Elevated Hb A1C level and revisional bariatric surgery complications.

BACKGROUND: Elevated Hb A1C is a modifiable risk factor for postoperative complications. However, in bariatric surgery, as published by our group and others, elevated preoperative Hb A1C may not be associated with increased postoperative complications. Previous literature has focused on primary bariatric surgery and has excluded the higher-risk revisional surgery cohort. OBJECTIVE: To assess the impact of Hb A1C on early postoperative outcomes in patients requiring revisional bariatric surgery. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. METHODS: We undertook a retrospective review of patients undergoing revisional bariatric surgery between 2017 and 2018 from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Two groups were studied, defined by Hb A1C cutoff, ≤8% versus >8% and ≤10% versus >10%. Early postoperative complications were compared at each threshold, with the primary outcome defined as a composite of all complications. Propensity score matching (PSM) was used with one-to-one matching for covariates, and the complication rates before and after PSM were calculated and assessed by Fisher's exact test and conditional logistic regression, respectively. RESULTS: A total of 16,234 patients had undergone revisional bariatric surgery. After PSM, elevated Hb A1C was not associated with worse outcomes. No significant difference was seen in the composite outcomes for Hb A1C ≤8% versus Hb A1C >8% (P = .22) or for patients with Hb A1C ≤10% versus Hb A1C >10% (P < .46). There were no differences in individual outcomes such as surgical-site infections, cardiopulmonary complications, or readmissions/reinterventions. CONCLUSION: In this study of revisional bariatric patients, elevated Hb A1C >8% or >10% was not associated with increased postoperative complications. Prospective studies are needed to investigate this further.

Routine preoperative endoscopy in patients undergoing bariatric surgery.

BACKGROUND: The role of routine preoperative endoscopy before primary weight loss surgery remains controversial. OBJECTIVE: We reviewed our experience to determine the frequency of abnormal findings in patients undergoing routine preoperative endoscopy before bariatric surgery. SETTING: A tertiary level, academic-affiliated bariatric surgery practice. METHODS: A retrospective chart review was performed between July 2014 and June 2016 of patients undergoing routine preoperative endoscopy before primary bariatric surgery. Variables evaluated included preendoscopy symptoms, planned bariatric surgical procedure, abnormal findings on endoscopy, and changes in planned bariatric surgical procedure after endoscopy. RESULTS: A total of 631 patients met inclusion criteria. Of patients, 72% (457) were female. The median age was 44 (interquartile range 36-55). The median body mass index was 46 (interquartile range 42-51). Most patients had no preendoscopy clinical symptoms (61.3%). The most frequent abnormal findings included esophagitis (26.5%), hiatal hernia (27.1%), gastric ulcer (4.9%), and biopsy-proven Barrett's esophagus (4.6%). Although patients with preoperative symptoms were more likely to have abnormal findings on endoscopy, there were no significant differences in rates of Barrett's esophagus in patients with (5.3%) or without (4.1%) symptoms. Of the total cohort, 18.4% had a change in their planned operation after endoscopy results. CONCLUSION: The findings in our large series suggest selective screening in symptomatic patients only may lead to failure of discovery of foregut pathology that should prompt consideration for changes in the planned bariatric surgical procedure. Further study is necessary to see if our findings have broad applicability.

Decreased access to bariatric care: an analysis of referral practices to bariatric specialists.

BACKGROUND: Substantial evidence reveals tolerability and co-morbid disease resolution after bariatric surgery; however, few physicians refer morbidly obese patients for bariatric consultation. OBJECTIVE: To evaluate morbidly obese patient access to bariatric surgical consultation. SETTING: A multidisciplinary, private, bariatric center of excellence. METHODS: Patient surveyed in person regarding preconsultation co-morbidities, physician discussion and support for bariatric surgery, and physician referral practices. RESULTS: The patients' (n = 388) co-morbid profile was 27.0% diabetes, 54.1% hypertension, 30.1% hyperlipidemia, and 37.1% obstructive sleep apnea. It was reported that 71.1% of patients stated that their primary care physician did not initiate a discussion about bariatric surgery. Among this group, 59.7% of patients initiated a conversation about bariatric surgery, with 80.6% of physicians supporting the decision and 18.4% referring to a bariatric practice. Overall referring specialty profile was 14.4% primary care, 4.4% cardiology, and 3.6% endocrinology. Diabetes and obstructive sleep apnea were more likely to prompt a referral (P = .008 and P = .014, respectively). CONCLUSION: Most primary care and subspecialists do not discuss bariatric surgical options, resulting in decreased access to bariatric care. The main barrier to referral is noncommunication by the primary care physician or subspecialist, despite the vast majority of physicians having positive attitudes about bariatric surgery. Co-morbidities of diabetes and obstructive sleep apnea are more likely to prompt a referral. Primary care physicians are most likely to refer, while endocrinologists are least likely. Improved familiarity with nationally recognized obesity management algorithms could contribute to improved referral rates.

Pulmonary considerations in obesity and the bariatric surgical patient.

Severe obesity can be associated with significant alterations in normal cardiopulmonary physiology. The pathophysiologic effects of obesity on a patient's pulmonary function are multiple and complex. The impact of obesity on morbidity and mortality are often underestimated. Bariatric surgery has been shown to be the most effective modality of reliable and durable treatment for severe obesity. Surgical weight loss improves and, in most cases, completely resolves the pulmonary health problems associated with obesity.