Understanding intraoperative fluorescent cholangiography: ten steps for an effective and successful procedure.

BACKGROUND: Common bile duct injuries (BDI) during laparoscopic cholecystectomy (LC) continue to be the source of morbidity and mortality. The reason for BDI is mostly related to the misidentification of the extrahepatic bile duct structures and the anatomic variability. Near-infrared fluorescent cholangiography (NIFC) has proven to enhance visualization of extrahepatic biliary structures during LCs. The purpose of this study was to describe the most important steps in the performance of NIFC. METHODS: In accordance to the most current surgical practice of LC at our institution, a consensus was achieved on the most relevant steps to be followed when utilizing NIFC. Dose of indocyanine green (ICG), time of administration, and identification of critical structures were previously determined based on prospective and randomized controlled studies performed at CCF. RESULTS: The ten steps identified as critical when performing NIFC during LC are preoperative administration of ICG, exposure of the hepatoduodenal ligament, initial anatomical evaluation, identification of the cystic duct and common bile duct junction, the cystic duct and its junction to the gallbladder, the CHD, the common bile duct, accessory ducts, cystic artery and, time-out and identification of Calot's triangle, and evaluation of the liver bed. CONCLUSIONS: Routine use of NIFC is a useful diagnostic tool to better visualize the extrahepatic biliary structures during LC. The implementation of specific standardized steps might provide the surgeon with a better algorithm to use this technology and consequently reduce the incidence of BDI.

Metabolic Surgery Reduces the Risk of Progression From Chronic Kidney Disease to Kidney Failure.

INTRODUCTION: According to the Chronic Kidney Disease Prognosis Consortium (CKD-PC), 1 in 4 patients age ≥ 65 in North America has some form of chronic kidney disease (CKD), while 3 in 100 will progress to kidney failure. The aim of this study was to evaluate whether bariatric surgery alters the progression of CKD to kidney failure in patients who are severely obese. METHODS: We conducted a retrospective review of all patients who underwent bariatric surgery at our institution over the last 16 years. Kidney function and injury were assessed using the average estimated glomerular filtration rate and urinary albumin-to-creatinine ratio (uACR) over 3 months preoperatively and postoperative at 12-month follow-up. The risk of progression from CKD to kidney failure was assessed using the Chronic Kidney Disease Prognosis Consortium (CKD-PC) equation. RESULTS: Out of 2924 patients reviewed over this period of time, 69 (2.4%) had the recorded data necessary to assess kidney injury and the risk of disease progression to kidney failure. Patients within moderate and severe stages of CKD-related albuminuria improved the most at 12-month follow-up (by 48% and 79%; P = 0.0001 and P = 0.025, respectively). This translated to a relative risk reduction for progression to kidney failure in CKD ≥ stage 3 patients of 70% at 2 years and 60% at 5 years (both P = 0.001). CONCLUSIONS: Bariatric surgery seems to improve kidney injury, especially among patients with the most severe stages of CKD. Marked 2- and 5-year risk reduction in the progression from CKD to kidney failure was observed.

Bariatric Surgery Improves Heart Geometry and Plasticity.

BACKGROUND: Obesity is commonly associated with increased sympathetic tone, changes in heart geometry, and mortality. The aforementioned translates into a higher and potentially modifiable mortality risk for this specific population. OBJECTIVES: The aim of the study was to analyze the extent of changes in the heart ventricular structure following rapid weight loss after bariatric surgery. SETTING: Academic, university-affiliated hospital. METHODS: We retrospectively reviewed all the patients that underwent bariatric surgery at our institution between 2010 and 2015. Data analyzed included demographics, BMI, and associated medical problems. Preoperative and postoperative echography readings were compared looking at the heart geometry, cardiac volumes, and wall thickness. RESULTS: Fifty-one patients who had bariatric surgery and had echocardiography before and after the surgery were identified. There were 33 females (64.7%). The mean age was 63.4 ± 12.0 years with an average BMI of 40.3 ± 6.3. The mean follow-up was 1.2 years after the procedure. At 1 year follow-up 25 patients (49%, p = 0.01) showed normal left ventricular geometry. The left ventricular mass (229 ± 82.1 vs 193.2 ± 42.5, p<0.01) and the left ventricular end diastolic volume (129.4 ± 53 vs 96.4 ± 36.5, p = 0.01) showed a significant modification following the procedure. There was a significant improvement in the interventricular septal thickness (p = 0.01) and relative wall thickness (p < 0.01) following surgery. CONCLUSION: The patients with obesity present a significant cardiac remodeling from concentric remodeling to normal geometry after bariatric surgery. The decrease in BMI has a direct effect on improvement of the left ventricular structure. Further studies must be carried out to define the damage of obesity to diastolic function.

Potential beneficial effects of bariatric surgery on the prevalence of kidney cancer: a national database study.

BACKGROUND: The incidence of obesity has been steadily increasing, especially in developed countries. Also, obesity is considered one of the modifiable risk factors of kidney cancer. OBJECTIVES: This study aims to determine the impact of bariatric surgery-induced weight loss on the prevention of kidney cancer. SETTING: Academic Hospital, United States. METHODS: The National (Nationwide) Inpatient Sample (NIS) was queried for the period 2010 to 2015 for first-time kidney cancer-related hospitalization, used as a proxy for cancer incidence, in patients with a history of bariatric surgery (cases) and patients with obesity but no history of bariatric surgery (controls). Patients with a previous diagnosis of cancer were excluded from the analysis. In order to identify comparable patients, all controls had to have a body mass index ≥35 kg/m2, as per the existing qualification criteria for bariatric surgery. The International Classification of Diseases-9 codes (ICD-9) was used to identify admissions for kidney cancer. A univariate analysis was conducted to compare demographics and co-morbidities between groups. A multivariate logistic regression model was performed to assess differences between surgical and control groups and adjust for independent variables such as smoking history and family history of malignancy. All percentages and means (with confidence intervals [CIs]) were weighted. RESULTS: A total of 2,300,845 were included in the analysis, of which 2,004,804 controls-subjects, with a mean age of 54.4 ± .05 years, and 296,041 treatment-subjects, with a mean age of 51.9 ± .05 years. Demographics and co-morbidities, such as tobacco use, diabetes, and hypertension, were also measured. Patients with a history of bariatric surgery were significantly less likely to experience renal cancer than patients without a history of bariatric surgery, with 5935 cases in the control group and 684 in the case group (P < .0001). After a multivariate logistic regression was performed, the OR was 1.10 (95% CI: 1.02-1.22, P < .0224). CONCLUSION: Our finding suggests that bariatric surgery-induced weight loss could significantly prevent first-time kidney cancer-related hospitalizations in patients with obesity. Prospective studies are needed to confirm our findings.

Weight loss following bariatric surgery decreases pericardial fat thickness lowering the risk of developing coronary artery disease.

BACKGROUND: Pericardial fat has a local atherosclerotic effect and is associated with both metabolic syndrome (MetS) and coronary artery disease (CAD). OBJECTIVES: The aim of this study is to report changes in pericardial fat thickness (PFT) after bariatric surgery, and to investigate its significance on the risk of developing coronary artery disease (CAD). SETTING: Academic institution. METHODS: We retrospectively measured the linear pericardial thickness from patients' computed tomography (CT) scans within 5 years preoperatively and compared to any available CT scan within 5 years postoperatively. The PFT was measured at the right ventricular wall, perpendicular to the myocardium, at the level of the sternum. The risk of developing CAD was estimated by calculating the Framingham risk score (FRS). We divided the patients into 2 groups: laparoscopic sleeve gastrectomy (SG, Group 1), and laparoscopic gastric Roux-en-Y gastric bypass (LRYGB, Group 2). Common demographic characteristics and co-morbidities were collected along with the preoperative and postoperative lipid profiles. RESULTS: A total of 113 patients met the inclusion criteria, with 64 (56.6%) patients in group 1 and 49 (43.3%) patients in group 2. Group 1 consisted of 83.6% (n = 53) female patients versus 75.5% (n = 37) in group 2. The percent excess body mass index loss (%EBMIL) at 12 months was 74.4 ± 35.8% for group 1 versus 67 ± 30.1% for group 2 (P = .292). Pericardial thickness before surgery was 5.6 ± 1.9 mm and 4.6 ± 1.6 mm after surgery (P = .0001). The risk of CAD in females was 9.1% before and 6.6% after surgery. We found statistically significant linear association between pericardial thickness after surgery and a lower risk of CAD (P = .001). CONCLUSION: Bariatric surgery decreases the PFT lowering risk of developing CAD. Further studies may be needed to better assess these findings.

Sleeve gastrectomy versus Roux-en-Y gastric bypass in patients Aged ≥65 years: a comparison of short-term outcomes.

BACKGROUND: Bariatric surgery in the elderly population has been reported as feasible and safe. Sleeve gastrectomy (SG) seems to have fewer complications than Roux-en-Y gastric bypass (RYGB) even in the 65 years of age population. We analyzed the difference in weight loss between SG and RYGB in patients age 65 years. OBJECTIVES: To analyze and compare outcomes between SG and RYGB in patients 65 years of age and older. SETTING: Academic hospital, United States. METHODS: After internal review board approval, we retrospectively reviewed 2486 patients who underwent either SG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative body mass index (BMI), and co-morbidities were described. We identified all patients age ≥65 years and subsequently divided them into 2 groups based on type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were completed. Postoperative BMI was reviewed at 6, 12, and 24 months and percent excess BMI loss (%EBMIL, as defined by the ASMBS clinical committee) was calculated accordingly. The t test and χ2 analysis were performed for nominal and categorical variables, respectively. RESULTS: From 2486 patients reviewed, 22.7% (n = 565) were aged ≥65 years. From these, 43.1% (n = 244) underwent SG and 56.8% (n = 321) underwent RYGB. White and female patients were predominant in both groups. Mean age was similar for both populations (SG: 71.1 ± 4.0, RYGB: 71.7 ± 4.5; P = .12). Pre-procedure mean BMI for both groups was close in value, but the difference was statistically significant (40.5 ± 5.5 for SG versus 43.7 ± 7.2 for RYGB; P < .0001). Postoperative follow-up rates were similar in both groups at 12 and 24 months (SG: 51.2% and 31.6%; RYGB: 48.3% and 34.3%; P = .49 and P = .5). The %EBMIL at 6, 12, and 24 months was higher for the RYGB group than the SG group (59.3 ± 27.9, 72.1 ± 29.5, 77.4 ± 26.1 versus 50.2 ± 21.9, 55.2 ± 25.6, 43.9 ± 32.2; P < .01, P < .01, and P < .01, respectively). Complication rates were significantly higher in RYGB versus SG (27.7% versus 9.4%; P < .01). We observed significantly higher anastomotic ulcer and stricture rates for RYGB versus SG (7.2% and 5.9 versus 0% and 0%; P < .01 and P < .01, respectively). RYGB had a higher rate for gastrointestinal obstruction requiring intervention (2.2% versus .4%; P = .07). A similar de novo gastroesophageal reflux disease rate was noted in both procedures (3.7% versus 3.7%; P = .98). No leaks were reported in either group. CONCLUSIONS: Both SG and RYGB are effective weight loss procedures for patients aged ≥65 years. RYGB seems to have higher %EBMIL at 1 and 2 years; however, when compared with SG, complication rates appear to be almost 3 times higher.

Short-term multiorgan metabolic benefits of rapid weight loss after sleeve gastrectomy in severely obese patients.

BACKGROUND: Sleeve gastrectomy (SG) has become the most prevalent bariatric-metabolic surgical approach in the United States. Its popularity among surgeons and patients is mainly due to a better safety profile and less overall morbidity, with broad benefits from a systemic and metabolic perspective. OBJECTIVE: Comprehensively describe the short-term multiorgan metabolic effects of rapid weight loss after SG. SETTING: Academic hospital, United States. METHODS: We retrospectively reviewed the charts of patients that underwent SG at our institution between 2012 and 2016. We analyzed the required variables to calculate multiple risk scores, such as cardiovascular, hypertension, and diabetes risk scores. Furthermore, the renal and hepatic functions and the metabolic and hematologic profiles were assessed at 12 months of follow-up. RESULTS: A total of 1002 patients were included in the analysis. The percentage of excess body mass index loss was, on average, 65% at 12 months of follow-up. We observed a positive cardio-renal-hepatic improvement, demonstrated by a substantial reduction of the 10-year cardiovascular risk. We noticed an improvement of renal function, which was more significant in chronic kidney disease (stage ≥2), and a significant improvement on liver function tests (measured by decreased aspartate aminotransferase and alanine transaminase) at 12 months of follow-up. Our data also show a positive impact on decreasing the risk of developing hypertension and type 2 diabetes. There was a positive impact on the lipid profile, with the exception of low-density lipoprotein. CONCLUSION: There are significant short-term benefits on multiorgan metabolic parameters after rapid weight loss in severely obese patients undergoing sleeve gastrectomy.

Google Trends as a resource for bariatric education: what do patients want to know?

BACKGROUND: Bariatric surgery (BaS) is the safest, most effective, and most durable therapy for obesity but is performed in less than 1% of the affected United States (US) population. It is challenging to determine from traditional surveys if this phenomenon is the result of poor access to care or lack of interest among Internet users. OBJECTIVES: The aim of this study was to use Google Trends (GT) as a tool to analyze the US general population interest in BaS. SETTING: Academic Hospital, United States. METHODS: GT was used to access data searched for the term bariatric surgery. The gathered information included data from 2008 through 2018 in English within the US. Search frequency, time intervals, locations, frequent topics of interest, and related searches were analyzed. GT reports search frequency on means, and a value of 100 represented peak popularity. RESULTS: The number of Google searches related to the term bariatric surgery has gradually increased over time, from a mean of 67% in 2008 to a 94% interest in 2017. Regarding interest by subregion in 2017, the state of Michigan lead the frequency of searches, followed by Indiana, Delaware, West Virginia, and Tennessee. Top searched terms by frequency were the following: patient eligibility for BaS, what is BaS, what are the complications of BaS, financial costs of BaS, and what insurance companies cover BaS. It appears that traditional Web sites only address a few. CONCLUSIONS: GT complements the understanding of interest in BaS. Using these trends can improve an Internet user's education, and tailor specific official Web sites for the public's general interest.

Bariatric surgery decreases the number of first-time hospital admissions for cancer in severely obese patients. A retrospective analysis of the National Inpatient Sample database.

BACKGROUND: According to the U.S. Centers for Disease Control, cancers linked to overweight or obesity accounted for roughly 40% of all U.S. malignancies in 2014. OBJECTIVES: The primary aim of this epidemiologic study was to assess whether bariatric surgery might have any preventative role against obesity-linked cancers among individuals with obesity. SETTING: Hospitals across the United States participating in the National Inpatient Sample database, created, updated, and monitored by the U.S. Healthcare Cost and Utilization Project. METHODS: National Inpatient Sample data collected from 2010 to 2014 were examined to identify any difference in the number of first cancer-related hospitalizations, as a proxy for cancer incidence, between patients with a history of prior bariatric surgery (cases) and those without (controls). Patients with any prior cancer diagnosis were excluded. To match the body mass index ≥35 kg/m2 generally required for bariatric surgery, all controls had to have a body mass index ≥35 kg/m2. International Classification of Diseases-9 codes were employed to identify admissions for 13 obesity-linked cancers. Multivariate logistic regression analysis was performed to identify any case-control differences, after matching for all baseline demographic, co-morbidity, and cancer risk-factor variables. All percentages and means (with confidence intervals) were weighted, per Healthcare Cost and Utilization Project guidelines. RESULTS: Among 1,590,579 controls and 247,015 bariatric surgery cases, there were 29,822 (1.93%; 95% confidence interval 1.91-1.96) and 3540 (1.43%; 1.38-1.47) first hospitalizations for cancer (adjusted odds ratio 1.17; 1.13-1.23; P < .0001). CONCLUSIONS: Preliminary findings from a large U.S. database suggest that bariatric surgery may reduce the incidence of cancer in patients considered at high risk because of severe obesity.

Outcomes of reoperative surgery in severely obese patients after sleeve gastrectomy: a single-institution experience.

BACKGROUND: Despite its popularity, sleeve gastrectomy (SG) is not devoid of postoperative complications and weight regain. Some of these cases warrant conversion to Roux-en-Y gastric bypass or proximal gastrectomy with Roux-en-Y esophagojejunostomy. Complications after conversion are scarcely reported in the literature. OBJECTIVES: Report and review the outcomes of reoperation on severely obese patients with weight regain or complications after SG. SETTING: Bariatric Surgery Center of Excellence; Community Hospital, United States. METHODS: We retrospectively reviewed the medical records of patients converted from SG to Roux-en-Y gastric bypass/proximal gastrectomy with Roux-en-Y esophagojejunostomy at our center, from 2004 to 2018. Patients were stratified by reason for conversion. Group A included those converted for complications (leaks, strictures, or gastroesophageal reflux disease) and group B for reported weight regain. Demographic characteristics, postoperative outcomes, and complications were described. RESULTS: From 77 conversions identified, 63.6% (n = 49) underwent primary SG at an outside hospital. We observed predominant female (68.8%; n = 53) and Caucasian (76.6%; n = 59) populations. Conversions for complications were performed in 67.5% (n = 52) and for weight regain in 32.4% (n = 25). The most common conversion indication in group A was chronic leak (29.9%; n = 23), followed by gastroesophageal reflux disease (20.8%; n = 16), and stricture (16.9%; n = 13). Overall, major complications occurred in 16.9% (n = 13) and minor complications in 19.4% (n = 15). In group A, most common major complications were anastomotic leak and organ space surgical site infection (3.9%; n = 2 each); the most common minor complication was nonperforated marginal ulcer (7.7%; n = 4). In group B, the most common major complication was perforated marginal ulcer (8%; n = 2); the most common minor complication was stricture (16%; n = 4). Group B mean preconversion body mass index was 38.4 ± 4.3 and percentage excess body mass index loss was 48 ± 33, 63 ± 45, 59 ± 63, and 73 ± 25 (12, 24, 36, ≥48 mo). CONCLUSIONS: Our experience shows that major complications can occur in up to 17% of patients after conversion. Conversion to Roux-en-Y gastric bypass in nonresponders appears to be a safe and effective option for body mass index reduction.