Impact of Rapid Weight Loss after Bariatric Surgery in Systemic Inflammatory Response and Pulmonary Hemodynamics in Severely Obese Subjects with Pulmonary Hypertension.

BACKGROUND: Pulmonary hypertension (PH) can be associated with obesity. The excessive production of proinflammatory mediators by dysfunctional adipocytes may enhance remodeling of the pulmonary vasculature and worsen pulmonary hemodynamics. This study aimed to describe the changes in pulmonary arterial pressures and systemic inflammation in patients with obesity with PH after bariatric surgery (BaS). STUDY DESIGN: In this retrospective cohort study, we compared patients with PH who underwent BaS from 2008 to 2018 at our institution (group 1) to a group of severely obese patients with PH (group 2). Echocardiographic right ventricular systolic pressure (RVSP) was used as an indirect measurement of pulmonary arterial pressures. Red blood cell distribution width (RDW) was used as a marker of systemic inflammation. RESULTS: A total of 40 patients were included, 20 per group. In group 1, the RVSP decreased from 44.69 ± 7.12 mmHg to 38.73 ± 12.81 mmHg (p = 0.041), and the RDW decreased from 15.22 ± 1.53 to 14.41 ± 1.31 (p = 0.020). In group 2, the RVSP decreased from 60.14 ± 18.08 to 59.15 ± 19.10 (0.828), and the RDW increased from 15.37 ± 1.99 to 15.38 ± 1.26 (0.983). For both groups, we found a positive correlation between RVSP and RDW changes, although the correlation was not statistically significant. CONCLUSIONS: Previous studies suggest BaS could be a safe and effective procedure to achieve weight loss in obese patients with PH, with an additional modest improvement in pulmonary hemodynamics. The results of this study reinforce this observation and suggest that such improvement could be related to a decrease in systemic inflammation. Further prospective studies with bigger samples are needed to better understand these findings.

Does bariatric surgery change the risk of acute ischemic stroke in patients with a history of transient ischemic attack? A nationwide analysis.

BACKGROUND: Stroke is the second leading cause of death worldwide and fifth in the United States, and it represents the major cause of disability in older adults. OBJECTIVE: We aimed to determine the risk of acute ischemic stroke (AIS) in individuals with obesity with a history of transient ischemic attack (TIA) compared with patients with a history of bariatric surgery. SETTING: Academic hospital, United States. METHODS: Using the Nationwide Inpatient Sample (NIS) database from 2010 to 2015, we retrospectively identified patients with obesity and past medical history of TIA and divided them into 2 groups: a treatment group of patients who underwent bariatric surgery, and a control group of patients with obesity. We compared incidence of new AIS in both groups using a univariate analysis and multivariate regression model. Covariates included were lifestyle (smoking status, alcohol habits, cocaine use), family history of stroke, co-morbidities (diabetes, hypertension, hyperlipidemia, atrial fibrillation) and long-term medical treatment (antiplatelet/antithrombotic treatment). RESULTS: A total of 91,640 patients met inclusion criteria, of which treatment patients were 12.3% (n = 11,284) and control patients 87.6% (n = 80,356). The average age of the treatment group was 62.9 ± 17.08 years, and the average of the control was 59.6 ± 12.74 years. The rate of AIS in the treatment group was significantly lower compared with the control group (2.8% versus 4.2%, P < .0001). After adjusting for covariables, the risk difference of AIS was still significant between groups (odds ratio = 1.33, P < .0001), showing that patients in the treatment group were less likely to have AIS compared with the control group. CONCLUSIONS: After analyzing nationwide information, we conclude bariatric surgery helps decrease risk of AIS in patients with a history of TIA. However, this comparison is limited by the nature of the database; further studies are needed to better understand these results.

Bariatric surgery decreases hospitalization rates of patients with obstructive lung diseases: a nationwide analysis.

BACKGROUND: Obesity can worsen outcomes in patients with chronic respiratory diseases. OBJECTIVES: The objective of the study was to determine the impact of bariatric surgery (BaS) on risk of hospitalization due to acute exacerbation (AE) of chronic obstructive lung diseases (OLDs). SETTING: Academic, University-affiliated Hospital; United States. METHODS: Nationwide Inpatient Sample data collected from 2010 to 2015 were examined. Patients were classified as treatment and control groups. Treatment subjects were defined as patients with a previous history of BaS, and control subjects, as patients with a body mass index ≥35 kg/m2 and without a history of BaS. The primary outcome was hospitalization due to AE of any OLD (chronic obstructive pulmonary disease, asthma, and bronchiectasis), and the secondary outcome was the total length of stay (LOS). Univariate analysis and multivariate regression model were performed to assess the difference in outcomes between groups. RESULTS: We included a total of 2,300,845 subjects: 2,004,804 controls and 296,041 treatments. Univariate analysis showed that the hospitalization rate was significantly lower for the treatment group than that for the control group (3.7% versus 9.8%, P < .0001), confirmed after adjusting for covariates (control versus treatment: odds ratio [OR] = 2.46, P < .0001). Subgroup analysis showed that the treatment group had a lower risk of LOS ≥3 days than controls (69.8% versus 77.4%, P < .0001), confirmed by multivariate analysis (control versus treatment: OR = 1.40, P < .0001). CONCLUSIONS: BaS-induced weight loss may decrease the risk of hospitalization due to AE in patients with OLD, also decreasing the LOS. We acknowledge that this comparison is limited by the nature of the database; hence, further prospective studies are needed to better understand these results.

A rare case of large left internal maxillary artery pseudoaneurysm secondary to mandibular fracture: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Pseudoaneurysms secondary to traumatic vessel wall disruption are a rare but potentially fatal complication after traumatic injury. The majority of the cases are found incidentally. CASE PRESENTATION: An 80-year-old woman was brought into our Level 1 Trauma Center after sustaining a ground-level fall with significant facial swelling. Her imaging revealed an acute traumatic comminuted fracture of the right mandibular condyle and left mandibular ramus. The patient underwent closed maxillomandibular fixation (MMF) to stabilize fractures, and allow the swelling to decrease for definitive fixation. During the definitive procedure, profuse bleeding was encountered. CT angiography evaluation was immediately performed and determined the presence of a left internal maxillary artery pseudoaneurysm which was successfully treated by coil and glue embolization. CLINICAL DISCUSSION: This case highlights an unusual presentation of a vascular injury following major traumatic mandibular fracture and its management. Mandibular fractures have been reported in a series of cases to be a risk factor for vascular injuries. When a vascular injury is suspected, or the evaluation is unclear, surgeons should carefully determine the necessity to perform additional studies like CT angiogram. Vascular injuries secondary to mandibular fractures can be fatal if left unrecognized and untreated. Hence adequate recognition and treatment are warranted to avoid prolonged length of stay with bad outcomes. CONCLUSION: Optimal management of pseudoaneurysms is achieved by endovascular approach with prior resuscitation and adequate hemodynamic stabilization. Open surgical management is deferred only for those cases where endovascular treatment is not available, or disruption is found intraoperatively.

Short-term rapid weight loss induced by bariatric surgery improves ventricular ejection fraction in patients with severe obesity and heart failure.

BACKGROUND: Obesity is a major risk factor for the development of metabolic syndrome, coronary artery disease, and heart failure (HF). Rapid weight loss following bariatric surgery can significantly improve outcomes for patients with these diseases. OBJECTIVES: To assess whether bariatric surgery improves ventricular ejection fraction in patients with obesity who have heart failure. SETTING: Private practice, United States. METHODS: We conducted a retrospective review of echocardiographic changes in systolic functions in patients with obesity that underwent bariatric surgery at our institution. Patients were divided into 2 groups, those (1) without known preoperative HF and (2) with preoperative HF. We compared the left ventricular ejection fraction (LVEF) before and after bariatric surgery in both groups. Common demographics and co-morbidities were also analyzed. RESULTS: A total of 68 patients were included in the analysis: 49 patients in group 1 and 19 in group 2. In group 1, 59.2% (n = 29) of patients were female, versus 57.9% (n = 11) in group 2. The excess body mass index lost at 12 months was 52.06 ± 23.18% for group 1 versus 67.12 ± 19.27% for group 2 (P = .0001). Patients with heart failure showed a significant improvement in LVEF, from 38.79 ± 13.26% before to 48.47 ± 14.57% after bariatric surgery (P = .039). Systolic function in patients from group 1 showed no significant changes (59.90 ± 6.37 mmHg) before and (59.88 ± 7.85 mmHg) after surgery (P = .98). CONCLUSION: Rapid weight loss after bariatric surgery is associated with a considerable increase in LVEF and a significant improvement of systolic function.

Impact of bariatric surgery on the risk of hospitalization due to influenza virus infection.

BACKGROUND: Obesity independently increases the risk of hospitalization due to viral respiratory infections, including influenza virus and, more recently, severe acute respiratory syndrome coronavirus 2. As an independent risk factor, obesity impairs the immune response to viral infections and decreases the effectiveness of immunizations. OBJECTIVES: Using influenza as a proxy, we aimed to determine the impact of bariatric surgery (BaS) on the risk of hospitalization due to viral respiratory infections. SETTING: Academic hospital, United States. METHODS: National (Nationwide) Inpatient Sample data collected from 2010 to 2015 were examined. Patients were classified as treatment and control groups. Treatment subjects were defined as patients with a history of BaS and control subjects as patients with a body mass index ≥35 kg/m2 and without a history of BaS. Any hospitalization with influenza as a primary diagnosis was identified. Univariate analysis and multivariate regression models were performed to assess the differences between groups. RESULTS: A total of 2,300,845 subjects were reviewed, of which 2,004,804 were control subjects and 296,041 were treated patients. Univariate analysis showed that the hospitalization rate in the treatment group was significantly lower than in the control group (.007% versus .019%, P < .0001), which was confirmed after adjusting for covariables (control versus treatment: odds ratio = 2.21, P = .0010). CONCLUSIONS: BaS may decrease the risk of hospitalization due to influenza, but further prospective studies are needed to confirm these results. We also suggest that these results should be translated into the development of similar studies to determine the impact of BaS on the incidence and severity of the coronavirus disease 2019.

Left ventricular mass index and ventricular contractility improvement in patients with severe obesity following rapid weight loss after bariatric surgery.

BACKGROUND: Obesity is a well-known risk factor for heart disease, resulting in a broad spectrum of cardiovascular changes. Left ventricular mass (LVM) and contractility are recognized markers of cardiac function. OBJECTIVES: To determine the changes of LVM and contractility after bariatric surgery (BaS). SETTING: University hospital, United States METHODS: To determine the cardiac changes in ventricular mass, ventricular contractility, and left ventricular shortening fraction (LVSF), we retrospectively reviewed the 2-dimensional echocardiographic parameters of patients with obesity who underwent BaS at our institution. We compared these results before and after BaS. RESULTS: A total of 40 patients met the inclusion criteria. The majority were females (57.5%; n = 23), with an average age of 63.5 ± 12.1. The excess body mass index (BMI) lost at 12 months was 48.9 ± 28.9%. The percent total weight loss after BaS was 16.46 ± 9.9%. The left ventricular mass was 234.9 ± 88.1 grams before and 181.5 ± 52.7 grams after BaS (P = .002). The LVM index was 101.3 ± 38.3 g/m2 before versus 86.7 ± 26.6 g/m2 after BaS (P = .005). The LVSF was 31% ± 8.8% before and 36.3% ± 8.2% after BaS (P = .007). We found a good correlation between the decrease in LVM index and the BMI after BaS (P = .03). CONCLUSION: Rapid weight loss results in a decrease of the LVM index, as well as improvement in the left ventricular muscle contractility. Our results suggest that there is left ventricular remodeling and an improvement of heart dynamics following bariatric surgery. Further studies are needed to better assess these findings.

Improvement of glucose metabolism following rapid weight loss after bariatric surgery and its impact on reduction of visceral abdominal fat versus free fat muscle.

BACKGROUND: Body fat distribution is highly associated with metabolic disturbances. Skeletal muscle plays an important role in glucose metabolism, as it serves as an important organ for glucose storage in the form of glycogen. In fact, low muscle mass has been associated with metabolic syndrome, type 2 diabetes (T2D), systemic inflammation, and decreased survival. OBJECTIVES: To compare the relationship between visceral abdominal fat (VAF) and fat free mass (FFM) with the improved glucose metabolism after bariatric surgery. SETTING: University hospital, United States. METHODS: A retrospective review was performed of all patients who underwent bariatric surgery between 2011 and 2017 at a university hospital in the United States. In severely obese patients with T2D, we measured the VAF via abdominal computed tomography scan and we calculated the FFM preoperatively and at a 12-month follow-up. Data collected included baseline demographic characteristics and perioperative parameters, such as treatment for hypertension (HTN) and T2D, body mass index (BMI), glycated hemoglobin (HbA1C), glucose, and lipid profile. RESULTS: A total of 25 patients met the inclusion criteria. The average age was 52.5 ± 11.6 years. The initial BMI was 41.41 ± 5.7 kg/m2 and the postoperative BMI was 31.7 ± 6.9 kg/m2 (P < .0001). The preoperative VAF volume was 184.6 ± 90.2 cm3 and the postoperative VAF volume was 93.8 ± 46.8 cm3 at the 12-month follow-up (P < .0001). The preoperative FFM was 55.2 ± 11.4 kg and the postoperative FFM was 49.1 ± 12 kg (P < .072). The preoperative HbA1C was 5.8% ± .9%, which decreased postoperatively to 5.3% ± .4% at the 12-month follow-up (P < .013). CONCLUSION: Bariatric surgery has been demonstrated to be an effective treatment modality for severe obesity and T2D. Our results suggest that at 12 months, there is a reduction in VAF and HbA1C without a significant loss of FFM. Further prospective studies are needed to better understand these findings.