Predictors of postoperative bleeding after minimally invasive bariatric surgery.

BACKGROUND: Minimally invasive bariatric surgeries provide effective weight loss with fewer complications. However, postoperative bleeding remains a significant concern due to its potential for serious morbidity and mortality. This study aimed to identify factors predicting postoperative bleeding following laparoscopic and robotic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). METHODS: We analyzed patients who underwent SG and RYGB using the MBSAQIP database from 2015 to 2021. Four multivariate logistic regression analyses were conducted to investigate the relationship between postoperative bleeding and 24 independent factors for laparoscopic SG (lapSG), robotic SG (rSG), laparoscopic RYGB (lapRYGB), and robotic RYGB (rRYGB). RESULTS: We analyzed 659,294 lapSG, 53,548 rSG, 267,171 lapRYGB, and 22,492 rRYGB patients. In lapSG, the most significant factors included anticoagulation (OR 3.76; 95% CI 3.13-4.51), renal insufficiency (OR 2.06; 95% CI 1.37-3.09), history of DVT (OR 1.87; 95% CI 1.23-2.85), history of PE (OR 1.69; 95% CI 1.04-2.76, and BMI ≤ 40 (OR 1.22; 95% CI 1.09-1.38). In the rSG group, anticoagulation (OR 4.95; 95% CI 2.83-8.66), COPD (OR 2.80; 95% CI 1.29-6.05), and hyperlipidemia (OR 1.90; 95% CI 1.29-6.05) were significant factors. In lapRYGB, the most significant factors included anticoagulation (OR 3.68; 95% CI 3.11-4.35), renal insufficiency (OR 1.60; 95% CI 1.04-2.44), history of DVT (OR 1.70; 95% CI 1.09-2.07), cardiac stent (OR 1.51; 95% CI 1.09-2.07), and BMI ≤ 40 (OR 1.16; 95% CI 1.03-1.29). For rRYGB, anticoagulation (OR 4.69; 95% CI 2.86-7.70), history of PE (OR 4.28; 95% CI 1.53-12.00), and cardiac stent (OR 2.15; 95% CI 0.06-4.34) were significant. CONCLUSION: Preoperative anticoagulation, renal insufficiency, history of DVT and PE, a cardiac stent, and BMI ≤ 40 are associated with an increased risk of postoperative bleeding. The predictive factors were consistent across laparoscopic and robotic approaches in SG and RYGB procedures.

Interstitial Lung Disease as an Emerging Contributor to Mortality in Patients With Inflammatory Bowel Disease: A Population-Based Epidemiological Study.

INTRODUCTION: We aim to investigate the contribution of interstitial lung disease (ILD) to mortality in patients with inflammatory bowel disease (IBD). METHODS: We performed a comprehensive retrospective, population-based epidemiological study across the United States from 2001 to 2020, using the Wide-ranging Online Data for Epidemiologic Research database. Mortality data were classified according to the International Classification of Diseases, Tenth Revision , with the codes J84 for ILD, K50 for Crohn's disease, and K51 for ulcerative colitis. To discern patterns, age-adjusted mortality rates (AMR) were computed, stratified by sex, geographic census region, and racial/ethnic demographics. RESULTS: From 2001 to 2020, there were 57,967 reported deaths among patients with IBD with an AMR per million significantly rising from 10.989 in 2001-2005 to 11.443 in 2016-2020 ( P < 0.0001). ILD was a contributor to death in 1.19% (692/57,967) of these cases, with AMR rising from 0.092 to 0.143 per million ( P = 0.010). The percentage of ILD-related deaths in the IBD population increased from 1.02% to 1.30% over 2 decades. ILD was a more common cause of death in patients with Crohn's disease than with ulcerative colitis (54.6% vs 45.4%), with a significant increase for both conditions from 2001 to 2020 ( P < 0.05). An upward trend in ILD-related mortality was observed in both sexes ( P < 0.05) and within the White population ( P = 0.010). DISCUSSION: The observed increase in mortality rates due to ILD among patients with IBD is concerning and highlights a critical need for systematic ILD screening protocols within the IBD patient population to facilitate early detection and management.

Laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass conversion versus primary Roux-en-Y gastric bypass: a propensity score matching analysis.

BACKGROUND: Secondary bariatric surgery rates have increased, accounting for approximately 19% of the total bariatric cases in the last years, most commonly conversion of sleeve gastrectomy to gastric bypass. Using the MBSAQIP, we evaluate the outcomes of this procedure compared to the primary RYGB surgery. METHODS: The new variable, conversion of sleeve gastrectomy to RYGB in the 2020 and 2021 MBSAQIP database was analyzed. Patients who underwent primary laparoscopic RYGB and those who underwent laparoscopic sleeve gastrectomy to RYGB conversion were identified. Using Propensity Score Matching analysis, the cohorts were matched for 21 preoperative characteristics. We then compared 30-day outcomes and bariatric-specific complications between primary RYGB and conversion from sleeve gastrectomy to RYGB. RESULTS: There were 43,253 primary RYGB procedures performed and 6,833 conversions from sleeve gastrectomy to RYGB. The matched cohorts (n = 5912) for the two groups have similar pre-operative characteristics. Propensity-matched outcomes showed that conversion from sleeve gastrectomy to RYGB was associated with more readmissions (6.9% vs 5.0%, p < 0.001), interventions (2.6% vs 1.7%, p < 0.001), conversion to open (0.7% vs 0.2%, p < 0.001), length of stay (1.79 ± 1.77 days vs 1.62 ± 1.66 days, p < 0.001), and operative time (119.16 ± 56.82 min vs 138.27 ± 66.00, p < 0.001). There were no significant differences in mortality (0.1% vs 0.1%, p = 0.405), and bariatric-specific complications such as anastomotic leak (0.5% vs 0.4%, p = 0.585), intestinal obstruction (0.1% vs 0.2%, p = 0.808), internal hernia (0.2% vs 0.1%, p = 0.285) or anastomotic ulcer (0.3% vs 0.3%, p = 0.731) rates. CONCLUSION: Conversion from sleeve gastrectomy to RYGB is a safe and feasible operation with reasonable outcomes compared with primary RYGB.

Do advances in technology translate to improved outcomes? Comparing robotic bariatric surgery outcomes over two-time intervals utilizing the MBSAQIP database.

BACKGROUND: This study aims to compare outcomes and utilization of robotics in bariatric procedures across two-time intervals, chosen because they correspond to drastic changes in technology utilization-namely, a new platform and a new stapling device. Outcomes of robotic Roux-en-Y gastric bypass (rRYGB) and robotic sleeve gastrectomy (rSG) across this changing landscape have not been well studied, despite increasing popularity. METHODS: The MBSAQIP database was analyzed over early (2015-2016) and late (2019-2020) time intervals. Patients who underwent rSG and rRYGB were identified, and the cohorts were matched for 26 preoperative characteristics using Propensity Score Matching Analysis. We then compared 30-day outcomes and bariatric-specific complications between the early and late time frames for rSG and rRYGB. RESULTS: 49,442 rSG were identified: 13,526 cases in the early time frame and 35,916 in the late time frame. The matched cohorts were 13,526 for the two groups. 30-day outcomes showed that in the late time frame, rSG was associated with lower rates of pulmonary complications (0.1% vs 0.3%, p < 0.001), readmissions (2.5% vs 3.6%, p < 0.001), interventions (0.6% vs 1.4%, p < 0.001), reoperations (0.7% vs 1.0%, p = 0.024), length of stay (1.36 ± 1.01 days vs 1.76 ± 1.79 days, p < 0.001), operative time (92.47 ± 41.70 min vs102.76 ± 45.67 min p < 0.001), staple line leaks (0.2% vs 0.4%, p = 0.001) and strictures (0.0% vs 0.2%, p < 0.001). Similarly, 21,933 rRYGB were found: 6,514 cases were identified in the early time frame and 15,419 in the late time frame. The matched cohorts were 6,513 for the two groups. 30-day outcomes revealed that the late time fame rRYGB was associated with lower rates of pulmonary complications (0.1% vs 0.3%, p = 0.012), readmissions (6.3% vs 7.2%, p = 0.050), interventions (2.0% vs 3.1%, p < 0.001), length of stay (1.69 ± 1.46 days vs 2.13 ± 2.12 days p < 0.001), postoperative bleeding (0.4% vs 0.7%, p = 0.001), stricture (0.4% vs 0.8%, p < 0.001) and anastomotic ulcer (0.2% vs 0.4%, p = 0.013). CONCLUSION: Compared to early robotic bariatric surgery outcomes, a significant reduction in pulmonary complications, readmissions, reoperations, interventions and length of stay were seen in 2019-20 after rSG and rRYGB. Potential contributing factors include increased surgical experience and advances in the robotic platform. A significant recent reduction in staple line leaks with faster operative times associated with rSG suggests that stapling technology has had a positive impact on patient outcomes.

Comparison of Hormonal Response to a Mixed-Meal Challenge in Hypoglycemia After Sleeve Gastrectomy vs Gastric Bypass.

CONTEXT: Exaggerated postprandial incretin and insulin responses are well documented in postbariatric surgery hypoglycemia (PBH) after Roux-en-Y gastric bypass (RYGB). However, less is known about PBH after sleeve gastrectomy (SG). OBJECTIVE: We sought to compare meal-stimulated hormonal response in those with PBH after SG vs RYGB. METHODS: We enrolled 23 post-SG (12 with and 11 without PBH) and 20 post-RYGB (7 with and 13 without PBH) individuals who underwent bariatric surgery at our institution. PBH was defined as plasma glucose less than 60 mg/dL on 4-hour mixed-meal tolerance test (MTT). Islet and incretin hormones were compared across the 4 groups. RESULTS: Participants (N = 43) were on average 5 years post surgery, with a mean age of 48 years, mean preoperative body mass index of 48.4, 81% female, 61% White, and 53% post SG. Regardless of PBH, the SG group showed lower glucose, glucagon, and glucagon-like peptide 1 (GLP-1) responses to MTT and similar insulin and glucose-dependent insulinotropic polypeptide (GIP) responses compared to the RYGB group. Among those with PBH, the SG group following the MTT showed a lower peak glucose (P = .02), a similar peak insulin (90.3 mU/L vs 171mU/L; P = .18), lower glucagon (P < .01), early GLP-1 response (AUC0-60 min; P = .01), and slower time to peak GIP (P = .02) compared to PBH after RYGB. CONCLUSION: Among individuals with PBH, those who underwent SG were significantly different compared to RYGB in meal-stimulated hormonal responses, including lower glucagon and GLP-1 responses, but similar insulin and GIP responses. Future studies are needed to better understand the differential contribution of insulin and non-insulin-mediated mechanisms behind PBH after SG vs RYGB.

GDF15 and Cortisol Response to Meal Tolerance Test in Post-Sleeve Gastrectomy Patients with Weight Regain.

BACKGROUND: Hormonal factors behind weight regain (WR) after surgical weight loss remain inadequately understood. Growth/differentiation factor 15 (GDF15) has emerged as a potential therapeutic target in obesity treatment. Cortisol, another stress hormone, has also been associated with weight gain at both low and high circulating concentrations. We aimed to compare meal-stimulated GDF15 and cortisol response in adults with and without WR after sleeve gastrectomy (SG). We hypothesized that GDF15 and cortisol response to meal tolerance test (MTT) will be lower in those with versus without WR after SG. METHODS: Cross-sectional study comprised 21 adults without diabetes, who underwent SG. WR was defined as 100 × (current weight - nadir)/(preoperative weight - nadir) > 10%. GDF15, cortisol, insulin, glucose, and incretins (total glucagon-like peptide (GLP)-1 and glucose-dependent insulinotropic polypeptide (GIP) circulating concentrations) were measured during MTT (0-240 min) after 3-6 years post-bariatric surgery. RESULTS: All participants were 48% White, 85% female, with mean (SD) age: 43(10) years, and BMI: 36.2(7.6) kg/m2. Compared to the non-WR group (n = 6), the WR group (n = 15) had significantly higher BMI (WR: 38.6 ± 7.6 kg/m2, non-WR: 30.3 ± 3.5 kg/m2, p = 0.02) and showed lower GDF15 response (WR AUC vs non-WR AUC (116143 ± 13973 vs 185798 ± 38884 ng*min/L, p = 0.047)) and lower cortisol response (WR AUC vs non-WR AUC (3492 ± 210 vs 4880 ± 655 µg*min/dL, p = 0.015)). Incretin response did not differ between the groups. CONCLUSIONS: GDF15 and cortisol responses to MTT were lower in those who regained the weight after SG compared to those who did not, suggesting that dysregulation in GDF15 and cortisol response following bariatric surgery.

Validation of the cumulative deficit theory in bariatric surgery: new bariatric frailty score is associated with non-home discharge, prolonged hospital stay and mortality in the era of fast-track bariatric surgery.

BACKGROUND: Frailty is a wasting disorder that can coexist with obesity, thus, the term "obese frailty syndrome". Frailty can be measured using the cumulative deficit model demonstrated in the Canadian Study of Health and Aging-Frailty Index (CSHA-FI). OBJECTIVES: To develop a Bariatric Frailty Score (BFS) to predict 30-day adverse postoperative outcomes. SETTING: University hospital. METHODS: Patients (aged 18-80 yr) who underwent sleeve gastrectomy (SG) and Roux-en-Y-gastric bypass (RYGB) were included using the 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Fourteen variables of the CSHA-FI were mapped onto 10 variables of MBSAQIP (each component equal 1 point). Correlations and multivariate logistical regression analysis were performed between BFS and 4 postoperative outcomes (non-home discharge, mortality, prolonged hospital stay, and ICU admissions). Finally, a propensity matching score (PSM) between low BFS (0-4) and high BFS (5-10) was performed. RESULTS: In 650,882 patients (72% SG, 28% RYGB), the increasing BFS was strongly correlated on linear regression. In the multivariate analysis, scores of 5, 6, and 7 strongly predicted the 4 postoperative outcomes of interest. After the PSM, high BFS (5-10) was associated with an increased rate of postoperative complications in SG and RYGB groups. CONCLUSION: Our BFS is a better predictor of non-home discharge, prolonged hospital stay, mortality, and unplanned ICU admission compared with age >60 years or American Society of Anesthesiologists (ASA) score of IV-V. Our study validated the cumulative deficit theory in bariatric surgery, implying that the cumulative effects of the existing co-morbidities are higher than if these co-morbidities were simply added.

Does endoscopic mean safer? A comparison of the short-term safety of endoscopic versus laparoscopic bariatric therapies.

Background and study aims There is minimal research on real-world, large-volume data comparing endoscopic bariatric therapy (EBT) to laparoscopic bariatric therapy (LBT). This study aimed to compare 30-day postoperative morbidity and mortality outcomes of primary EBT vs LBT using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Patients and methods Patients aged 18 to 80 with body mass index (BMI) 35 to 40 kg/m 2 undergoing primary procedures were included. Propensity score matching 1:50 was performed for EBT versus LBT based on age, sex, and BMI. Results We matched 211 EBTs with 9,059 LBTs. Operative length (63.9, 95 % confidence interval [CI]: 57.9, 69.8 versus 81.1, 95 % CI: 80.1, 82.1) and length of stay (0.49 days, 95 % CI: 0.29, 0.69 versus 1.43 days, 95 % CI: 1.41, 1.45) were significantly lower in the EBT group than the LBT group. There was no difference between EBT and LBT in the odds of readmission (odds ratio [OR] = 0.31, 95 % CI: 0.08, 1.25), reoperation (OR = 0.39, 95 % CI: 0.05, 2.84), or reintervention (OR = 0.98, 95 % CI: 0.24, 3.99). After controlling for chronic obstructive pulmonary disease, sleep apnea, history of myocardial infarction, hypertension requiring medications, and diabetes, EBT continued to be associated with lower odds of having any adverse event (AE) than LBT, with an OR of 0.34 (95 % CI: 0.16, 0.69). Subgroup analysis comparing EBT to laparoscopic sleeve gastrectomy (LSG) showed that EBT was associated with a lower risk having any AE than LSG, with an OR of 0.39 (95 % CI: 0.19, 0.79). Conclusions EBT is associated with a lower 30-day AE rate and shorter procedural length and length of stay than LBT, with similar rates of readmission, reintervention, and reoperation.

Gastric per-oral endoscopic myotomy (G-POEM) for the treatment of gastric sleeve stenosis: a feasibility and safety study.

BACKGROUND: Traditional endoscopic treatments have limited success in gastric sleeve stenosis (GSS). Gastric peroral endoscopic myotomy (G-POEM) could conceivably obliterate the twist/angulation that causes GSS through a tunneled stricturotomy. We report early outcomes of G-POEM for GSS treatment. METHODS: We retrospectively reviewed all patients with GSS treated with G-POEM at our center. The primary end point was clinical success, defined as symptom improvement with resumption of adequate oral intake, without requiring further intervention. RESULTS: 13 patients (mean age 43 ±â€Š10.9 years; 12 female) underwent G-POEM for predominantly helical (11/13, 85 %) GSS. Three (23 %) had concurrent sleeve leak and 10 (77 %) had prior GSS treatment. Two intraoperative complications occurred, with no deviation to the procedure; no major complications occurred. At median follow-up of 175 (interquartile range [IQR] 119-260) days, clinical success was achieved in 10 patients (77 %). Median Gastroparesis Cardinal Symptom Index score in responders decreased from 2.06 (IQR 1.5-2.8) to 0.39 (IQR 0.2-0.5). Three patients (23 %) required surgical revision. CONCLUSIONS: G-POEM was feasible and safe, and may provide an alternative option for those averse to undergoing surgical revision for treatment of GSS.

SARS-CoV-2 outbreak in a tri-national urban area is dominated by a B.1 lineage variant linked to a mass gathering event.

The first case of SARS-CoV-2 in Basel, Switzerland was detected on February 26th 2020. We present a phylogenetic study to explore viral introduction and evolution during the exponential early phase of the local COVID-19 outbreak from February 26th until March 23rd. We sequenced SARS-CoV-2 naso-oropharyngeal swabs from 746 positive tests that were performed at the University Hospital Basel during the study period. We successfully generated 468 high quality genomes from unique patients and called variants with our COVID-19 Pipeline (COVGAP), and analysed viral genetic diversity using PANGOLIN taxonomic lineages. To identify introduction and dissemination events we incorporated global SARS-CoV-2 genomes and inferred a time-calibrated phylogeny. Epidemiological data from patient questionnaires was used to facilitate the interpretation of phylogenetic observations. The early outbreak in Basel was dominated by lineage B.1 (83·6%), detected first on March 2nd, although the first sample identified belonged to B.1.1. Within B.1, 68·2% of our samples fall within a clade defined by the SNP C15324T ('Basel cluster'), including 157 identical sequences at the root of the 'Basel cluster', some of which we can specifically trace to regional spreading events. We infer the origin of B.1-C15324T to mid-February in our tri-national region. The other genomes map broadly over the global phylogenetic tree, showing several introduction events from and/or dissemination to other regions of the world via travellers. Family transmissions can also be traced in our data. A single lineage variant dominated the outbreak in the Basel area while other lineages, such as the first (B.1.1), did not propagate. A mass gathering event was the predominant initial source of cases, with travel returners and family transmissions to a lesser extent. We highlight the importance of adding specific questions to epidemiological questionnaires, to obtain data on attendance of large gatherings and their locations, as well as travel history, to effectively identify routes of transmissions in up-coming outbreaks. This phylogenetic analysis in concert with epidemiological and contact tracing data, allows connection and interpretation of events, and can inform public health interventions. Trial Registration: ClinicalTrials.gov NCT04351503.

Providing complex GI surgical care with minimally invasive approaches: a survey of the practice patterns of Fellowship Council alumni.

INTRODUCTION: The Fellowship Council (FC) oversees 172 non-ACGME surgical fellowships offering 211 fellowship positions per year. These training programs cover multiple specialties including Advanced gastrointestinal (GI), Advanced GI/MIS, Bariatric, Hepatopancreaticobiliary (HPB), Flexible Endoscopy, Colorectal, and Thoracic Surgery. Although some data have been published detailing the practice environments (i.e., urban vs. rural) and yearly total case volumes of FC alumni, there is a lack of granular data regarding the practice patterns of FC graduates. The aim of this study was to gather detailed data on the specific case types performed and surgical approaches employed by recent FC alumni. METHODS: A 21-item survey covering 64 data points was emailed to 835 FC alumni who completed their fellowship between 2013 and 2017. Email addresses were obtained from FC program directors and FC archives. RESULTS: We received 327 responses (39% response rate). HPB, Advanced Colorectal, and Advanced Thoracic alumni appear to establish practices focused on their respective fields. Graduates from Advanced GI, Adv GI/MIS, and Bariatric programs appear to build practices with a mix of several complex GI case types including bariatrics, colorectal, foregut, HPB, and hernia cases. CONCLUSIONS: This is the first large data set to provide granular information on the practice patterns of FC alumni. FC trained surgeons perform impressive volumes of complex procedures, and minimally invasive approaches are extremely prevalent in these practices. Further, many graduates carve out practices with large footprints in robotics and endoscopy.

Implementation of an enhanced recovery program for bariatric surgery.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs have been successfully implemented in several surgical fields; however, there have been mixed results observed in bariatric surgery. Our institution implemented an enhanced recovery program with specific pre-, intra-, and post-operative protocols aimed at patients, nursing staff, and physicians. The aim of the study is to assess the effectiveness of the ERAS program. METHODS: Patients who underwent bariatric surgery prior to the implementation of the enhanced recovery program in the calendar year 2015 were compared to those who had surgery after implementation in 2017. Data for our institution was drawn from the Premier Hospital Database. Poisson and quantile regressions were used to examine the association between ERAS protocol and LOS and cost, respectively. Logistic regression was used to assess the impact of ERAS on 30-day complications and readmissions. RESULTS: 277 bariatric surgical procedures were performed in the pre-ERAS group, compared to 348 procedures post-ERAS. While there was a 25.6% increase in volume, there was no statistical difference between the patient populations or the type of procedure performed between the 2 years. A decrease in length of stay was observed from 2.77 days in 2015 to 1.77 days in 2017 (p < 0.001), while median cost was also cut from $11,739.03 to $9482.18 (p < 0.001). 30-day readmission rate also decreased from 7.94% to 2.86% (p = 0.011). After controlling for other factors, ERAS protocol was associated with decreased LOS (IRR 0.65, p < 0.001), cost (- $2256.88, p < 0.001), and risk of 30-day readmission (OR 0.37, p = 0.011). CONCLUSION: The implementation of a standardized enhanced recovery program resulted in reduced length of stay, cost, and 30-day readmissions. Total costs saved were greater than $800,000 in one calendar year. This study highlights that the value of an enhanced recovery program can be observed in bariatric surgery, benefiting both patients and hospital systems.

Gastric mucosal devitalization (GMD): translation to a novel endoscopic metabolic therapy.

Background and study aims The metabolic effects of bariatric surgery may partially result from removal of the gastric mucosa, an often underappreciated endocrine organ. Using argon plasma coagulation (APC), we may be able to selectively devitalize (ablate) the mucosa. The aim of this study was to identify the optimal tissue color that would correspond to selective gastric mucosal devitalization (GMD) using ex-vivo human stomach specimens. Patients and methods Stomach specimens were obtained at sleeve gastrectomy. Prior to APC application, a submucosal fluid cushion was created. APC was then applied over a 2 × 2-cm area to the fundus and body, aiming for the three indicator colors (white, golden, brown). Pathological analysis was then performed independently and in a blinded fashion by two pathologists to determine the depth of mucosal and submucosal percent thermal injury and mucosal percent cell death. Results Six patients were enrolled. There was a significant correlation between tissue color and mucosal percent thermal injury. The highest percent mucosal thermal injury was seen with brown (99.6 %, 95 % CI: 98.7, 100), followed by golden (92.5 %, 95 % CI: 85.5, 99.5), and then white (75.2 %, 95 % CI: 58.3, 92.1, P  < 0.01). Submucosal thermal injury was seen in 88.9 % of the slides. Greater than minimal submucosal injury (> 10 % depth) was found significantly more with brown tissue color (91.6 %) than golden (75 %) or white (33.3 %, P  < 0.05). However, 91.7 % of the entire sample set < 50 % injury. Conclusion GMD is achievable using APC without thermal injury to muscularis propria. A golden color results in sufficient mucosal injury with only superficial injury to the submucosa.

Mobilization of Environmental Toxicants Following Bariatric Surgery.

OBJECTIVE: Persistent organic pollutants (POPs) are lipophilic environmental toxicants that accumulate in adipose tissue. Weight loss leads to mobilization and increased redistribution of these toxicants. Many are obesogens and endocrine disruptors. Increased exposure could pose long-term health risks. The study objective was to measure the changes in serum concentrations of lipophilic POPs during significant weight loss. METHODS: This study enrolled 27 patients at a university hospital in a longitudinal, 6-month, observational study examining changes in POP blood levels after bariatric surgery. The primary outcome was the changes in the concentrations of 24 polychlorinated biphenyls (PCBs), 9 organochlorine pesticides (OCPs), 11 polybrominated diphenyl ethers, 2,2',4,4',5,5'-hexabromobiphenyl, and 4 perfluorochemicals (PFCs). RESULTS: Older adults (those born before 1976) had baseline levels of PCBs, OCPs, and PFCs that were two- to fivefold higher than younger adults (those born after 1976). Older adults had greater increases in PCBs, OCPs, and polybrominated diphenyl ethers associated with weight loss. Conversely, younger adults had greater increases in PFCs associated with weight loss. On average, blood POP levels increased as weight loss occurred. CONCLUSIONS: Although weight loss is considered beneficial, the release and redistribution of POPs to other lipid-rich organs such as the brain, kidneys, and liver warrant further investigation. Interventions should be considered to limit organ exposure to POPs when weight loss interventions are planned.

Changes in Gut Microbiome after Bariatric Surgery Versus Medical Weight Loss in a Pilot Randomized Trial.

BACKGROUND: Gut microbiota likely impact obesity and metabolic diseases. We evaluated the changes in gut microbiota after surgical versus medical weight loss in adults with diabetes and obesity. METHODS: We performed 16S rRNA amplicon sequencing to identify the gut microbial composition at baseline and at 10% weight loss in adults with diabetes who were randomized to medical weight loss (MWL, n = 4), adjustable gastric banding (AGB, n = 4), or Roux-en-Y gastric bypass (RYGB, n = 4). RESULTS: All participants were female, 75% reported black race with mean age of 51 years. At similar weight loss amount and glycemic improvement, the RYGB group had the most number of bacterial species (10 increased, 1 decreased) that significantly changed (p < 0.05) in relative abundance. Alpha-diversity at follow-up was significantly lower in AGB group compared to MWL and RYGB (observed species for AGB vs. MWL, p = 0.0093; AGB vs. RYGB, p = 0.0093). The relative abundance of Faecalibacterium prausnitzii increased in 3 participants after RYGB, 1 after AGB, and 1 after MWL. CONCLUSIONS: At similar weight loss and glycemic improvement, the greatest alteration in gut microbiota occurred after RYGB with an increase in the potentially beneficial bacterium, F. prausnitzii. Gut microbial diversity tended to decrease after AGB and increase after RYGB and MWL. Future studies are needed to determine the impact and durability of gut microbial changes over time and their role in long-term metabolic improvement after bariatric surgery in adults with type 2 diabetes. CLINICAL TRIAL REGISTRATION: NCTDK089557- ClinicalTrials.gov.

Safety and Efficacy of Endoscopically Secured Fully Covered Self-Expandable Metallic Stents (FCSEMS) for Post-Bariatric Complex Stenosis.

BACKGROUND: The use of fully covered self-expandable metallic stents (FCSEMS) has opened the door to treat stenosis in the post-bariatric stomach. We hypothesized that endoscopically securing a FCSEMS would be technically feasible, effective, and safe for > 30-day dwell time. OBJECTIVES: To assess the technical feasibility, clinical efficacy, and safety of endoscopically secured FCSEMS in the stomach for > 30 days. METHODS: A retrospective review (September 2016 to April 2018) of consecutive patients who underwent FCSEMS suturing in the stomach at a single academic institution was reviewed. Technical success, stent dwell time, symptoms, and adverse events were recorded. RESULTS: Fifteen patients (median age of 49 (31-70)) were included. Stents were inserted for gastrojejunal (GJ) stricture or gastric stenosis in 9/15 and 6/15 of patients, respectively. All procedures were technically successful (100%). Immediate and short-term clinical success (prior to stent removal) was 100% in patients who did not have stent migration. Stent migration was seen in 3 cases (20%) after a median dwell time of 211 days. However, 2/3 (66.6%) had not attended their scheduled removal. Recurrence of symptoms after stent removal was seen in 53.3% of patients with 40% undergoing repeat stenting. Median stent dwell was 117 (30-342) days. Sixty percent and 33% of patients had stent dwell of at least 90 and 180 days, respectively. CONCLUSIONS: A FCSEMS, if secured, may be safe and effective for even > 90-day dwell time in the post-bariatric stomach and may result in long-term clinical success for GJ stricture after stent removal.

Secured Lumen-Apposing Fully Covered Metallic Stents for Stenoses in Post-Bariatric Surgery Patients.

New approaches for refractory stenosis in post-bariatric surgical patients include fully covered lumen-apposing metallic stents (LAMS); however, stent migration continues to be a problem. Endoscopic suture placement to LAMS can reduce the migration. Aiming to assess the feasibility and safety of the procedure, we evaluated nine consecutive patients with inability to tolerate a solid diet due to a benign gastrointestinal stricture recalcitrant to previous attempts at endoscopic therapy. All patients were symptom-free starting from 1-week follow-up. Median stent dwell time was nearly 3 months. During the removal procedures, three incidental foreign bodies were found and removed. No stent migration was observed in any patients. Suturing LAMS is a feasible technique allowing for prolonged stent dwell times; however, it requires a high level of expertise plus additional procedure time.

Comparative Effects of Medical Versus Surgical Weight Loss on Body Composition: a Pilot Randomized Trial.

OBJECTIVE: Bariatric surgery leads to more rapid and greater weight loss (WL) compared to medical weight loss (MWL), but the differences in body composition (BC) changes for these modalities remain unclear. Due to the known health risks associated with central adiposity, we compared the changes in regional distribution of fat mass (FM) and lean mass (LM) after surgical versus MWL. METHODS: In this 1:1:1 randomized trial among 15 persons with type 2 diabetes and body mass index (BMI) 30-39.9 kg/m2, we compared changes in BC, by dual-energy X-ray absorptiometry and abdominal computerized tomography, at time of 10%WL or 9 months after intervention (whichever came first). Participants underwent MWL, adjustable gastric banding (AGB), or Roux-en-Y gastric bypass (RYGB). Non-parametric tests evaluated BC differences (FM, LM, and visceral adipose tissue [VAT]) within and across all three arms and between pair-wise comparisons. RESULTS: Twelve female participants (75% African American) completed the study. Patient age, BMI, and baseline anthropometric characteristics were similar across study arms. AGB lost more LM (MWL - 5.2%, AGB - 10.3%, p = 0.021) and VAT (MWL + 10.9%, AGB - 28.0%, p = 0.049) than MWL. RYGB tended to lose more VAT (MWL +10.9%, RYGB - 20.2%, p = 0.077) than MWL. AGB tended to lose more LM than RYGB (AGB - 12.38%, RYGB - 7.29%, p = 0.15). CONCLUSIONS: At similar WL, AGB lost more LM and VAT than MWL; RYGB similarly lost more VAT. Given the metabolic benefits of reducing VAT and retaining LM, larger studies should confirm the changes in BC after surgical versus medical WL. CLINICAL TRIAL REGISTRATION: NCTDK089557 - ClinicalTrials.gov.

A Real-World, Insurance-Based Algorithm Using the Two-Fold Running Suture Technique for Transoral Outlet Reduction for Weight Regain and Dumping Syndrome After Roux-En-Y Gastric Bypass.

BACKGROUND AND AIMS: Transoral outlet reduction (TORe) by devitalization and/or endoscopic suturing (ES) has been implemented in the management of weight regain post-RYGB. This study aims to assess the efficacy and safety of TORe following an insurance-based algorithm. METHODS: A prospectively maintained database of patients who underwent TORe between September 2015 and January 2018 at a single academic center was reviewed. An algorithm was followed whereby management was based on insurance coverage. As part of the algorithm, all patients presented for a repeat endoscopy at 8 weeks. Patients did not receive any diet, lifestyle intervention, or pharmacotherapy. RESULTS: In total, 55 patients were included (median age 48 years), out of which 50 were females (90.9%). Patients presented for evaluation at a mean of 8.7 years post-RYGB. The main presenting symptom was combined dumping syndrome (DS) and weight regain (49.1%), followed by weight regain alone (45.5%). Twenty-nine patients required treatment at their second procedure, and 11 required treatment at their third procedure. Average percent total body weight loss (%TBWL) after TORe observed at 3-, 6-, 9-, and 12-month follow-up was 8.2, 9.3, 8.4, and 5.5%, respectively. The mean DS Severity Score was significantly reduced from 23.3 ± 12.4 before TORe to 16.3 ± 6.51 after TORe (p < 0.01). The adverse event rate from TORe was 14.5%. CONCLUSION: TORe is effective in halting ongoing weight regain and achieving moderate short-term weight loss as well as improving DS in post-RYGB patients. Durability at 1 year remains questionable due to weight recidivism.