Conversion to Roux-En-Y Gastric Bypass: a successful means of mitigating reflux after laparoscopic sleeve gastrectomy.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric procedure due to the technical ease and weight loss success of the operation. However, there has been concern that LSG contributes to gastroesophageal reflux disease (GERD) postoperatively with a proportion of patients requiring conversion to a Roux-En-Y Gastric Bypass (RYGB). The objective of this study was to characterize the patients who underwent revision in our hospital system and to better understand pre-operative predictors of GERD and revision. METHODS: After IRB approval, a retrospective review was conducted assessing for patients who had conversion of LSG to RYGB at three hospitals within the University of Pennsylvania Health System from January 2015 to December 2021. The patients' charts were then reviewed to evaluate for demographics, BMI, operative findings, imaging and endoscopic reports, and post-operative outcomes. RESULTS: 97 patients were identified who underwent conversion of LSG to RYGB between January 2015 and December 2021. The cohort was predominantly female (n = 89, 91.7%) with an average age of 42.7 ± 10.6 years at the time of conversion. The most common indications for revision were GERD (72.2%) and obesity/insufficient weight loss (24.7%). Patients lost an average of 11.1 ± 12.9 kg after revision to RYGB. Of the patients who underwent revision for GERD, 80.2% noted global symptomatic improvement after revision and 19.4% were able to stop their proton pump inhibitor (PPI) postoperatively, with most patients decreasing the frequency of the PPI use postoperatively. CONCLUSION: The majority of patients who underwent conversion from LSG to RYGB due to GERD and saw marked improvements in GERD symptoms and outcomes. These findings illuminate the real-world practices and outcomes of bariatric revisional procedures for reflux and the need for more research on standardized practice.

Perspectives of adolescents with severe obesity on social Media in Preparation for weight-loss surgery: a qualitative study.

BACKGROUND: Currently the most effective treatment for severe obesity in adolescents is weight-loss surgery coupled with lifestyle behavior change. In preparation for weight-loss surgery, adolescents are required to make changes to eating and activity habits (lifestyle changes) to promote long term success. Social media support groups, which are popular among adolescents, have the potential to augment preoperative lifestyle changes. The purpose of this study was to qualitatively assess the perceived role of social media as a support tool for weight-loss, and to identify motivators and constraints to lifestyle changes and social media use in adolescents preparing for weight-loss surgery. METHODS: Thematic analysis of social media comments from 13 (3 male, 10 female) adolescents aged 16 ± 1.3 years with a body mass index (BMI) 45 ± 7.3 kg/m2 enrolled in a weight-management program preparing for bariatric surgery and who participated in a 12-week pilot social media intervention was performed. Participants commented on moderator posts and videos of nutrition, physical activity, and motivation that were shared three to four times per week. Social media comments were coded using NVivo 11.0 to identify recurrent themes and subthemes. RESULTS: 1) Social media provided accountability, emotional support, and shared behavioral strategies. 2) Motivators for lifestyle changes included family support, personal goals, and non-scale victories. 3) Challenges included negative peers, challenges with planning and tracking, and time constraints. CONCLUSION: Adolescents considering bariatric surgery identified social media as a tool for social support and reinforcement of strategies for successful behavior change. Important motivators and challenges to lifestyle changes were identified.

Mammographic breast density decreases after bariatric surgery.

PURPOSE: Breast density (BD), an important risk factor for breast cancer, can change over time in some women, but the underlying mechanism is unclear. Very little is known about the impact of surgical weight loss on BD. Our hypothesis is that weight loss after bariatric surgery is associated with a significant and favorable change in mammographic BD. METHODS: We identified 1097 women 40 years of age or older who underwent gastric bypass or sleeve gastrectomy at our institution from 2010 to 2014. Women who did not have either pre- and post-bariatric surgery mammograms performed at our institution were excluded; 110 had both mammograms and comprised the cohort. Breast density was determined both qualitatively, using reported BI-RADS density, and quantitatively, using the Laboratory for Individualized Breast Radiodensity Assessment. RESULTS: Qualitative BI-RADS density, quantitative breast area, and percent BD significantly decreased in post-bariatric surgery mammograms (p = 0.009, <0.001, and <0.001, respectively). CONCLUSIONS: Our retrospective study demonstrated that surgical weight loss was associated with a significant decrease in breast density. Additional studies are warranted to validate our findings and elucidate the molecular mechanisms underlying breast density change after weight loss surgery.

Corner store purchases made by adults, adolescents and children: items, nutritional characteristics and amount spent.

OBJECTIVE: Corner stores, also known as bodegas, are prevalent in low-income urban areas and primarily stock high-energy foods and beverages. Little is known about individual-level purchases in these locations. The purpose of the present study was to assess corner store purchases (items, nutritional characteristics and amount spent) made by children, adolescents and adults in a low-income urban environment. DESIGN: Evaluation staff used 9238 intercept surveys to directly examine food and beverage purchases. SETTING: Intercepts were collected at 192 corner stores in Philadelphia, PA, USA. SUBJECTS: Participants were adult, adolescent and child corner store shoppers. RESULTS: Among the 9238 intercept surveys, there were 20 244 items. On average, at each corner store visit, consumers purchased 2.2 (sd 2.1) items (1.3 (sd 2.0) foods and 0.9 (sd 0.9) beverages) that cost $US 2.74 (sd $US 3.52) and contained 2786.5 (sd 4454.2) kJ (666.0 (sd 1064.6) kcal). Whether the data were examined as a percentage of total items purchased or as a percentage of intercepts, the most common corner store purchases were beverages, chips, prepared food items, pastries and candy. Beverage purchases occurred during 65.9% of intercepts and accounted for 39.2% of all items. Regular soda was the most popular beverage purchase. Corner store purchases averaged 66.2 g of sugar, 921.1 mg of sodium and 2.5 g of fibre per intercept. Compared with children and adolescents, adults spent the most money and purchased the most energy. CONCLUSIONS: Urban corner store shoppers spent almost $US 3.00 for over 2700 kJ (650 kcal) per store visit. Obesity prevention efforts may benefit from including interventions aimed at changing corner store food environments in low-income, urban areas.

Psychopathology, disordered eating, and impulsivity as predictors of weight loss 24 months after metabolic and bariatric surgery.

BACKGROUND: The relationship between theoretically relevant psychosocial and behavioral variables and outcomes of metabolic and bariatric surgery remains unclear. Some studies have found that the presence of psychopathology, disordered eating, and impulsivity, either before surgery or during the early postoperative period, is associated with suboptimal postoperative weight loss. Other studies have not found these relationships. OBJECTIVE: Examine the relationship between psychopathology, disordered eating, impulsivity, and weight loss 24 months postoperatively. SETTING: Two large, urban university health systems. METHODS: Participant characteristics were collected using validated interviews, patient-reported outcome measures, and computerized assessment methods. Linear mixed effect models were used to test the association of the variables of interest on percent weight loss (%WL). RESULTS: Three hundred participants were enrolled at baseline; weight data at 24 months were available for 227 participants; between 181 and 53 individuals completed other outcome measures. The mean %WL was 23.3 ± 9.9% at 24 months. Patients who underwent Roux-en-Y gastric bypass lost more weight than those who underwent sleeve gastrectomy. The presence of subjective binge episodes at baseline was related to a greater %WL at 24 months; there were no other baseline predictors. The presence of eating disorder diagnoses and disordered eating symptoms after surgery were associated with smaller weight losses over 24 months. Current and lifetime psychopathology and impulsivity were unrelated to %WL at 24 months. CONCLUSION: Disordered eating after bariatric surgery was associated with a smaller %WL at postoperative year 2. Additional monitoring of these symptoms in the early postoperative period is recommended. Psychotherapeutic and/or dietary interventions may promote more optimal weight loss outcomes.

Nutritional considerations with antiobesity medications.

The improved efficacy and generally favorable safety profile of recently approved and emerging antiobesity medications (AOMs), which result in an average weight reduction of ≥15%, represent significant advancement in the treatment of obesity. This narrative review aims to provide practical evidence-based recommendations for nutritional assessment, management, and monitoring of patients treated with AOMs. Prior to treatment, clinicians can identify preexisting nutritional risk factors and counsel their patients on recommended intakes of protein, dietary fiber, micronutrients, and fluids. During treatment with AOMs, ongoing monitoring can facilitate early recognition and management of gastrointestinal symptoms or inadequate nutrient or fluid intake. Attention should also be paid to other factors that can impact response to treatment and quality of life, such as physical activity and social and emotional health. In the context of treatment with AOMs, clinicians can play an active role in supporting their patients with obesity to improve their health and well-being and promote optimal nutritional and medical outcomes.

Changes in Eating Behaviors and Their Relation to Weight Change 6 and 12 Months After Bariatric Surgery.

INTRODUCTION: Identifying eating behaviors associated with suboptimal weight loss following bariatric surgery remains important. This study assessed the relationship between eating behaviors and weight loss following bariatric surgery in a racially diverse sample. METHODS: Participants were assessed before surgery and 6 and 12 months postoperatively, with the Structured Clinical Interview for DSM-5, the Eating Disorder Examination-Bariatric Surgery Version, and validated measures assessing a range of eating behaviors. Linear mixed effect models were used to test the impact of eating behaviors on percent weight loss (%WL) at 6 and 12 months. RESULTS: We enrolled 300 participants (mean age 40.1 years; BMI 45.9 kg/m2; 87% women; 62% Black and 30% White). The majority (82%) underwent sleeve gastrectomy (SG). Mean %WL was 23.0 ± 5.1% at 6 months and 26.2 ± 7.6% at 12 months. Subjective binge episodes prior to surgery predicted greater %WL over the first 12 postoperative months (p = 0.028). Postoperative disinhibition, hunger, night eating symptoms, objective binge episodes, global disordered eating attitudes and behaviors, and snacks per day were associated with smaller %WL over 12 months (all p's < 0.01). The presence of picking/nibbling and addictive-like eating behaviors was not associated with %WL at the end of the first postoperative year. CONCLUSION: Among a diverse participant sample, problematic eating behaviors following surgery were associated with smaller %WL over 12 months. Postoperative assessment and treatment of eating behaviors are needed to address these issues as they arise and to prevent attenuation of early weight loss in some patients.

Behavioral Interventions After Bariatric Surgery.

Purpose of Review: Bariatric surgery is the most effective and durable treatment for severe obesity. Postoperative behavioral weight management approaches are available for optimizing weight change for both short- and long-term outcomes. Recent Findings: Varying settings such as groups and telemedicine along with techniques such as cognitive behavioral therapy have been assessed in the post-bariatric surgery population. The assessment and application of these programs have been limited due to methodological, financial, and attrition-related constraints. Summary: This review aims to summarize the current evidence for different postoperative behavioral interventions on postoperative outcomes, specifically highlighting weight loss. Future opportunities for study include mechanisms for overcoming some of the barriers to implementing these programs in clinical, non-research settings.

Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Adult Weight Management.

A person's weight is an anthropometric measure factored into assessing health risk, not a measure of worth, ability, or overall health. Adult weight management is a spectrum of lifelong care services available for persons whose goals can be achieved through evidence-based, weight-related interventions and intersects most practice areas of nutrition. An adult weight management registered dietitian nutritionist (RDN) is responsible for providing a psychologically safe, accessible, and respectful setting and empowering care to those seeking nutrition services. This requires the RDN to act as an advocate by proactively seeking to identify personal and external weight biases, understanding the influence of those predispositions, and acknowledging how weight-related prejudices are intricately connected with systems that influence nutrition both inside and outside of health care. Increases in average weight influence potentially counterproductive discussions about judgment, an individual's body, and relationship with health. RDNs are equipped to provide dynamic care and be on the forefront of implementing weight-inclusive built environments, policies, and person-centered communications to minimize harm and maximize benefit for the individual and society. The authors, Weight Management Dietetic Practice Group, and the Academy of Nutrition and Dietetics Quality Management Committee revised the Standards of Practice and Standards of Professional Performance for RDNs in Adult Weight Management to update established criteria of competent practice, further define core values, and set direction for future areas of opportunity. The Adult Weight Management Standards of Practice and Standards of Professional Performance are complementary tools intended for RDNs to benchmark and identify progressive routes and goals for professional advancement.

How safe is adolescent bariatric surgery? An analysis of short-term outcomes.

BACKGROUND: The prevalence of childhood obesity in the U.S. has tripled over the last three decades. However, fewer than 1% of children with severe obesity undergo surgical weight loss interventions each year. MATERIALS AND METHODS: All patients age 10 to 19 years old who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2015 through 2018 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were included in this retrospective cohort analysis. The primary outcomes were mortality and overall complications. Procedural trends, readmission and reoperation rates were also examined using a multivariate regression model. RESULTS: Patients had a mean BMI of 47.3 kg/m2 and 80.0% were either 18 or 19 years old (n = 4,051). There were two reported deaths. Reoperation within 30 days occurred in 1.1% of patients, readmission in 3.5%, and complications in 1.2%. Among all readmissions, primary reasons included nausea/vomiting or nutritional depletion (41.3%) and abdominal pain (16.3%). RYGB was associated with higher odds for readmission (p = 0.006) and complications (p = 0.005). Higher BMI and younger age were not associated with an increased likelihood to experience poorer outcomes. The proportion of patients undergoing SG increased yearly over RYGB from 73.9% in 2015 to 84.3% in 2018. CONCLUSIONS: Bariatric surgery appears to be low risk for adolescents and SG has become the operation of choice. More research on early consideration of surgical therapy in adolescents with severe obesity is needed given the safety profile. LEVEL OF EVIDENCE: III.

Practical considerations of developing and conducting a successful telehealth practice in response to COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic posed significant challenges to clinicians practicing in outpatient settings focused on chronic disease treatment and management. Many interprofessional teams transitioned to telehealth to continue to provide care while minimizing in-person interaction to reduce risk of transmission. Given that telehealth will likely remain as a care option even as the pandemic subsides, this review summarizes the applied recommendations on telehealth in interprofessional patient care, provides practical insights for successfully transitioning care from an academic medical center bariatric surgery program, and highlights future opportunities for research.

Risk factors for postdischarge venous thromboembolism among bariatric surgery patients and the evolving approach to extended thromboprophylaxis with enoxaparin.

BACKGROUND: Venous thromboembolism (VTE) is one of the most common causes of postoperative mortality following bariatric surgery. The majority of VTE events occur after discharge from the hospital. Little consensus exists regarding who should receive extended enoxaparin thromboprophylaxis or how they should be dosed, namely whether to use weight-based or BMI-stratified dosing strategies. OBJECTIVES: Provide an overview of the risk factors associated with VTE in procedures among bariatric patients including the use of predictive tools to stratify risk and the various approaches to enoxaparin chemoprophylaxis in obesity. SETTING: Multiple centers. METHODS: A review of the literature identified studies evaluating risk factors for VTE including demographic characteristics, co-morbidities, and operative factors. The use of calculators to stratify patients by risk and approaches to extended thromboprophylaxis in obesity were evaluated as well. RESULTS: VTE was associated with increased age, weight, male sex, and prior history of VTE, all frequently included in risk calculators. Outside of those major risk factors, there is little consensus about the importance of patient diagnoses. Weight-based dosing was often superior to standardized dosing in studies across disciplines in generating target anti-Xa levels however there is no consistent association of reduced risk of VTE with therapeutic anti-Xa levels. CONCLUSIONS: Risk calculators may be a valuable tool for identifying patients at high-risk for VTE, but their efficacy depends on the rating algorithm and inclusion of various risk factors and is methodologically limited by prophylactic interventions. Future work should consider if biochemical factors should be included in patient stratification approaches in particular when defining the ideal chemoprophylaxis approach. Transparency and consistency in data collection and reporting is needed to better assess and inform the ideal dosing strategy to prevent VTE following bariatric surgery.

Psychopathology, disordered eating, and impulsivity in patients seeking bariatric surgery.

BACKGROUND: Most patients who undergo bariatric surgery experience significant weight loss and improvements in obesity-related co-morbidities in the first 6-18 months after surgery. However, 20%-30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. Psychosocial functioning may contribute to suboptimal weight loss and/or postoperative psychosocial distress. OBJECTIVE: Assess psychosocial functioning, eating behavior, and impulsivity in patients seeking bariatric surgery. SETTING: Two university hospitals. METHODS: Validated interviews and questionnaires. Impulsivity assessed via computer program. RESULTS: The present study included a larger (n = 300) and more racially diverse (70% non-White) sample than previous studies of these relationships. Forty-eight percent of participants had a current psychiatric diagnosis and 78% had at least 1 lifetime diagnosis. Anxiety disorders were the most common current diagnosis (25%); major depressive disorder was the most common lifetime diagnosis (44%). Approximately 6% of participants had a current alcohol or substance use disorder; 7% had a positive drug screen before surgery. A current psychiatric diagnosis was associated with greater symptoms of food addiction and night eating. Current diagnosis of alcohol use disorder or a lifetime diagnosis of anxiety disorders was associated with higher delay discounting. CONCLUSION: The study identified high rates of psychopathology and related symptoms among a large, diverse sample of bariatric surgery candidates. Psychopathology was associated with symptoms of disordered eating and higher rates of delay discounting, suggesting impulse control issues.

Validation and improvement of a highly predictive bariatric surgery mortality risk calculator to include sleeve gastrectomy using MBSAQIP 2015-2017 data.

BACKGROUND: Initial development of a prominent bariatric surgery mortality risk calculator comprising cases that now account for <10% of commonly performed operations. Whether the previously highly predictive model is valid with more recent data is unknown. OBJECTIVES: To validate and improve a bariatric-surgery-specific mortality calculator with updated case mix and outcomes data. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited bariatric surgery programs. METHODS: The Metabolic and Bariatric Accreditation and Quality Improvement Program Participant Use File from years 2015 to 2017 was used for the analysis. C-statistics were calculated with observed death as the outcome and estimated 30-day mortality risk as the only predictor and receiver operating characteristic curve was plotted. Similar analyses were repeated for each body mass index (BMI) subgroup. Backward selection logistic regression was used to investigate the potential of improving the robustness of the model. RESULTS: Patients were predominantly female (n = 446,149, 80.4%) and white (n = 409,350, 73.7%) with a mean (standard deviation) age of 45.4 (12.0) years and BMI of 44.5 (8.4) kg/m2, and the most commonly performed operation was sleeve gastrectomy (n = 338,061, 60.9%). Assessing previous model using present data, area under the curve was .7412. By BMI subgroup, area under the curve for BMI <45 kg/m2 was .7645, for BMI 45 to 60 kg/m2 was .7586, and for BMI >60 kg/m2 was .6576. DISCUSSION: The present study found that the model previously developed maintains discrimination with changing surgical procedures. Though variables in the initial calculator are helpful, additional factors should be considered when weighing risk, such as sex, previous surgery, and renal function. Future studies are needed to determine whether changes in modifiable risk factors will impact mortality rates.

Laparoscopic Sleeve Gastrectomy Carries a Lower Perioperative Mortality Including Sudden Cardiac Death over Roux-en-Y Gastric Bypass in Patients with a Prior Cardiac History: An MBSAQIP Analysis.

BACKGROUND: Although bariatric surgery has proven beneficial for those with cardiovascular disease (CVD), the overall and procedure-specific risk associated with bariatric surgery in this patient population remains unknown. DESIGN: Patients who underwent primary laparoscopic, laparoscopic-assisted, or robotic-assisted Roux-En-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at a MBSAQIP-accredited center were included (n = 494,611). Exposures include history of MI, PCI, or cardiac surgery who underwent RYGB or SG. Outcome measures were 30-day mortality, perioperative cardiac arrest, and rehospitalization. RESULTS: Of 494,611 patients enrolled in MBSAQIP, 15,923 had a history of MI, PCI, or cardiac surgery (prior cardiac history). Patient history of MI, PCI, and cardiac surgery was associated with significantly increased adjusted risk of perioperative cardiac arrest requiring CPR (OR: 2.31, 2.12, 2.42, respectively) and adjusted 30-day mortality (OR: 1.72, 1.50, 1.68, respectively). Prior cardiac history was associated with increased adjusted 30-day readmission rate (MI - OR, 1.42; PCI - OR, 1.45; and cardiac surgery - OR, 1.68). Further, 30-day postoperative readmission, postoperative cardiac arrest, and death were lower for patients undergoing SG compared to RYGB (OR: 0.48, 0.49, and 0.54 respectively). CONCLUSION AND RELEVANCE: Prior cardiac history was associated with significant greater risk of perioperative cardiac arrest and 30-day mortality among patients undergoing bariatric surgery. SG was associated with less adverse events than RYGB among this population. While there is a clear benefit to weight loss in patients with CVD, it is important to consider whether cardiac patients considering bariatric surgery may require additional preoperative optimization, perioperative interventions, and postoperative monitoring.

Prebariatric surgery care and postoperative outcomes: increased number of visits associated with smaller weight losses over first 2 postoperative years.

BACKGROUND: The prebariatric surgery assessment process can be challenging to patients and serve as a barrier to surgery. There is limited evidence to support its utility in improving postoperative outcomes for the majority of patients. OBJECTIVES: To assess the relationship between preoperative care and postoperative weight loss and follow-up in the first 2 postoperative years. SETTING: University Hospital, United States. METHODS: Frequency and duration of preoperative assessment and medical weight management contacts were retrospectively collected and assessed in relation to percent weight change over the first 24 months postoperatively in adults who underwent an initial bariatric surgical procedure between 2009 and 2014. RESULTS: Patients (n = 1303) were 44.4 ± 11.9 years with a body mass index of 48 ± 8.6 kg/m2. The frequency of preoperative contacts (all types) and duration of preoperative care were not associated with postoperative weight loss or follow-up. A greater number of individual (one-to-one) visits with the bariatric surgery team and additional psychology visits were associated with smaller postoperative weight losses (individual = -.27%, 95% confidence interval -.47%, -.07%; P = .01; psychology = -1.46%, 95% confidence interval -2.79%, -.12%; P = .03). CONCLUSIONS: These observations suggest the intensity and length of the preoperative assessment period is unrelated to early postoperative weight loss. Additional individual visits with the bariatric team and the psychologist before surgery were associated with smaller postoperative weight loss, suggesting that clinicians may be appropriately identifying complex patients and are making efforts to address this complexity with additional preoperative assessment and care.

National Postoperative Bariatric Surgery Outcomes in Patients with Chronic Kidney Disease and End-Stage Kidney Disease.

PURPOSE: Obesity is a major risk factor for end-stage kidney disease (ESKD) and is often a barrier to kidney transplantation. However, limited evidence exists evaluating postoperative bariatric surgery outcomes in patients with chronic kidney disease (CKD) and ESKD. MATERIALS AND METHODS: We performed a retrospective cohort study of patients who underwent bariatric surgery in 2015-2016 using the national Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program dataset. Propensity score matching was used to balance characteristics across patients with CKD and ESKD vs. those without CKD. RESULTS: There were 323,034 patients without CKD, 1694 patients with CKD, and 925 patients with ESKD who underwent bariatric surgery. Patients with CKD and ESKD had a significantly increased risk of 30-day reoperation (CKD odds ratio [OR] 2.25 95% confidence interval [CI] 1.45-3.51; ESKD OR 3.10, 95% CI 1.72-5.61) and readmission (CKD OR 1.98, 95% CI 1.53-2.56; ESKD OR 2.97, 95% CI 2.05-4.31) compared to patients without CKD; mortality risk was elevated in patients with ESKD (OR 11.59, 95% CI 6.71-20.04) but not in those with CKD (OR 1.00, 95% CI 0.32-3.11). Rates of adverse outcomes were < 15% across all groups. There were 12, 50, and 172 deaths per 1000 person-years among patients without CKD, with CKD, and with ESKD, respectively. CONCLUSION: Patients with CKD and ESKD experienced higher risk of postbariatric surgery complications compared to those without kidney disease, although absolute complication rates were low across all groups. CKD and ESKD should not be perceived as contraindications to bariatric surgery.

Weight Loss Prior to Bariatric Surgery and 30-Day Mortality, Readmission, Reoperation, and Intervention: an MBSAQIP Analysis of 349,016 Cases.

INTRODUCTION: Despite preoperative weight loss being a common prerequisite to metabolic and bariatric surgery, its relationship to 30-day postoperative outcomes is unclear. The aim of this study was to assess whether preoperative weight loss is associated with 30-day postoperative quality outcomes in adults undergoing metabolic and bariatric surgery. METHODS: Retrospective cohort study assessing adults who underwent Roux-en-Y gastric bypass or sleeve gastrectomy in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use File, years 2015-2017. The relationship between preoperative weight loss and 30-day readmission, reoperation, mortality, intervention, and morbidity was assessed using multivariable logistic regression. RESULTS: Preoperative weight loss, body mass index loss, and percent weight loss were not associated with 30-day postoperative overall readmission, reoperation, mortality, or intervention (p > 0.01). Preoperative percent weight loss was associated with increased incidence of superficial surgical site infections (OR = 1.023, 95% CI 1.009-1.036; p = 0.001) and urinary tract infections (OR = 1.044, 95% CI 1.030-1.059; p < 0.001). CONCLUSION: Weight loss prior to metabolic and bariatric surgery may not be necessary or safe for all patients. Unsafe weight loss prior to surgery may compromise nutrition status and lead to increased infection rates.

Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery.

Outcomes of bariatric surgery, while frequently impressive, are not universal and vary between patients and across surgical procedures. Between 20% and 30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. The reasons for this are not fully understood, but likely involve both physiologic processes, behavioral factors, and psychological characteristics. Evidence suggests that preoperative psychosocial status and functioning can contribute to suboptimal weight losses and/or postoperative psychosocial distress. Much of this work has focused on the presence of recognized psychiatric diagnoses and with particular emphasis on mood disorders as well as binge eating disorder. Several studies have suggested that the presence of preoperative psychopathology is associated with suboptimal weight losses, postoperative complications, and less positive psychosocial outcomes. Contemporary psychological theory suggests that it may be shared features across diagnoses, rather than a discrete diagnosis, that better characterizes psychopathology. Mood and substance use disorders as well as binge eating disorder, share common features of impulsivity, although clinicians and researchers often use complementary, yet different terms, such as emotional dysregulation or disinhibition (i.e., loss of control over eating, as applied to food intake), to describe the phenomenon. Impulse control is a central factor in eating behavior and extreme obesity. It also may contribute to the experience of suboptimal outcomes after bariatric surgery, including smaller than expected weight loss and psychosocial distress. This paper reviews the literature in these areas of research and articulates a direction for future studies of these complex relationships among persons with extreme obesity.

Bariatric surgery before and after kidney transplantation: long-term weight loss and allograft outcomes.

BACKGROUND: Severe obesity is frequently a barrier to kidney transplantation, and kidney transplant recipients often have significant weight gain following transplantation. OBJECTIVES: The goals of this study were to evaluate the long-term risks and benefits of bariatric surgery before and after kidney transplantation. SETTING: University Hospital, United States. METHODS: We performed a retrospective cohort study of 43 patients who had pretransplantation bariatric surgery and 21 patients who had posttransplantation bariatric surgery from 1994 to 2017 with propensity-score matching to identify matched controls using national registry data. RESULTS: Body mass index at the time of transplantation was similar in patients who underwent bariatric surgery before versus after transplantation (32 versus 34 kg/m2, P = .172). There was no significant difference in body mass index in the 5 years after bariatric surgery among patients who underwent bariatric surgery before versus after kidney transplantation (36 versus 32 kg/m2, P = 0.814). Compared with matched controls, bariatric surgery before (n = 38) and after (n = 18) kidney transplantation was associated with a decreased risk of allograft failure (hazard ratio .31 [95% confidence interval .29-0.33] and .85 [95% confidence interval .85-.86] for pre- and posttransplant, respectively) and mortality (hazard ratio .57 [95% confidence interval .53-.61] and .80 [95% confidence interval .79-.82] for pre- and posttransplant, respectively). CONCLUSIONS: Bariatric surgery before and after kidney transplantation results in similar maintenance of weight loss and improved long-term allograft survival compared with matched controls. Bariatric surgery appears to be a safe and reasonable approach to weight loss both before and after transplantation.