Background Many insurance companies have considerable pre-bariatric surgery requirements despite a lack of evidence for improved clinical outcomes. The hypothesis of this study is that insurance-specific requirements will be associated with a decreased progression to surgery and increased delay in time to surgery. Methods Retrospective data collection was performed for patients undergoing bariatric surgery evaluation from 2010–2015. Patients who underwent surgery (SGY; n= 827; mean BMI 49.1) were compared to those who did not (no-SGY; n= 648; mean BMI 49.4). Univariate and multivariate analysis were performed to identify specific comorbidity and insurance specific predictors of surgical dropout and time to surgery. Results A total of 1475 patients using 12 major insurance payers were included. Univariate analysis demonstrated insurance requirements associated with surgical drop out included longer median diet duration (no-SGY= 6 months; SGY=3 months; p< 0.001); PCP letter of necessity (p<0.0001); laboratory testing (p=0.019); and evaluation by cardiology (p<0.001), pulmonology (p<0.0001), or psychiatry (p=0.0003). Using logistic regression to control for comorbidities, longer diet requirement (OR 0.88, p<0.0001), PCP letter (OR 0.33, p<0.0001), cardiology evaluation (OR 0.22, p=0.038), and advanced laboratory testing (OR 5.75, p=0.019) independently predicted surgery dropout. Additionally, surgical patients had an average interval between initial visit and surgery of 5.8±4.6 months with significant weight gain (2.1 kg, p<0.0001). Conclusion Many pre-bariatric surgery insurance requirements were associated with lack of patient progression to surgery in this study. In addition, delays in surgery were associated with preoperative weight gain. Although prospective and multicenter studies are needed, these findings have major policy implications suggesting insurance requirements may need to be reconsidered to improve medical care.

While the development of a fistulous tract from the kidney to the proximal adjacent organs is relatively common, a tract leading to the skin is a rare occurrence. The primary cause of a fistula is prior surgical intervention or malignancy leading to abscess formation. Our case involves Xanthogranulomatous pyelonephritis (XGP) causing a longstanding lobulated abscess, ultimately leading to the formation of a fistulous tract.

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Patients with refractory malnutrition benefit from feeding tube placement, which results in a significant increase in BMI.

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