatric surgery as the only effective and enduring treatment for this disease. a concern has been raised, that, postoperatively, alcohol metabolism might be altered in gastric bypass patients. We hypothesized that alcohol metabolism in the postoperative gastric bypass patient would be altered.Of 36 subjects, 17 control and 19 postgastric bypass subjects each consumed 5 oz of red wine. They underwent an alcohol breath analysis every 5 minutes. The outcomes recorded included symptoms, initial peak alcohol breath level, and the time for alcohol breath levels to normalize.The gastric bypass group was on average 10 years older and had a greater weight and body mass index than the control group. The average time after gastric bypass was 2 years, with an average body mass index loss of 18 kg/m(2) (51 kg/m(2) before versus 33 kg/m(2) after). The gastric bypass patients had a peak alcohol breath level of 0.08% and the controls had a level of 0.05%. The gastric bypass group needed, on average, 108 minutes to reach an alcohol breath level of 0; the control group reached this level after an average of 72 minutes. Both groups showed a similar postingestion symptom profile.In this study, alcohol metabolism was significantly different between the postgastric bypass and control subjects. Although the gastric bypass patients' had a greater peak alcohol level and a longer time for the alcohol level to reach 0 than the controls, the gastric bypass group did not experience more symptoms than the control group. These findings provide caution regarding alcohol use by gastric bypass patients.

    View details for DOI 10.1016/j.soard.2007.07.003

    View details for Web of Science ID 000261097400015

    View details for PubMedID 17903777

  • Weight gain after bariatric surgery as a result of large gastric stoma: endotherapy with sodium morrhuate to induce stomal stenosis may prevent the need for surgical revision GASTROINTESTINAL ENDOSCOPY Morton, J. M. 2007; 66 (2): 246-247

    View details for DOI 10.1016/j.gie.2007.05.008

    View details for Web of Science ID 000248678700007

    View details for PubMedID 17643696

  • Nature versus nurture: Identical twins and bariatric surgery OBESITY SURGERY Hagedorn, J. C., Morton, J. M. 2007; 17 (6): 728-731


    Genetics and environment both play a role in weight maintenance. Twin studies may help clarify the influence of nature vs nurture in weight loss. We present the largest U.S. experience with monozygotic (MZ) twins undergoing bariatric surgery.We retrospectively reviewed the charts of four sets of MZ twins who underwent Roux-en-Y gastric bypass (RYGBP) surgery and laparoscopic adjustable gastric band (LAGB) placement at three different institutions. BMI and co-morbidities were examined pre- and postoperatively, and laboratory values were recorded.All four sets of twins are female, live together, and have similar professions. Twin cohort 1 had near identical weight loss patterns after open RYGBP surgery in 1996 (preop 146/142 kg; 2 years 82/82; and 10 years 108/107). Twin cohort 1 also both underwent cholecystectomies within the first year postoperatively. Twin cohort 2 underwent laparoscopic RYGBP surgery and also required cholecystectomies in the first postoperative year. Cohort 2 also experienced nearly identical weight loss at 1 year (36.7% vs 37.0% BMI loss). Twin cohort 3 underwent LAGB placement with two different surgeons with differing amounts of weight loss at 6 months (6.5% vs 15.7% BMI loss). Finally, twin cohort 4 underwent laparoscopic RYGBP with 2-year BMI loss of 39% vs 34%. In twin cohort 4, the twin who lost less weight lived apart from her twin and extended family, and her weight loss was less than the twin living with her family.Two sets of MZ twins had identical responses to bariatric surgery. The other two sets of identical twins had differential weight loss results, possibly due to differences in surgical approach and social support. While genetics do exert a strong influence on weight loss and maintenance, this case series demonstrates the potential effect of social support and postoperative management upon postoperative weight loss in the presence of identical genetics.

    View details for Web of Science ID 000246911800005

    View details for PubMedID 17879569

  • Transnasal small-caliber esophagogastroduodenoscopy for preoperative evaluation of the high-risk morbidly obese patient SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Alami, R. S., Schuster, R., Friedland, S., Curet, M. J., Wren, S. M., Soetikno, R., Morton, J. M., Safadi, B. Y. 2007; 21 (5): 758-760


    Esophagogastroduodenoscopy (EGD) is an important facet of the preoperative evaluation for bariatric surgery. Morbidly obese patients are at high risk for airway complications during this procedure, and an attractive alternative is transnasal EGD. This report describes a series of patients evaluated successfully using this technique.All patients undergoing preoperative transnasal small-caliber EGD for morbid obesity surgery between September 2004 and June 2005 at a Veterans Affairs Hospital were included in the analysis. The variables assessed were the adequacy of the examination, patient tolerance, the need for sedation, and the ability to perform interventions.The study enrolled 25 patients (17 men and 8 women) with an average age of 55 years (range, 44-63 years) and an average body mass index (BMI) of 47 kg/m2 (range, 38-69 kg/m2). All the patients met the 1991 National Institutes of Health (NIH) Consensus Conference Criteria for bariatric surgery and were undergoing preoperative evaluation. The most common comorbidities were hypertension (82%), diabetes mellitus (80%), and obstructive sleep apnea (68%). All 25 patients had successful cannulation of the duodenum's second portion with excellent tolerance. There were no sedation requirements for 23 (92%) of the 25 patients. Significant pathology was found in 14 (56%) of the 25 patients, including hiatal hernia (28%), gastritis (16%), esophageal intestinal metaplasia (16%), esophagitis (12%), gastric polyps (8%), gastric ulcer (4%) and esophageal varices (4%). Biopsies were indicated for 12 patients and successful for all 12 (100%).Transnasal small-caliber EGD is a feasible and safe alternative to conventional EGD for the preoperative evaluation of patients undergoing bariatric surgery. It requires minimal to no sedation in a population at high risk for complications in this setting. In addition, this technique is effective in identifying pathology that requires preoperative treatment and offers a complete examination with biopsy capabilities. This technique should be considered for all morbidly obese patients at high risk for airway compromise during EGD.

    View details for DOI 10.1007/s00464-006-9101-z

    View details for Web of Science ID 000246351800013

    View details for PubMedID 17235723

  • Disappointing weight loss among shift workers after laparoscopic gastric bypass surgery OBESITY SURGERY Ketchum, E. S., Morton, J. M. 2007; 17 (5): 581-584


    Shift work is an increasingly common employment structure in the United States and has been associated with increased rates of obesity and the metabolic syndrome. Shift work can necessitate altered patterns of sleep, eating, and activity over traditional work schedules. We investigated the effects of shift work on postoperative weight loss in bariatric surgery patients.A retrospective chart review of 389 patients undergoing laparoscopic Roux-en-Y gastric bypass was conducted. Shift workers were identified as patients with at least 2 years of employment primarily outside the hours of 8:00 am to 5:00 pm preoperatively and without return to a traditional schedule in the period up to 1 year postoperatively. Trends in excess body weight loss were categorized and compared between the shift workers and the non-shift workers in the cohort. Student's t-test was used for statistical analysis.8 shift workers were identified in the cohort. They had an average age of 45.9 years and preoperative BMI of 54.6, as compared to an age of 43.6 and BMI of 47.0 for the non-shift-workers in the cohort. 75% were female, compared to 83% for the non-shift-workers. Average postoperative excess weight loss for the shift workers was significantly lower than in the non-shift-workers: 29.9% vs 43.8% (P < .01) at 3 months, 46.4% vs 61.3% (P < .01) at 6 months, and 56.5% vs 76.8% (P < .01) at 12 months.The postoperative period in bariatric surgery requires significant adjustments in patients' lives. The potential for altered sleep physiology, reduced quantity of sleep, altered hormonal balance, increased tendency to disordered eating, and poorer quality of food intake, are all possible etiologies for substandard weight loss outcomes in shift workers undergoing bariatric surgery. Additional care should be taken in preoperative counseling and postoperative management of these patients.

    View details for Web of Science ID 000246158200003

    View details for PubMedID 17658014

  • Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial 23rd Annual Meeting of the American-Society-for-Bariatric-Surgery Alami, R. S., Morton, J. M., Schuster, R., Lie, J., Sanchez, B. R., Peters, A., Curet, M. J. ELSEVIER SCIENCE INC. 2007: 141–45


    Roux-en-Y gastric bypass surgery is the leading surgical treatment of morbid obesity in the United States. The role of preoperative weight loss in gastric bypass surgery remains controversial. We performed a prospective randomized trial to determine whether preoperative weight loss results in better outcomes after laparoscopic gastric bypass.A total of 100 patients undergoing laparoscopic gastric bypass surgery from May 2004 to October 2005 were randomized preoperatively to either a weight loss group with a 10% weight loss requirement or a group that had no weight loss requirements. The patients were followed prospectively. The variables analyzed included perioperative complications, operative time, postoperative weight loss, and resolution of co-morbidities.Data were available for 26 patients in the weight loss group and 35 in the nonweight loss group. The 2 groups had similar preoperative characteristics, conversion and complication rates, and resolution of co-morbidities. The initial body mass index was 48.7 kg/m(2) and 49.3 kg/m(2) for the weight loss group and nonweight loss group, respectively (P = NS). The preoperative body mass index was 44.5 kg/m(2) and 50.7 kg/m(2) for the weight loss group and nonweight loss group, respectively (P = 0.0027). The operative time was 220.2 and 257.6 minutes for the 2 groups (P = 0.0084). The percentage of excess weight loss at 3 and 6 months for the weight loss group and nonweight loss group was 44.1% and 33.1% (P = 0.0267) and 53.9% and 50.9% (P = NS), respectively. The interval to surgery from the initial consultation was 5.4 months and 5.2 months for the 2 groups (P = NS).Preoperative weight loss before laparoscopic Roux-en-Y gastric bypass was associated with a decrease in the operating room time and an improved percentage of excess weight loss in the short term. Preoperative weight loss, however, did not affect the major complication or conversion rates, and its long-term effects were not apparent through this study. Also, preoperative weight loss did not have any bearing on the resolution of co-morbidities.

    View details for DOI 10.1016/j.soard.2006.11.006

    View details for Web of Science ID 000261097100006

    View details for PubMedID 17331803

  • Clinical resolution of severely symptomatic pseudotumor cerebri after gastric bypass in an adolescent SURGERY FOR OBESITY AND RELATED DISEASES Chandra, V., Dutta, S., Albanese, C. T., Shepard, E., Farrales-Nguyen, S., Morton, J. 2007; 3 (2): 198-200


    Pseudotumor cerebri is a disease characterized by increased intracranial pressure, often manifested by headaches, and occasionally leading to severe visual impairment or even blindness. Most cases in adolescents, as in adults, are associated with obesity. We report a 16-year-old morbidly obese adolescent girl (body mass index 42.3 kg/m(2)) with severely symptomatic pseudotumor cerebri who had progressive visual field deficits and elevated intracranial pressure (opening pressure on lumbar puncture of 50 cm H(2)O) despite intensive medical management and placement of both ventriculoperitoneal and lumboperitoneal shunts. Six months after she underwent gastric bypass surgery, she had lost 43% of her excess body weight and had had near complete regression of her visual field deficits, along with normalization of her intracranial pressures. This case demonstrates the dramatic reversal of symptoms of pseudotumor cerebri with surgically induced weight loss. Gastric bypass should be considered as a treatment option for adolescents with severe and progressive pseudotumor cerebri.

    View details for DOI 10.1016/j.soard.2006.11.015

    View details for Web of Science ID 000261097100020

    View details for PubMedID 17324634

  • New device for introduction of circular stapler OBESITY SURGERY Morton, J. M. 2007; 17 (3): 426-426

    View details for Web of Science ID 000245043900025

    View details for PubMedID 17546857

  • Abnormal findings on routine upper GI series following laparoscopic Roux-en-Y gastric bypass 11th World Congress of the International-Federation-for-the-Surgery-of-Obesity Raman, R., Raman, B., Raman, P., Rossiter, S., Curet, M. J., Mindelzun, R., Morton, J. M. SPRINGER. 2007: 311–16


    The use of postoperative upper GI series (UGIS) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies among bariatric surgeons. The authors describe the findings and impact of UGIS after LRYGBP.From July 2003 to January 2006, 487 patients undergoing primary LRYGBP at a single academic institution had a single-contrast Gastrografin UGIS performed on the first postoperative day, without complication. Patient and operative demographics were: mean age 43 years, mean BMI 47 kg/m2, female 84%, and laparoscopic 100%.Of the 487 patients, the UGIS revealed 14 (2.9%) major and 88 (15.2%) minor abnormalities. Among the major UGIS abnormalities, 6 (1.2%) demonstrated a gastrojejunal anastomotic (GJA) leak, 8 (1.4%) confirmed complete obstruction at the GJA, and 1 (0.2%) disclosed a communication with the bypassed stomach. For the minor UGIS abnormalities, 45 (9.2%) displayed significant delay in contrast passage through the GJA, 23 (5.0%) had evidence of dilated loops of small and/or large bowel, and 6 (1.2%) verified miscellaneous abnormal findings (malrotation, lower esophageal dysmotility, jejunal clots). Patients with UGIS abnormalities necessitated additional procedures, delayed oral intake and/or longer length of stay (LOS).UGIS on postoperative day 1 is a useful means of evaluating postoperative LRYGBP anatomy and influenced postoperative care.

    View details for Web of Science ID 000245043900005

    View details for PubMedID 17546837

  • IPEG panel on clinical investigation JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Morton, J., Albanese, C. T., Barnhart, D., Dutta, S. 2007; 17 (1): 67-76

    View details for DOI 10.1089/lap.2006.9998

    View details for Web of Science ID 000245056900015

    View details for PubMedID 17362183

  • Gastric bypass reduces biochemical cardiac risk factors SURGERY FOR OBESITY AND RELATED DISEASES Williams, D. B., Hagedorn, J. C., Lawson, E. H., Galanko, J. A., Safadi, B. Y., Curet, M. J., Morton, J. M. 2007; 3 (1): 8-13


    Coronary artery disease (CAD) is the leading cause of death in the United States, with obesity as a leading preventable risk factor for CAD. Certain biochemical markers have demonstrated strong prediction for cardiovascular events. We hypothesized that in addition to weight reduction, gastric bypass will also induce a salutary effect on the biochemical cardiac risk factors.At a single academic institution, from 2003 to 2004, we measured the biochemical cardiac risk factors in gastric bypass patients preoperatively and at 3, 6, and 12 months postoperatively. These risk factors included total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein cholesterol, total cholesterol/HDL cholesterol ratio, triglyceride/HDL cholesterol ratio, triglycerides, lipoprotein A, high-sensitivity C-reactive protein, and homocysteine. The data were analyzed using the Wilcoxon signed rank test.The mean age of the 356 patients was 43 years; 84% were women; the mean body mass index was 47 kg/m(2); 33% were diabetic; 50% were hypertensive; 23% were taking lipid-lowering medications; and 2% had known CAD. Significant improvement occurred in the biochemical cardiac factors from preoperatively to 12 months. The beneficial changes were as follows: total cholesterol, 192 mg/dL preoperatively to 166 mg/dL at 12 months; HDL cholesterol, 46 mg/dL preoperatively to 54 mg/dL at 12 months; low-density lipoprotein, 125 mg/dL preoperatively to 88 mg/dL at 12 months; total cholesterol/HDL cholesterol ratio, 4 preoperatively to 3 at 12 months; triglyceride/HDL cholesterol ratio, 3 preoperatively to 2 at 12 months; triglycerides, 133 mg/dL preoperatively to 92 mg/dL at 12 months; lipoprotein A, 14 mg/dL preoperatively to 13 mg/dL at 12 months; high-sensitivity C-reactive protein, 8 mg/L preoperatively to 1 mg/L; and homocysteine, 10 mumol/L preoperatively to 8 mumol/L at 12 months.The results of our study have shown that gastric bypass significantly improves all biochemical markers of CAD risk, particularly C-reactive protein, which had an 80% reduction. As a result, gastric bypass decreases the cardiac risk by both weight loss and advantageous alterations of biochemical cardiac risk factors.

    View details for DOI 10.1016/j.soard.2006.10.003

    View details for Web of Science ID 000261052900004

    View details for PubMedID 17196442

  • Attitude of prospective surgical residents regarding surgery for morbid obesity OBESITY SURGERY Schuster, R., Morton, J. M., Liu, G. Y., Alami, R. S., Curet, M. J. 2006; 16 (11): 1464-1468


    Obesity and associated co-morbidities have become an epidemic in the United States. As surgery for obesity becomes more common, surgical training programs need to address this growing demand. We conducted this study to assess prospective surgery trainees' attitudes and knowledge regarding surgery for morbid obesity.An anonymous and voluntary questionnaire was given to prospective surgical residency applicants to complete during their interview. The questionnaire included basic demographic information and addressed the applicants' attitudes and basic knowledge about surgery for obesity.57 applicants to the surgical residency program completed the survey. Demographic information included: 51% male, 36% from the Northeast, 32% with obese family members, and 93% applying for a categorical surgery position. 81% of applicants had been exposed to bariatric surgery. Although 70% of applicants would perform bariatric surgery as part of their practice, only 44% would make this their career. Reasons for reluctance to treat bariatric surgery patients included: more complications (46%), non-compliant patients (33%), and technically demanding surgery (18%). 89% responded that they would recommend bariatric surgery to a family member, but only 77% would consider it for themselves. Overall correct answers regarding bariatric surgery knowledge were 74%.Attitudes and knowledge about surgery for morbid obesity were generally positive in prospective surgical trainees. Medical school curriculum and surgical training programs should continue to expose trainees to information from this ever-growing field.

    View details for Web of Science ID 000241926700011

    View details for PubMedID 17132412

  • Concurrent gastric bypass and repair of anterior abdominal wall hernias OBESITY SURGERY Schuster, R., Curet, M. J., Alami, R. S., Morton, J. M., Wren, S. M., Safadi, B. Y. 2006; 16 (9): 1205-1208


    Many patients seeking surgical treatment for morbid obesity present with anterior abdominal wall hernias. Although principles of hernia repair involve a tension-free repair with the use of prosthetic mesh, there is concern about the use of mesh in gastric bypass surgery due to potential contamination with the contents of the gastrointestinal tract and resultant mesh infection. We report our series of patients undergoing Roux-en-Y gastric bypass (RYGBP) and simultaneous anterior abdominal wall hernia repair.All patients who underwent simultaneous RYGBP surgery and anterior abdominal wall hernia repair were reviewed.12 patients underwent concurrent RYGBP and anterior wall hernia repair. There were 5 women and 7 men with average age 54.9 +/- 8.5 years (range 35 to 64) and average body mass index (BMI) 50.4 +/- 10.3 kg/m(2) (range 38 to 70). Two open and 10 laparoscopic RYGBP operations were performed. Nine patients (75%) underwent incisional hernia repairs and 3 patients (25%) underwent umbilical hernia repair concurrent with gastric bypass. Average size of defect was 14.7 +/- 13.4 cm(2). One patient had primary repair and 11 patients had prosthetic mesh repair: polypropylene in 3 patients (25%) and polyester in 8 patients (67%). With a 14.1 +/- 9.3 month follow-up, there have been no mesh infections and 2 recurrences, one in the patient who underwent primary repair and one in a patient repaired with polyester mesh but with two previous failed incisional hernia repairs.Concurrent RYGBP and repair of anterior abdominal wall hernias is safe and feasible. In order to optimize success, tension-free principles of hernia repair with the use of prosthetic mesh should be followed since no mesh infections occurred in our series.

    View details for Web of Science ID 000240355400015

    View details for PubMedID 16989705

  • Pulmonary embolus after retrieval of a temporary inferior vena caval filter in a Jehovah's Witness undergoing gastric bypass surgery OBESITY SURGERY Hagedorn, J. C., Morton, J. M. 2006; 16 (8): 1096-1100


    We present the case of pulmonary embolus after retrieval of a temporary inferior vena caval (IVC) filter in a Jehovah's Witness patient who underwent uneventful laparoscopic gastric bypass surgery. The 40-year-old female was admitted to the hospital 2 days after retrieval of the filter with bilateral pulmonary emboli for which she received anticoagulation therapy and consequently developed thoracic bleeding. We present this complicated case to highlight the risk of pulmonary emboli after IVC filter removal without anticoagulation, and to demonstrate the additional risk in managing a Jehovah's Witness patient.

    View details for Web of Science ID 000239667700257

    View details for PubMedID 16901367

  • Nis vs sages - A comparison of national and voluntary databases SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Morton, J. M., Galanko, J. A., Soper, N. J., Low, D. E., Hunters, J., Traverso, L. W. 2006; 20 (7): 1124-1128


    Surgical outcomes are increasingly examined in an effort to improve quality and reduce medical error. The Nationwide Inpatient Sample (NIS) is a retrospective, claims-derived and population-based database and the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Outcomes Project is a prospective, voluntary and specialty surgeon database. We hypothesized that these two sources of outcome data would differ in regard to a single, commonly performed procedure.Both the NIS, a national sample of all nonfederal hospital discharges, and the gastroesophageal reflux disease log of the SAGES Outcomes Project were queried for all fundoplications performed between 1999 and 2001 using either ICD-9 procedure code 44.66 or CPT codes 43280 or 43324. Patients with an emergency admission, age <17 years, and/or diagnoses for either esophageal cancer or achalasia were excluded. Both demographic and outcome variables were compared by either t-test or chi-square analysis, with a p value of <0.05 as significant.Both data sets were comparable for age and gender; however, the SAGES group had a higher rate of teaching hospital affiliation (71 vs 48%, p < 0.001). SAGES fundoplications had a consistently higher rate of comorbidities, including Barrett's esophagus (2.3 vs 1.1%, p = 0.005). The NIS fundoplications had a clear trend toward more associated procedures, including cholecystectomy (7.2 vs 2%, p < 0.001). Complication rates for the NIS data set were higher, including pulmonary complications (1.7 vs 0.5%, p = 0.03). No statistically significant differences existed between the two data sets for either length of stay or mortality.The two databases indicate that fundoplication is an operation with low morbidity and mortality. The SAGES Outcomes Project demonstrated that participating surgeons had a higher affiliation with teaching hospitals, higher reporting of comorbidity, and lower associated procedures than the NIS. Despite having more comorbidity and technical difficulty, patients from the SAGES Outcomes Project had equivalent or lower complication rates.

    View details for DOI 10.1007/s00464-004-8829-6

    View details for Web of Science ID 000239458900021

    View details for PubMedID 16703443

  • Intra-operative fluid volume influences postoperative nausea and vomiting after laparoscopic gastric bypass surgery OBESITY SURGERY Schuster, R., Alami, R. S., Curet, M. J., Paulraj, N., Morton, J. M., Brodsky, J. B., Brock-Utne, J. G., Lemmens, H. J. 2006; 16 (7): 848-851


    Laparoscopic Roux-en-Y gastric bypass (RYGBP) is a commonly performed operation for morbid obesity. A significant number of patients experience postoperative nausea and vomiting (PONV) following this procedure. The aim of this study was to determine the effect, if any, of intra-operative fluid replacement on PONV.Patients who underwent laparoscopic (RYGBP) for morbid obesity during a 12-month period were included in this retrospective analysis. Demographic data including age, gender, and body mass index (BMI) were collected. Perioperative data also included total volume of intra-operative fluids administered, rate of administration, urine output, length of surgery, and incidence of PONV as determined by nursing or anesthesia records in the postanesthesia care unit (PACU). Data were analyzed by t-test.The table below depicts demographic and perioperative data, comparing patients who experienced PONV (n=125) in the PACU with those who did not (n=55). Values are mean +/- standard deviation.PONV is a common complication after laparoscopic RYGB. Patient who did not experience PONV received a larger volume of intravenous fluid at a faster rate than similar patients who complained of PONV.

    View details for Web of Science ID 000239131000007

    View details for PubMedID 16839481

  • Methamphetamine use following bariatric surgery in an adolescent OBESITY SURGERY Dutta, S., Morton, J., Shepard, E., Peebles, R., Farrales-Nguyen, S., Hammer, L. D., Albanese, C. T. 2006; 16 (6): 780-782


    Bariatric surgery is increasingly popular as a therapeutic strategy for morbidly obese adolescents. Adolescence represents a sensitive period of psychosocial development, and children with considerable weight loss may experience greater peer acceptance, accompanied by both positive and negative influences. Substance abuse exists as one of these negative influences. We present the case of an adolescent bariatric surgical patient who abused methamphetamines in the postoperative period, with consequent nutritional instability. A concerted effort must be made in the preoperative assessment of adolescent bariatric patients to delineate a history of illicit drug use, including abuse of diet pills and stimulants. Excessive postoperative weight loss or micronutrient supplementation non-compliance should raise a suspicion of stimulant use and appropriate screening tests should be performed. The consequent appetite suppression may manifest with signs of malnutrition such as bradycardia, hypotension, and weakness. Inpatient nutritional rehabilitation and psychiatric assessment should be considered.

    View details for Web of Science ID 000238156200019

    View details for PubMedID 16756743

  • Orogastric tube complications in Laparoscopic Roux-en-Y gastric bypass OBESITY SURGERY Sanchez, B. S., Safadi, B. Y., Kieran, J. A., Hsu, G. P., Brodsky, J. B., Curet, M. J., Morton, J. M. 2006; 16 (4): 443-447


    Recent national efforts have focused on improving patient safety in surgical procedures including examining adverse events. An adverse event in laparoscopic Roux-en-Y gastric bypass (LRYGBP) which has not received much scrutiny involves orogastric tube complications during gastric pouch formation.Retrospective review was conducted of all LRYGBPs (n=727) performed by 5 surgeons over 5 years at 2 institutions. Cases with intraoperative orogastric tube (OGT) related complications (n=9) were identified.9 patients (1.2%) had preventable orogastric tube-related complications. Mean patient demographics were as follows: age 47 years, female 56%, pre-op BMI 52 kg/m(2), co-morbidities 3.5 and mortality 0%. 7 of 9 patients' cases were complicated by stapling of an orogastric tube during gastric pouch formation. The remaining 2 patients had complications involving suturing of the Levacuator tube during gastrojejunostomy formation. All complications required gastric pouch or anastomotic revision. 2 patients required conversion to an open procedure, 2 required re-operation for anastomotic leak, and 1 had respiratory failure and prolonged hospital stay.Orogastric tube complications can occur during laparoscopic RYGBP, but are seldom reported and can be associated with significant morbidity. Treatment options are dependent upon the situation. More importantly, prevention strategies must include constant communication with the anesthesiologist and removal or manipulation of an OGT prior to stapling or suturing, use of large bore OGTs for increased visual or tactile recognition, retraction of the OGT proximal to the anastomosis during gastrojejunal construction and employing alternatives to esophageal temperature probes (i.e. Foley temperature probes).

    View details for Web of Science ID 000236566000166

    View details for PubMedID 16608608

  • Robotic-assisted laparoscopic Roux-en-Y gastric bypass in a patient with midgut malrotation. Surgery for obesity and related diseases Alami, R. S., Schuster, R., Morton, J. M., Curet, M. J. 2006; 2 (2): 222-225

    View details for PubMedID 16925348

  • Analysis of the SAGES outcomes initiative groin hernia database SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Velanovich, V., Shadduck, P., Khaitan, L., Morton, J., Maupin, G., Travers, L. W. 2006; 20 (2): 191-198


    In 1999, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) introduced the SAGES Outcomes Initiative as a way for its members to track their own outcomes. It contains perioperative and postoperative data on nearly 20,000 operations. This report provides a descriptive analysis of the groin hernia database.The SAGES Outcomes Initiative database was accessed for all groin hernia cases from September 1999 to February 2005. The data from the preoperative, intraoperative, and postoperative entries were summarized. These data are purely descriptive and no statistical analysis was done.The hernia registry contains 1,607 entries, with 1,070 follow-up entries. Males comprised 85% of patients, 63% were employed, 62% had at least one comorbidity, with 84% ASA class I or II. Primary, unilateral hernia accounted for 86% of cases, whereas 14% were recurrent, 11% bilateral, 6% incarcerated, and 3% required emergency repair. The operating surgeon was the attending surgeon in 83% of cases. Anesthetic techniques were general anesthesia in 74% of cases, regional in 7%, and local in 34%, with only 16% of cases local only. Most patients had symptomatic hernias and symptoms were improved in more than 95% of patients. Most repairs were open, although 45% were endoscopic. The most frequently cited postoperative event was significant bruising (6%), with more than 99% of complications being class I or II. More than 95% of patients were able to return to work by the first postoperative visit. Patients who underwent endoscopic repair were reported to have fewer days of narcotic use than patients undergoing open repairs (0 vs 3).First analysis of the SAGES Outcomes Initiative groin hernia database demonstrates that (a) this is one of the largest prospective; voluntary hernia registries; (b) missing data are infrequent; and (c) the data are similar to published data from national, mandatory registries and randomized trials. Although the SAGES Outcomes Initiative is a voluntary registry, initially designed for surgeon self-assessment, and it therefore has the potential for methodological concerns inherent to voluntary registries, the findings from this first analysis are encouraging. Efforts are ongoing to simplify data entry (PDA), refine data parameters, increase surgeon participation, and determine the role of data audit and thereby the potential for clinical research.

    View details for DOI 10.1007/s00464-005-0436-7

    View details for Web of Science ID 000235059700003

    View details for PubMedID 16341567

  • Analysis of the SAGES outcomes initiative cholecystectomy registry Annual Meeting of the Society-of-American-Gastrointestinal-and-Endoscopic-Surgeons Velanovich, V., Morton, J. M., McDonald, M., Orlando, R., Maupin, G., Travers, L. W. SPRINGER. 2006: 43–50


    In 1999, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) introduced the SAGES Outcomes Initiative as a method for its members to use for tracking their own outcomes. This report provides a descriptive analysis of the cholecystectomy database.The SAGES Outcome Initiative database was accessed for all gallbladder cases from September 1999 to February 2005. The data from the preoperative, intraoperative, and postoperative entries were summarized. These data are purely descriptive, and no statistical analysis was performed.The gallbladder registry contained 3,285 cases, with 2,005 follow-up cases. Most patients were employed women with some comorbidities who had elective surgery under general anesthesia. Most of the operating surgeons were attending surgeons and surgical assistants. Most of the patients had biliary colic, and symptoms were improved for more than 95% of the patients. More than 90% of the cases were managed laparoscopically, with a conversion rate of 3%. Biliary imaging was used in the vast majority of cases, with most shown to be normal. Intraoperative gallbladder perforation was common, with bile duct injury occurring in 0.25% of cases. The most frequently cited postoperative event was wound infection, with most complications classified as class 1. More than 95% of the patients were able to return to work.The SAGES Outcomes Initiative database demonstrates that most participating SAGES members perform laparoscopic cholecystectomies themselves using intraoperative cholangiograms. Adverse outcomes are few, with most patients able to return to normal activity. Importantly, there were relatively few missing data points, implying that when surgeons enter data, the information is relatively complete.

    View details for DOI 10.1007/s00464-005-0378-0

    View details for Web of Science ID 000234485400005

    View details for PubMedID 16333539

  • The SAGES bariatric surgery outcome initiative Annual Meeting of the Society-of-American-Gastrointestinal-and-Endoscopic-Surgeons Nguyen, N. T., Morton, J. M., Wolfe, B. M., Schirmer, B., Ali, M., Travers, L. W. SPRINGER. 2005: 1429–38


    The recent initiative for identifying centers of excellence in bariatric surgery calls for documentation of surgical outcomes. The SAGES Outcomes Initiative is a national database introduced in 1999 as a method for surgeons to accumulate and compare their data with summary national data. A bariatric-specific dataset was established later in 2001. The aim of this study was to compare the outcomes of bariatric surgery from the Society of American Gastrointestinal Endoscopic Surgeons' (SAGES) bariatric database with data derived from a national administrative database of academic centers.Between 2001 and 2004, 24 surgeons with 1,954 patients participated in the SAGES Bariatric Outcome Initiative, and 97 institutions with 42,847 patients participated in the University HealthSystem Consortium (UHC) database. Only 7 of the 24 surgeons participating in the SAGES Bariatric Outcome Initiative submitted more than 50 cases. The main outcome measures included demographics, comorbidities, type of bariatric procedure, operative time, length of hospital stay, short- and long-term complications, mortality, and weight loss.Both datasets were comparable for gender. Roux-en-Y gastric bypass had been performed for 88% of the patients in the SAGES database and 96% of the patients in the UHC database. Associated comorbidities were similar between the two groups except for a higher rate of hyperlipidemia for the patients in the SAGES database. The SAGES database contains more bariatric-specific information such as body mass index, operative time, blood loss, bariatric-specific complications, long-term complications, and weight loss data than the UHC database. According to the available data, no statistically significant differences exist between the two datasets in terms of perioperative complications and mortality.The SAGES Bariatric Outcome Initiative provides valuable bariatric-specific data not currently available in an administrative database that may be useful for benchmarking purposes. However, this database is currently underutilized.

    View details for DOI 10.1007/s00464-005-0301-8

    View details for Web of Science ID 000233933700001

    View details for PubMedID 16206007

  • Incidental finding of gastrointestinal stromal tumors (GISTs) during laparoscopic gastric bypass OBESITY SURGERY Sanchez, B. R., Morton, J. M., Curet, M. J., Alami, R. S., Safadi, B. Y. 2005; 15 (10): 1384-1388


    Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for <1% of all neoplasms of the alimentary tract. GISTs have not been previously reported in association with gastric bypass surgery.This study is a retrospective review of 517 consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) between January 2002 and August 2005. Incidental intraoperative findings of gastric GIST were recorded.4 patients (0.8%) were noted to have GISTs intra-operatively upon inspection of the stomach prior to partition. All GISTs were identified along the anterior aspect of the upper third of the stomach and were removed by laparoscopic wedge excision with at least a 1 cm margin. The 4 tumors were <1 cm in size and all had immunohistochemical analysis positive for CD117 (c-kit). None of the tumors had determinants of malignant behavior (high mitotic rate, necrosis or pleomorphism).We have found a 0.8% incidence of gastric GISTs in our morbidly obese patients undergoing LRYGBP. All of these small, benign tumors were found incidentally in asymptomatic patients. This case series underscores the need to fully assess the stomach prior to gastric pouch formation. Without the ability to grossly determine the benign or malignant behavior of GISTs, all these tumors found incidentally should be resected with adequate margins.

    View details for Web of Science ID 000233506900005

    View details for PubMedID 16354516

  • Laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs and high-volume academic facilities: a comparison of institutional outcomes 29th Annual Surgical Symposium of the Association-of-VA-Surgeons Alami, R. S., Morton, J. M., Sanchez, B. R., Curet, M. J., Wren, S. M., Safadi, B. Y. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2005: 821–25


    Outcomes of bariatric surgery have been linked to institutional case volume. The objective of our study was to compare outcome of laparoscopic Roux-en-y gastric bypass (RYGB) in 2 settings: a low-volume Veterans Affairs (VA) and a high-volume university hospital (UH).Over a period of 27 months, 140 patients underwent RYGB (137 laparoscopic, 3 open) performed by 1 surgeon. Fifty-five were performed at a VA and 85 at a UH with an annual caseload close to 300.The body mass index in both groups was similar, but patients at the VA were older, mostly men, and more likely to have hypertension (HTN), obstructive sleep apnea, and diabetes mellitus (DM). Operative and anesthesia times were significantly longer at the VA. There were no differences in 30-day mortality (none), major morbidity, conversion rates, or reoperation rates.Laparoscopic RYGB can be performed safely at a VA facility despite a higher risk population and low annual volume.

    View details for DOI 10.1016/j.amjsurg.2005.07.027

    View details for Web of Science ID 000232935200030

    View details for PubMedID 16226965

  • Comparison of totally robotic laparoscopic Roux-en-Y gastric bypass and traditional laparoscopic Roux-en-Y gastric bypass. Surgery for obesity and related diseases Sanchez, B. R., Mohr, C. J., Morton, J. M., Safadi, B. Y., Alami, R. S., Curet, M. J. 2005; 1 (6): 549-554


    Laparoscopic gastric bypass is a technically demanding operation, especially when hand-sewing is required. Robotics may help facilitate the performance of this difficult operation. This study was undertaken to compare a single surgeon's results using the daVinci Surgical System with those using traditional laparoscopic Roux-en-Y gastric bypass (LRYGB) when the techniques were learned simultaneously.From July 2004 to April 2005, the new laparoscopic fellow's first 50 patients were randomized to undergo either LRYGB or totally robotic laparoscopic Roux-en-Y gastric bypass (TRRYGB). Data were collected on patient age, gender, body mass index (BMI), co-morbidities, operative time, complication rates, and length of stay. Student's t test with unequal variances was used for statistical analysis.No significant differences in age, gender, co-morbidities, complication rates, or length of stay were found between the two groups. The mean operating time was significantly shorter for TRRYGB than for LRYGB (130.8 versus 149.4 minutes; P = 0.02), with a significant difference in minutes per BMI (2.94 versus 3.47 min/BMI; P = 0.02). The largest difference was in patients with a BMI >43 kg/m(2), for whom the difference in procedure time was 29.6 minutes (123.5 minutes for TRRYGB versus 153.2 minutes for LRYGB; P = 0.009) and a significant difference in minutes per BMI (2.49 versus 3.24 min/BMI; P = 0.009).Our data indicate that the use of the daVinci Surgical System for TRRYGB is safe and feasible. The operating room time is shorter with the use of the robotic system during a surgeon's learning curve, and that decrease is maximized in patients with a larger BMI. TRRYGB may be a better approach to gastric bypass when hand-sewing is required, especially early in a surgeon's experience.

    View details for PubMedID 16925289

  • Weighing in on bariatric surgery - Procedure use, readmission rates, and mortality JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Wolfe, B. M., Morton, J. M. 2005; 294 (15): 1960-1963

    View details for Web of Science ID 000232602600026

    View details for PubMedID 16234503

  • The impact of preoperative weight loss in patients undergoing Laparoscopic Roux-en-Y gastric bypass OBESITY SURGERY ALVARADO, R., Alami, R. S., Hsu, G., Safadi, B. Y., Sanchez, B. R., Morton, J. M., Curet, M. J. 2005; 15 (9): 1282-1286


    Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a widely performed bariatric operation. Preoperative factors that predict successful outcomes are currently being studied. The goal of this study was to determine if preoperative weight loss was associated with positive outcomes in patients undergoing LRYGBP.A retrospective analysis was performed of all patients undergoing LRYGBP at our institution between July 2002 (when a policy of preoperative weight loss was instituted) and August 2003. Outcome measures evaluated at 1 year postoperatively included percent excess weight loss (EWL) and correction of co-morbidities. Statistical analysis was performed by multiple linear regression. P<0.05 was considered significant.The study included 90 subjects. Initial BMI ranged from 35.4 to 63.1 (mean 48.1). Preoperative weight loss ranged from 0 to 23.8% (mean 7.25). At 12 months, postoperative EWL ranged from 40.4% to 110.9 % (mean 74.4%). Preoperative loss of 1% of initial weight correlated with an increase of 1.8% of postoperative EWL at 1 year. In addition, initial BMI correlated negatively with EWL, so that an increase of 1 unit of BMI correlated with a decrease of 1.34% of EWL. Finally, preoperative weight loss of >5% correlated significantly with shorter operative times by 36 minutes. Preoperative weight loss did not correlate with postoperative complications or correction of co-morbidities.Preoperative weight loss resulted in higher postoperative weight loss at 1 year and in shorter operative times with LRYGBP. No differences in correction of co-morbidities or complication rates were found with preoperative weight loss in this study. Preoperative weight loss should be encouraged in patients undergoing bariatric surgery.

    View details for Web of Science ID 000233014200014

    View details for PubMedID 16259888

  • Laparoscopic Roux-en-Y gastric bypass: Differences in outcome between attendings and assistants of different training backgrounds OBESITY SURGERY Hsu, G. P., Morton, J. M., Jin, L., Safadi, B., Satterwhite, T. S., Curet, M. J. 2005; 15 (8): 1104-1110


    Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a significant learning curve. We hypothesize that differences in surgeon and assistant training backgrounds may significantly impact outcomes during the learning curve.Retrospective analysis was performed on patients undergoing LRYGBP at an academic medical center between January 1998 and August 2003. Operations were performed by surgeons with different training backgrounds: without formal laparoscopic fellowship (S1, n=95); immediately following laparoscopic fellowship (S2, n=100); and with extensive laparoscopic experience post fellowship (S3, n=88). First assistants were attendings, fellows, or residents. The variables analyzed included demographics, operative times, estimated blood loss (EBL), rate of conversion, length of stay (LOS), ICU stay, re-operation/re-admission rate, and complications. Results were analyzed by ANOVA and Fisher's exact test.There were significant differences among surgeons of different training backgrounds in EBL, LOS, rate of ICU admission, and intraoperative and late complications rates. Among assistants of different training levels, there were significant differences in operative time, EBL, intraoperative complication rates and re-admission rates.Differences in training background of the surgeons resulted in significant differences in outcome, including EBL, LOS, ICU admission and intraoperative and late complication rates. Lower assistant training levels significantly impacted efficiency through lengthened operative times and increased EBL, as well as increased intraoperative complication rates and re-admission rates. Our results suggested that participating in a laparoscopic fellowship and operating with a more experienced assistant may improve outcomes during the learning curve.

    View details for Web of Science ID 000232592700004

    View details for PubMedID 16197780

  • Nitrous oxide and laparoscopic bariatric surgery OBESITY SURGERY Brodsky, J. B., Lemmens, H. J., Collins, J. S., Morton, J. M., Curet, M. J., Brock-Utne, J. G. 2005; 15 (4): 494-496


    Nitrous oxide (N2O) is frequently used to supplement more potent anesthetic agents. One side-effect of N2O is its ability to expand an air-containing space. We investigated if N2O adversely affected operating conditions by distending normal bowel during laparoscopic bariatric procedures.50 morbidly obese patients were divided into 2 study groups. Group 1 patients were ventilated with a halogenated anesthetic/oxygen/air mixture, while Group 2 received a halogenated anesthetic/oxygen/N2O mixture. At 30, 60, and 90 min intervals during the operation, the surgeon was asked if N2O was being used.The surgeons responded correctly only 42% (30 min), 50% (60 min), and 48% (90 min) of the time. In Group 2 (N2O) patients, they incorrectly answered that N2O was not being used 88% (30 min), 68% (60 min), and 68% (90 min); and in Group 1 (air) patients, they incorrectly answered that N2O was being used 28% (30 min), 32% (60 min), and 36% (90 min) of the time.We found that using N2O did not cause noticeable bowel distention during laparoscopic bariatric procedures of relatively short duration.

    View details for Web of Science ID 000228911000006

    View details for PubMedID 15946427

  • A national comparison of surgical versus percutaneous drainage of pancreatic pseudocysts: 1997-2001 38th Annual Meeting of the Pancreas-Club Morton, J. M., Brown, A., Galanko, J. A., NORTON, J. A., Grimm, I. S., Behrns, K. E. SPRINGER. 2005: 15–20


    Case series results indicate that a surgical approach is superior to percutaneous drainage of pancreatic pseudocysts. To determine if this surgical advantage is persistent, national outcomes for both approaches were compared from 1997 through 2001. The National Inpatient Sample, a 20% sample of all nonfederal hospital discharges, was searched for patients who had a pancreatic pseudocyst diagnosis, an ICD-9 diagnosis code 577.2, and an ICD-9 procedure code of 52.01 for percutaneous drainage (PD) or 52.4 and 52.96 for the surgical approaches. Variables were compared by using either t test or chi2 analysis. Confounding variables were controlled for by linear or logistic regression models. No clinically significant demographic, comorbidity, and disease-specific severity-of-illness differences existed between the two groups. Significant differences in complications, length of stay (15+/-15 versus 21+/-22 days, P<0.0001), and inpatient mortality (5.9% versus 2.8%, P<0.0001) favored the surgical approach. In addition, endoscopic retrograde cholangiopancreatography use had a protective effect on mortality (odds ratio, 0.7), whereas percutaneous drainage had an increased risk of mortality (odds ratio, 1.4). This population-based study suggests that surgical drainage of pancreatic pseudocysts, particularly when coupled with use of endoscopic retrograde cholangiopancreatography, leads to decreased complications, length of stay, and mortality in comparison with percutaneous drainage.

    View details for DOI 10.1016/j.gassur.2004.10.005

    View details for Web of Science ID 000226973200005

    View details for PubMedID 15623440

  • Introducing laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs medical facility 28th Annual Surgical Symposium of the Association-of-VA-Surgeons Safadi, B. Y., Kieran, J. A., Hall, R. G., Morton, J. M., Bellatorre, N., Shinoda, E., Johnson, P. J., Curet, M. J., Wren, S. M. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2004: 606–10


    Previous studies have shown that advanced age, diabetes, and male gender are associated with higher morbidity and mortality after bariatric surgery. Those risk factors are characteristic of patients in the Veterans Affairs (VA) health care system. Laparoscopic Roux-en-Y gastric bypass (RYGB) has become an established treatment modality for morbid obesity. Our objective was to review the initial experience with laparoscopic (RYGB) for morbid obesity at our VA facility.A retrospective review was used.Between May of 2002 and April of 2004, 40 patients underwent laparoscopic RYGB. All patients met National Institutes of Health consensus statement guidelines for bariatric surgery. There were 30 (75%) male and 10 (25%) female patients, with an average age of 49.9 +/- 8.7 years and an average body mass index (BMI) of 48.1 +/- 8.5 kg/m(2). Preoperative comorbidities included diabetes mellitus (DM) in 59%, hypertension in 79%, and obstructive sleep apnea in 74.4%. The procedure was converted to an open procedure in 3 patients (7.5%). There were no mortalities. Immediate (within 30 days) complications developed in 9 (22.5%) patients, necessitating abdominal re-operation in 3 patients (7.5%). The median length of hospital stay was 3 days. Late complications (>30 days) developed in 8 (20%) patients. Percent excess weight loss at 3, 6, and 12 months was 44% (n = 34), 59% (n = 29), and 70.0% (n = 22), respectively. In 23 patients who were followed-up for more than 3 months, DM resolved in 79% and improved in 21% at a mean follow-up evaluation of 13 months.Laparoscopic RYGB can be performed with acceptable morbidity and with good short-term results in a VA hospital setting. Morbid obesity is prevalent in the VA patient population and access to bariatric surgery should be an available alternative.

    View details for DOI 10.1016/j.amjsurg.2004.07.021

    View details for Web of Science ID 000225208600032

    View details for PubMedID 15546580

  • What do surgery residents do on their call nights? AMERICAN JOURNAL OF SURGERY Morton, J. M., Baker, C. C., Farrell, T. M., Yohe, M. E., Kimple, R. J., Herman, D. C., Udekwu, P., Galanko, J. A., Behrns, K. E., Meyer, A. A. 2004; 188 (3): 225-229


    Surgical resident education is entering a critical era of achieving core competencies despite work hour restrictions. An assessment of on-call activity is needed to maximize educational merit.A time-motion study of resident on-call activity was performed at a university medical center and an urban affiliate hospital. Residents were followed by "shadow" residents who concurrently recorded resident activity.Activities of daily living and patient evaluation comprised the majority of on-call activity. Residents slept a median of 200 minutes per night. Cross-coverage activities accounted for 41% of pages and 19% of patient evaluation. Direct patient contact comprised only 7% of call night duties. Communication activity occupied 15% of total minutes, and a mean of 16 pages were received nightly. Significant differences in activities existed between resident levels and hospitals.Call activity consists primarily of activities of daily living, patient evaluation, and communication. Sleep accounts for nearly one third of all on-call activity. These data may be useful in improving both patient care and resident call experience.

    View details for DOI 10.1016/j.amjsurg.2004.06.011

    View details for Web of Science ID 000223921400004

    View details for PubMedID 15450824

  • Bovine pericardium buttress limits recanalization of the uncut Roux-en-Y in a porcine model 43rd Annual Meeting of the Society-for-Surgery-of-the-Alimentary-Tract Morton, J. M., Lucktong, T. A., Trasti, S., Farrell, T. M. SPRINGER. 2004: 127–31


    In contrast to the traditional Roux-en-Y reconstruction, an uncut Roux-en-Y provides biliopancreatic diversion and may preserve myoelectric continuity. Previous iterations of the uncut Roux have been plagued by recanalization of the uncut staple line in the afferent small bowel. Our aim was to determine if bovine pericardium buttress prevents recanalization of the stapled small bowel partition in a porcine model. Sixteen female pigs ( approximately 30 kg) underwent a side-to-side stapled jejunojejunostomy, 20 cm distal to the ligament of Treitz, with placement of a nondivided stapled partition with a single row of 2.5 mm width staples in the intervening jejunal loop. Nine animals in the experimental group had a bovine pericardium buttressed staple line (5 permanent, 4 absorbable), whereas seven animals in the control group had a nonbuttressed staple line. At 6 or 12 weeks, necropsy was performed and the primary outcome, staple line recanalization, was assessed grossly and histologically. Statistical analysis was performed by means of the chi-square test. There were no major complications and all animals gained weight. Overall, eight of nine bovine pericardium buttressed staple lines were grossly and histologically intact at necropsy, whereas all nonbuttressed uncut staple lines had recanalized completely (P<0.05). At 6 weeks, both permanent (N=4) and absorbable (N=3) buttress preparations prevented recanalization. At 12 weeks the permanent buttress remained closed (N=1), but the absorbable buttress had allowed partial recanalization (N=1). The use of bovine pericardium buttress will prevent small bowel recanalization of uncut small bowel staple lines at early follow-up. Pilot data at intermediate follow-up suggest permanent buttress is more durable than absorbable buttress. These results warrant investigation of bovine pericardium for intestinal applications in humans.

    View details for DOI 10.1016/j.gassur.2003.09.024

    View details for Web of Science ID 000188663900031

    View details for PubMedID 14746845

  • Gallbladder function before and after fundoplication 43rd Annual Meeting of the Society-for-Surgery-of-the-Alimentary-Tract Morton, J. M., Bowers, S. P., Lucktong, T. A., Mattar, S., Bradshaw, W. A., Behrns, K. E., Koruda, M. K., Herbst, C. A., McCartney, W., Halkar, R. K., Smith, C. D., Farrell, T. M. SPRINGER. 2002: 806–10


    No study has reported an association between gastroesophageal reflux disease (GERD) or its therapies and gallbladder function. We compared pre- and postoperative gallbladder function in patients undergoing fundoplication to determine the following: (1) whether patients with chronic GERD have preexisting gallbladder motor dysfunction; (2) whether medical or surgical therapy alters gallbladder function; and (3) whether division of the hepatic branch of the anterior vagus nerve is detrimental to gallbladder motility. Nineteen patients with documented GERD consented to a preoperative cholecystokinin-stimulated technetium hepatobiliary (CCK-HIDA) scan to quantify the gallbladder ejection fraction (GBEF). All patients underwent laparoscopic Nissen fundoplication. One month after fundoplication, 12 patients completed a repeat CCK-HIDA scan for determination of GBEF, with comparison to the preoperative GBEF. Among patients with preoperative GERD, 11 (58%) of 19 met the scintigraphic criteria for gallbladder dysfunction (GBEF <35%), which is a ratio comparable to that in patients undergoing a CCK-HIDA scan for presumed biliary dyskinesia during the same time period (31 [60%] of 53; P = NS, chi-square test) and exceeds the rate of abnormal GBEF reported in healthy volunteers (3%). Six of seven patients with a low preoperative GBEF who underwent repeat evaluation postoperatively had normalization of the GBEF (P < 0.05, paired t-test). In the 12 patients who underwent postoperative CCK-HIDA scanning, there was no association between preservation or division of the hepatic branch of the anterior vagus nerve and postoperative gallbladder dysfunction (P = NS, chi-square test). Unexpectedly, 58% of patients with GERD demonstrated gallbladder motor dysfunction prior to fundoplication, with improvement to normal occurring in most of those studied postoperatively. These data support controlled trials to determine the effect of chronic GERD and antisecretory therapy on gallbladder and global gastrointestinal smooth muscle function. Preservation of the hepatic branch of the anterior vagus nerve during fundoplication offered no clear benefit with regard to early postoperative gallbladder function.

    View details for Web of Science ID 000180763100004

    View details for PubMedID 12504218

  • Resection of benign esophageal stricture through a minimally invasive endoscopic and transgastric approach 70th Annual Meeting of the Southeastern-Surgical-Congress Lucktong, T. A., Morton, J. M., Shaheen, N. J., Farrell, T. M. SOUTHEASTERN SURGICAL CONGRESS. 2002: 720–23


    Recurrent benign esophageal strictures that are refractory to dilation can be difficult to manage. We report a novel technique for treatment of a recurrent esophageal stricture using a minimally invasive endoscopic and transgastric approach. The patient is a 40-year-old women who developed a recurrent distal esophageal stricture after repair of an esophageal perforation. Multiple prior dilations had been unsuccessful in achieving sustained esophageal patency, and the patient presented with a complete distal obstruction demonstrated on barium esophagram. Two flexible endoscopes were used: one placed through the mouth and another through a gastrostomy. While the transilluminated lesion was visualized from below the obstruction was traversed with an endoscopic aspiration needle from above. A guidewire was placed through the needle and pulled out the gastrostomy. Both the esophageal lesion and the gastrostomy tract were then serially dilated over the wire. After dilation the residual stricture was resected using a circular stapler placed through the dilated gastrostomy tract. After this procedure the patient maintained esophageal patency with a diminished need for dilation. Details of our technique are described and the literature is reviewed.

    View details for Web of Science ID 000177559900021

    View details for PubMedID 12206608