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1.
Am J Physiol Endocrinol Metab ; 320(2): E392-E398, 2021 02 01.
Article in English | MEDLINE | ID: mdl-33427046

ABSTRACT

Reductions in ß-cell number and function contribute to the onset type 2 diabetes (T2D). Roux-en-Y gastric bypass (RYGB) surgery can resolve T2D within days of operation, indicating a weight-independent mechanism of glycemic control. We hypothesized that RYGB normalizes glucose homeostasis by restoring ß-cell structure and function. Male Zucker Diabetic Fatty (fa/fa; ZDF) rats were randomized to sham surgery (n = 16), RYGB surgery (n = 16), or pair feeding (n = 16). Age-matched lean (fa/+) rats (n = 8) were included as a secondary control. Postprandial metabolism was assessed by oral glucose tolerance testing before and 27 days after surgery. Fasting and postprandial plasma GLP-1 was determined by mixed meal tolerance testing. Fasting plasma glucagon was also measured. ß-cell function was determined in isolated islets by a glucose-stimulated insulin secretion assay. Insulin and glucagon positive areas were evaluated in pancreatic sections by immunohistochemistry. RYGB reduced body weight (P < 0.05) and improved glucose tolerance (P < 0.05) compared with sham surgery. RYGB reduced fasting glucose compared with both sham (P < 0.01) and pair-fed controls (P < 0.01). Postprandial GLP-1 (P < 0.05) was elevated after RYGB compared with sham surgery. RYGB islets stimulated with 20 mM glucose had higher insulin secretion than both sham and pair-fed controls (P < 0.01) and did not differ from lean controls. Insulin content was greater after RYGB compared with the sham (P < 0.05) and pair-fed (P < 0.05) controls. RYGB improves insulin secretion and pancreatic islet function, which may contribute to the remission of type 2 diabetes following bariatric surgery.NEW & NOTEWORTHY The onset and progression of type 2 diabetes (T2D) results from failure to secrete sufficient amounts of insulin to overcome peripheral insulin resistance. Here, we demonstrate that Roux-en-Y gastric bypass (RYGB) restores islet function and morphology compared to sham and pair-fed controls in ZDF rats. The improvements in islet function were largely attributable to enhanced insulin content and secretory function in response to glucose stimulation.


Subject(s)
Body Weight , Diabetes Mellitus, Experimental/surgery , Diabetes Mellitus, Type 2/surgery , Gastric Bypass/methods , Homeostasis , Insulin-Secreting Cells/physiology , Obesity/prevention & control , Animals , Blood Glucose/analysis , Diabetes Mellitus, Experimental/pathology , Diabetes Mellitus, Type 2/pathology , Insulin Resistance , Male , Rats , Rats, Zucker
2.
Diabetes Obes Metab ; 21(9): 2058-2067, 2019 09.
Article in English | MEDLINE | ID: mdl-31050119

ABSTRACT

AIM: To assess the potential protective effect of bariatric surgery on mortality after myocardial infarction (MI) or cerebrovascular accident (CVA). MATERIALS AND METHODS: Using the National Inpatient Sample (2007-2014), 2218 patients with a principal discharge diagnosis of acute MI and 2168 patients with ischaemic CVA who also had history of prior bariatric surgery were identified. Utilizing propensity scores, these patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Control group-1 included participants with obesity (BMI ≥ 35 kg/m2 ) only and participants in control group-2 were matched according to post-surgery BMI with the bariatric surgery group. The primary and secondary endpoints were in-hospital all-cause mortality and length of hospital stay, respectively. Outcomes after MI and CVA were separately compared among groups in multivariate regression models. RESULTS: A total of 48 300 (weighted) participants were included in the analysis. The distribution of covariates was well balanced after propensity matching. Mortality rates after MI were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.85% vs 3.03%; odds ratio (OR), 0.61; 95% confidence interval (CI), 0.44-0.86; P = 0.004) and with control group-2 (2.00% vs 3.26%; OR, 0.62; 95% CI, 0.44-0.88; P = 0.008). Similarly, in-hospital mortality rates after CVA were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.43% vs 2.74%; OR, 0.54; 95% CI, 0.37-0.79; P = 0.001) and with control group-2 (1.54% vs 2.59%; OR, 0.61; 95% CI, 0.41-0.91; P = 0.015). Furthermore, length of stay was significantly shorter in the bariatric surgery group for all comparisons (P < 0.001). CONCLUSION: Prior bariatric surgery is associated with significant protective effect on survival after MI and CVA.


Subject(s)
Bariatric Surgery/adverse effects , Myocardial Infarction/mortality , Obesity, Morbid/mortality , Postoperative Complications/mortality , Stroke/mortality , Aged , Female , Hospital Mortality , Humans , Length of Stay , Male , Middle Aged , Myocardial Infarction/etiology , Obesity, Morbid/complications , Obesity, Morbid/surgery , Odds Ratio , Postoperative Complications/etiology , Propensity Score , Retrospective Studies , Stroke/etiology
3.
Surg Endosc ; 29(7): 1856-61, 2015 Jul.
Article in English | MEDLINE | ID: mdl-25294550

ABSTRACT

BACKGROUND: The approach to repair of paraesophageal hernias (PEHs) is controversial. Recent data suggest that mesh repair leads to recurrence rates similar to non-mesh approaches, while subjecting patients to mesh-associated complications. Routine fundoplication during PEH repair has been favored despite significant dysphagia rates. We present our multicenter prospective data on laparoscopic PEH repairs using a modified Boerema anterior gastropexy without fundoplication. METHODS: We prospectively followed patients after modified Boerema PEH repair at three institutions. Patient demographics, perioperative data, and postoperative outcomes were evaluated. Subjective and objective outcomes were assessed via clinical assessment, follow-up questioning, endoscopy, and radiographic swallow studies. RESULTS: A total of 101 patients were followed a mean of 10.8 (median, 12) months. We encountered 9 (8.9%) intraoperative complications and 13 (12.9%) postoperative complications. There was no mortality. Reflux symptoms were absent in 71 patients (70.3%) postoperatively. Of the remaining subjects, 8 (7.9%) had mild intermittent reflux without the need for proton pump inhibitors (PPI), 12 (11.9%) had moderate reflux necessitating PPI as needed, and 10 (9.9%) had reflux requiring daily PPI. Our recurrence rate, assessed at postoperative endoscopy/barium swallow, was 16.8%. Of these, 10 (9.9%) were small segmental recurrences and 7 (6.9%) were large recurrences. CONCLUSION: Herein, we demonstrate a favorable recurrence rate while avoiding the potential major complications associated with mesh hiatoplasty. Our data tend to support a tailored approach to incorporation of fundoplication during PEH repair. Postoperative acid reflux was absent in most of our patients, and pharmacotherapy alone was sufficient for those experiencing reflux symptoms.


Subject(s)
Gastropexy , Hernia, Hiatal/surgery , Laparoscopy , Adult , Aged , Aged, 80 and over , Female , Follow-Up Studies , Gastroesophageal Reflux/drug therapy , Gastroesophageal Reflux/etiology , Humans , Intraoperative Complications , Male , Middle Aged , Postoperative Complications , Prospective Studies , Proton Pump Inhibitors/therapeutic use
4.
Obes Surg ; 34(6): 2017-2025, 2024 Jun.
Article in English | MEDLINE | ID: mdl-38689074

ABSTRACT

PURPOSE: Bariatric surgery is associated with a greater venous thromboembolism (VTE) risk in the weeks following surgery, but the long-term risk of VTE is incompletely characterized. We evaluated bariatric surgery in relation to long-term VTE risk. MATERIALS AND METHODS: This population-based retrospective matched cohort study within three United States-based integrated health care systems included adults with body mass index (BMI) ≥ 35 kg/m2 who underwent bariatric surgery between January 2005 and September 2015 (n = 30,171), matched to nonsurgical patients on site, age, sex, BMI, diabetes, insulin use, race/ethnicity, comorbidity score, and health care utilization (n = 218,961). Follow-up for incident VTE ended September 2015 (median 9.3, max 10.7 years). RESULTS: Our population included 30,171 bariatric surgery patients and 218,961 controls; we identified 4068 VTE events. At 30 days post-index date, bariatric surgery was associated with a fivefold greater VTE risk (HRadj = 5.01; 95% CI = 4.14, 6.05) and a nearly fourfold greater PE risk (HRadj = 3.93; 95% CI = 2.87, 5.38) than no bariatric surgery. At 1 year post-index date, bariatric surgery was associated with a 48% lower VTE risk and a 70% lower PE risk (HRadj = 0.52; 95% CI = 0.41, 0.66 and HRadj = 0.30; 95% CI = 0.21, 0.44, respectively). At 5 years post-index date, lower VTE risks persisted, with bariatric surgery associated with a 41% lower VTE risk and a 55% lower PE risk (HRadj = 0.59; 95% CI = 0.48, 0.73 and HRadj = 0.45; 95% CI = 0.32, 0.64, respectively). CONCLUSION: Although in the short-term bariatric surgery is associated with a greater VTE risk, in the long-term, it is associated with a substantially lower risk.


Subject(s)
Bariatric Surgery , Obesity, Morbid , Venous Thromboembolism , Humans , Bariatric Surgery/adverse effects , Bariatric Surgery/statistics & numerical data , Venous Thromboembolism/epidemiology , Venous Thromboembolism/etiology , Female , Male , Retrospective Studies , Adult , Middle Aged , Obesity, Morbid/surgery , Obesity, Morbid/complications , Obesity, Morbid/epidemiology , Risk Factors , United States/epidemiology , Postoperative Complications/epidemiology , Incidence , Body Mass Index
5.
BMJ ; 383: e071027, 2023 12 18.
Article in English | MEDLINE | ID: mdl-38110235

ABSTRACT

The prevalence of obesity continues to rise around the world, driving up the need for effective and durable treatments. The field of metabolic/bariatric surgery has grown rapidly in the past 25 years, with observational studies and randomized controlled trials investigating a broad range of long term outcomes. Metabolic/bariatric surgery results in durable and significant weight loss and improvements in comorbid conditions, including type 2 diabetes. Observational studies show that metabolic/bariatric surgery is associated with a lower incidence of cardiovascular events, cancer, and death. Weight regain is a risk in a fraction of patients, and an association exists between metabolic/bariatric surgery and an increased risk of developing substance and alcohol use disorders, suicidal ideation/attempts, and accidental death. Patients need lifelong follow-up to help to reduce the risk of these complications and other nutritional deficiencies. Different surgical procedures have important differences in risks and benefits, and a clear need exists for more long term research about less invasive and emerging procedures. Recent guidelines for the treatment of obesity and metabolic conditions have been updated to reflect this growth in knowledge, with an expansion of eligibility criteria, particularly people with type 2 diabetes and a body mass index between 30.0 and 34.9.


Subject(s)
Alcoholism , Bariatric Surgery , Diabetes Mellitus, Type 2 , Obesity, Morbid , Adult , Humans , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/surgery , Alcoholism/complications , Bariatric Surgery/adverse effects , Bariatric Surgery/methods , Obesity/complications , Obesity/surgery , Obesity, Morbid/complications , Obesity, Morbid/surgery
6.
Front Surg ; 10: 1249441, 2023.
Article in English | MEDLINE | ID: mdl-37869423

ABSTRACT

Like all surgical fields, bariatric surgery has evolved immensely, so much so that previous procedures are now obsolete. For instance, the jejunoileal bypass has fallen out of favor after severe metabolic consequences resulted in prolonged morbidity and even mortality. Despite this, several patients persevered long enough to develop other pathology, such as cancer. This progression has been validated in animal models but not human patients. Nonetheless, contemporary surgeons may encounter situations where they must resect and re-establish intestinal continuity in patients with this antiquated anatomy. When faced with this scenario, the question of whether or not the previously bypassed small bowel can be safely reunited plagues the surgeon remains unanswered. Unfortunately, the literature does not effectively answer this question, even anecdotally through case reports or series. Therefore, we share our experience with three patients who developed colon cancer following jejunoileal bypass and subsequently underwent oncologic resection with simultaneous reversal of their jejunoileal bypasses.

7.
Surg Obes Relat Dis ; 18(8): 1087-1101, 2022 08.
Article in English | MEDLINE | ID: mdl-35752593

ABSTRACT

Bariatric and metabolic surgery is an effective treatment for patients with severe obesity and obesity-related diseases. In patients with type 2 diabetes, it provides marked improvement in glycemic control and even remission of diabetes. In patients with type 1 diabetes, bariatric surgery may offer improvement in insulin sensitivity and other cardiometabolic risk factors, as well as amelioration of the mechanical complications of obesity. Because of these positive outcomes, there are increasing numbers of patients with diabetes who undergo bariatric surgical procedures each year. Prior to surgery, efforts should be made to optimize glycemic control. However, there is no need to delay or withhold bariatric surgery until a specific glycosylated hemoglobin target is reached. Instead, treatment should focus on avoidance of early postoperative hyperglycemia. In general, oral glucose-lowering medications and noninsulin injectables are not favored to control hyperglycemia in the inpatient setting. Hyperglycemia in the hospital is managed with insulin, aiming for perioperative blood glucose concentrations between 80 and 180 mg/dL. Following surgery, substantial changes of the antidiabetic medication regimens are common. Patients should have a clear understanding of the modifications made to their treatment and should be followed closely thereafter. In this review article, we describe practical recommendations for the perioperative management of diabetes in patients with type 2 or type 1 diabetes undergoing bariatric surgery. Specific recommendations are delineated based on the different treatments that are currently available for glycemic control, including oral glucose-lowering medications, noninsulin injectables, and a variety of insulin regimens.


Subject(s)
Bariatric Surgery , Diabetes Mellitus, Type 1 , Diabetes Mellitus, Type 2 , Gastric Bypass , Hyperglycemia , Obesity, Morbid , Bariatric Surgery/methods , Blood Glucose/metabolism , Diabetes Mellitus, Type 1/surgery , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/surgery , Gastrectomy/methods , Gastric Bypass/methods , Humans , Hyperglycemia/etiology , Insulin/therapeutic use , Obesity/surgery , Obesity, Morbid/complications , Obesity, Morbid/surgery , Treatment Outcome
8.
Obes Surg ; 31(3): 1233-1238, 2021 Mar.
Article in English | MEDLINE | ID: mdl-33205367

ABSTRACT

INTRODUCTION: Bariatric enhanced recovery protocols can decrease length of stay (LOS) and hospital costs without compromising patient safety. Increased data is needed to compare patient outcomes before and after application of enhanced recovery pathways. We present a bariatric enhanced recovery protocol (BERP) at a community hospital. The objectives were to decrease hospital LOS and reduce schedule II substance use (medications with a high potential for abuse, potentially resulting in psychological or physical dependence), without compromising patient safety. METHODS: This was a combined retrospective and prospective analysis of all patients undergoing bariatric surgery by two surgeons from September 2016 to April 2018. Mann-Whitney U, Pearson chi-square, and Fisher's exact tests were used to compare demographics, comorbidities, and outcomes. RESULTS: Two hundred patients were evaluated. Overall median (interquartile range) age was 43.0 (36.0-54.0) years and body mass index (BMI) was 45.0 (40.6-50.3) kg/m2. Pre-protocol mean hospital LOS was 2.3 days while enhanced recovery protocol patients mean LOS was 1.4 days (p < 0.001). Sixty-five percent of BERP patients were discharged on hospital day 1, while no patients prior to the protocol were discharged before hospital day 2. Only 9% of BERP patients were discharged with schedule II medications, compared to 100% of the pre-protocol patients (p < 0.001). Intraoperative, in-hospital, and 30-day complication rates were not statistically significant between the two groups. CONCLUSION: Community hospitals can reduce length of stay and narcotic prescribing without compromising safety-related outcomes. Significant reductions in the amount of schedule II medications can be achieved when using multimodal enhanced recovery protocol approaches.


Subject(s)
Bariatric Surgery , Obesity, Morbid , Adult , Humans , Length of Stay , Middle Aged , Obesity, Morbid/surgery , Postoperative Complications , Prospective Studies , Retrospective Studies
9.
Surg Obes Relat Dis ; 17(1): 153-160, 2021 Jan.
Article in English | MEDLINE | ID: mdl-33046419

ABSTRACT

BACKGROUND: Despite thromboprophylaxis, postoperative deep vein thrombosis and pulmonary embolism occur after bariatric surgery, perhaps because of failure to achieve optimal prophylactic levels in the obese population. OBJECTIVES: The aim of this study was to evaluate the adequacy of prophylactic dosing of enoxaparin in patients with severe obesity by performing an antifactor Xa (AFXa) assay. SETTING: An academic medical center METHODS: In this observational study, all bariatric surgery cases at an academic center between December 2016 and April 2017 who empirically received prophylactic enoxaparin (adjusted by body mass index [BMI] threshold of 50 kg/m2) were studied. The AFXa was measured 3-5 hours after the second dose of enoxaparin. RESULTS: A total of 105 patients were included; 85% were female with a median age of 47 years. In total, 16 patients (15.2%) had AFXa levels outside the prophylactic range: 4 (3.8%) cases were in the subprophylactic and 12 (11.4%) cases were in the supraprophylactic range. Seventy patients had a BMI <50 kg/m2 and empirically received enoxaparin 40 mg every 12 hours; AFXa was subprophylactic in 4 (5.7%) and supraprophylactic in 6 (8.6%) of these patients. Of the 35 patients with a BMI ≥50 who empirically received enoxaparin 60 mg q12h, no AFXa was subprophylactic and 6 (17.1%) were supraprophylactic. Five patients (4.8%) had major bleeding complications. One patient developed pulmonary embolism on postoperative day 35. CONCLUSION: BMI-based thromboprophylactic dosing of enoxaparin after bariatric surgery could be suboptimal in 15% of patients with obesity. Overdosing of prophylactic enoxaparin can occur more commonly than underdosing. AFXa testing can be a practical way to measure adequacy of pharmacologic thromboprophylaxis, especially in patients who are at higher risk for venous thromboembolism or bleeding.


Subject(s)
Bariatric Surgery , Venous Thromboembolism , Anticoagulants , Body Mass Index , Enoxaparin , Female , Humans , Male , Middle Aged , Prospective Studies , Venous Thromboembolism/etiology , Venous Thromboembolism/prevention & control
10.
Obes Surg ; 30(10): 4159-4164, 2020 10.
Article in English | MEDLINE | ID: mdl-32458364

ABSTRACT

Due to the profound effect of novel coronavirus disease 2019 (COVID-19) on healthcare systems, surgical programs across the country have paused surgical operations and have been utilizing virtual visits to help maintain public safety. For those who treat obesity, the importance of bariatric surgery has never been more clear. Emerging studies continue to identify obesity and several other obesity-related comorbid conditions as major risk factors for a more severe COVID-19 disease course. However, this also suggests that patients seeking bariatric surgery are inherently at risk of suffering severe complications if they were to contract COVID-19 in the perioperative period. The aim of this protocol is to utilize careful analysis of existing risk stratification for bariatric patients, novel COVID-19-related data, and consensus opinion from multiple academic bariatric centers within our organization to help guide the reanimation of our programs when appropriate and to use this template to prospectively study this risk-stratified population in real time. The core principles of this protocol can be applied to any surgical specialty.


Subject(s)
Bariatric Surgery , Betacoronavirus , Coronavirus Infections/epidemiology , Infection Control/organization & administration , Obesity, Morbid/surgery , Pneumonia, Viral/epidemiology , Adult , COVID-19 , Clinical Protocols , Cohort Studies , Coronavirus Infections/prevention & control , Female , Humans , Male , Middle Aged , Obesity, Morbid/complications , Pandemics/prevention & control , Patient Selection , Pneumonia, Viral/prevention & control , Risk Factors , SARS-CoV-2
11.
Surg Laparosc Endosc Percutan Tech ; 28(5): 291-294, 2018 Oct.
Article in English | MEDLINE | ID: mdl-29847482

ABSTRACT

OBJECTIVES: Previous comparisons between single-port laparoscopic appendectomy (SPLA) and multi-port laparoscopic appendectomy have been conflicting and limited. We compare our single-surgeon, SPLA experience with multi-port cases performed during the same time. METHODS: A retrospective chart review of 128 single-surgeon single-port and 941 multi-port laparoscopic appendectomy cases from April 2009 to December 2014 was conducted. RESULTS: Patient demographics and preoperative laboratory values were comparable. SPLA was associated with shorter operative time (P=0.0001). There was no statistically significant difference in length of hospitalization, postoperative pain medication use, cost, postoperative complication rates (ileus, urinary retention, deep space infection), or readmission between the 2 groups. There were no postoperative incisional hernias in the single-port group. The single-port group had more postoperative oxycodone use (P=0.0110). CONCLUSIONS: Our study supports recently published metaanalyses that fail to support older studies demonstrating longer operative times, and higher hernia rates with SPLA.


Subject(s)
Appendectomy/methods , Appendicitis/surgery , Laparoscopy/methods , Adult , Analgesics, Opioid/therapeutic use , Female , Humans , Learning Curve , Male , Operative Time , Pain, Postoperative/etiology , Pain, Postoperative/prevention & control , Patient Readmission/statistics & numerical data , Postoperative Complications/etiology , Retrospective Studies , Treatment Outcome
12.
Surg Obes Relat Dis ; 14(10): 1495-1500, 2018 Oct.
Article in English | MEDLINE | ID: mdl-30177427

ABSTRACT

BACKGROUND: The increase in life expectancy presents health systems with a growing challenge in the form of elderly obesity. Bariatric surgery has been shown to be a safe and effective treatment for obesity with reduction of excess weight and improvement in obesity-related co-morbidities. However, only recently have surgeons begun performing these operations on elderly patients on a larger scale, making data regarding mid- and long-term outcomes scarce. The objective of this study was to evaluate the safety and midterm efficacy of laparoscopic sleeve gastrectomy (LSG) in patients aged ≥60 years. METHODS: All patients aged ≥60 years who underwent LSG between 2008 and 2014 and achieved ≥24-month follow-up were retrospectively reviewed. Demographic characteristics and perioperative data were analyzed. Weight loss parameters and co-morbidity resolution rates were compared with preoperative data. RESULTS: In total 55 patients aged ≥60 years underwent LSG. Mean patient age was 63.9 ± 3.2 years (range, 60-75.2), and mean preoperative body mass index was 43 ± 6.0 kg/m2. Perioperative morbidity included 5 cases of hemorrhage necessitating operative exploration, 2 cases of reduced hemoglobin levels treated with blood transfusion, and 1 case of portal vein thrombosis managed with anticoagulation. There were no mortalities. Mean follow-up time was 48.6 (range, 25.6-94.5) months. Mean percentage of excess weight loss was 66.4 ± 19.7, 67.5 ±1 6.4, 61.4 ± 18.3, 66.7 ± 25.6, 50.7 ± 21.4 at 12, 24, 36, 37 to 60, and 61 to 96 months, respectively. Statistically significant improvement of type 2 diabetes, hypertension, and dyslipidemia were observed at the latest follow-up (P < .01). CONCLUSION: LSG offers an effective treatment of obesity and its co-morbidities in patients aged ≥60 years, albeit with a high perioperative bleeding rate at our center; efficacy is maintained for at least 4.5 years.


Subject(s)
Bariatric Surgery/methods , Gastrectomy/methods , Laparoscopy/methods , Obesity, Morbid/surgery , Aged , Blood Loss, Surgical/statistics & numerical data , Female , Humans , Intraoperative Complications/etiology , Male , Middle Aged , Multiple Chronic Conditions , Obesity, Morbid/complications , Treatment Outcome , Weight Loss/physiology
13.
Surg Obes Relat Dis ; 14(5): 652-657, 2018 05.
Article in English | MEDLINE | ID: mdl-29503096

ABSTRACT

BACKGROUND: National quality programs have been implemented to decrease the burden of adverse events on key outcomes in bariatric surgery. However, it is not well understood which complications have the most impact on patient health. OBJECTIVE: To quantify the impact of specific bariatric surgery complications on key clinical outcomes. SETTING: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: Data from patients who underwent primary bariatric procedures were retrieved from the MBSAQIP 2015 participant use file. The impact of 8 specific complications (bleeding, venous thromboembolism [VTE], leak, wound infection, pneumonia, urinary tract infection, myocardial infarction, and stroke) on 5 main 30-day outcomes (end-organ dysfunction, reoperation, intensive care unit admission, readmission, and mortality) was estimated using risk-adjusted population attributable fractions. The population attributable fraction is a calculated measure taking into account the prevalence and severity of each complication. The population attributable fractions represents the percentage reduction in a given outcome that would occur if that complication were eliminated. RESULTS: In total, 135,413 patients undergoing sleeve gastrectomy (67%), Roux-en-Y gastric bypass (29%), adjustable gastric banding (3%), and duodenal switch (1%) were included. The most common complications were bleeding (.7%), wound infection (.5%), urinary tract infection (.3%), VTE (.3%), and leak (.2%). Bleeding and leak were the largest contributors to 3 of 5 examined outcomes. VTE had the greatest effect on readmission and mortality. CONCLUSION: This study quantifies the impact of specific complications on key surgical outcomes after bariatric surgery. Bleeding and leak were the complications with the largest overall effect on end-organ dysfunction, reoperation, and intensive care unit admission after bariatric surgery. Furthermore, our findings suggest that an initiative targeting reduction of post-bariatric surgery VTE has the greatest potential to reduce mortality and readmission rates.


Subject(s)
Bariatric Surgery/adverse effects , Health Priorities , Postoperative Complications/etiology , Adult , Anastomotic Leak/etiology , Critical Care/statistics & numerical data , Female , Humans , Male , Middle Aged , Patient Readmission/statistics & numerical data , Postoperative Hemorrhage/etiology , Prospective Studies , Reoperation/statistics & numerical data , Risk Assessment , Surgical Wound Infection/etiology , Treatment Outcome , Urinary Tract Infections/etiology , Venous Thromboembolism/etiology
15.
Eur J Endocrinol ; 174(1): R19-28, 2016 Jan.
Article in English | MEDLINE | ID: mdl-26340972

ABSTRACT

Obesity is associated with an increased risk of type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, osteoarthritis, numerous cancers and increased mortality. It is estimated that at least 2.8 million adults die each year due to obesity-related cardiovascular disease. Increasing in parallel with the global obesity problem is metabolic syndrome, which has also reached epidemic levels. Numerous studies have demonstrated that bariatric surgery is associated with significant and durable weight loss with associated improvement of obesity-related comorbidities. This review aims to summarize the effects of bariatric surgery on the components of metabolic syndrome (hyperglycemia, hyperlipidemia and hypertension), weight loss, perioperative morbidity and mortality, and the long-term impact on cardiovascular risk and mortality.


Subject(s)
Bariatric Surgery , Metabolic Syndrome/surgery , Obesity/complications , Obesity/surgery , Adult , Bariatric Surgery/adverse effects , Bariatric Surgery/mortality , Blood Glucose/analysis , Cardiovascular Diseases , Diabetes Mellitus, Type 2 , Humans , Hyperglycemia , Hyperlipidemias , Hypertension , Metabolic Syndrome/etiology , Postoperative Complications , Risk Factors , Weight Loss
16.
Surg Obes Relat Dis ; 12(1): 127-31, 2016 Jan.
Article in English | MEDLINE | ID: mdl-26077701

ABSTRACT

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in the United States; 85%-95% of the morbidly obese population have NAFLD and 33% have nonalcoholic steatohepatitis. There is a lack of comparative data assessing various bariatric procedures and their effect on NAFLD. OBJECTIVES: To assess and compare the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on NAFLD. SETTING: Academic Center, United States METHODS: All bariatric cases performed at the authors' institution (an academic center in the United States) between 2005 and 2012 that had both intraoperative and postoperative liver biopsies were included. NAFLD Activity Score (NAS) and fibrosis stages were used to evaluate improvement in liver histology. RESULTS: Fourteen RYGB and 9 SG patients with liver biopsies were identified. 57% and 73% in each group were female, respectively. P = .2. RYGB patients were older (56.2 ± 8.6 versus 46.3 ± 11.7; P<.05), and had lower initial body mass index (BMI) and higher NAS (51.0 ± 13.0 kg/m(2) versus 72.7 ± 21.0 kg/m(2); P<.05) and (4.4 ± 1.7 versus 2.6 ± 1.6; P<.05), respectively. Prevalence of co-morbidities was comparable between groups. After a mean follow-up of 1.5 years, weight loss percentage was 32% ± 11.8% and 25% ± 6.8% after RYGB and SG, respectively (P value not significant). Percentage of excess weight loss was higher in RYGB patients (69.8% ± 27% versus 37.2% ± 12.3%; P<.05). NAS after RYGB significantly improved in all morphologic characteristics, whereas only steatosis and total NAS improved after SG. Fibrosis state improved in both groups but to a greater degree after RYGB (2.5 ± 1.3 versus .3 ± .6; P< .05). CONCLUSIONS: There were no significant differences in NAS score decrease after RYGB and SG procedures, although the baseline characteristics of the groups differ. This exploratory data supports the idea of conducting a randomized trial to determine the differential effects of SG and RYGB on NAFLD.


Subject(s)
Gastrectomy/methods , Gastric Bypass/methods , Laparoscopy/methods , Liver/pathology , Non-alcoholic Fatty Liver Disease/complications , Weight Loss , Body Mass Index , Female , Follow-Up Studies , Humans , Male , Middle Aged , Non-alcoholic Fatty Liver Disease/pathology , Obesity, Morbid , Postoperative Period , Retrospective Studies , Treatment Outcome
17.
J Laparoendosc Adv Surg Tech A ; 26(5): 361-5, 2016 May.
Article in English | MEDLINE | ID: mdl-26978594

ABSTRACT

BACKGROUND: Further minimization of abdominal wall trauma during laparoscopic bariatric surgery is a topic of great interest. Reducing the number of trocars may provide superior cosmetic results with less pain and shorter length of stay (LOS). However, it remains unclear if this approach compromises safety or effectiveness of weight loss. The aim of this study is to report initial safety and feasibility results using a three-port minimally invasive sleeve gastrectomy technique. MATERIALS AND METHODS: A retrospective review of patients who underwent laparoscopic three-port sleeve gastrectomy (3PSG) at our institution was conducted. Patient demographics, intraoperative parameters, and perioperative outcomes were extracted and analyzed. Postoperative data were obtained from routine follow-up history and physical examination. RESULTS: From May 2013 to April 2014, 45 morbidly obese patients underwent 3PSG. The cohort had a male-to-female ratio of 20:25, mean age of 47.4 ± 11.6 years, and a mean preoperative body mass index (BMI) of 47.6 ± 9.7 kg/m(2). The mean number of comorbidities was 4 (range 0-8), and the mean American Society of Anesthesiologists score was 2.82 (range 1-4). Mean procedural duration and blood loss were 165 ± 31.9 minutes and 27.0 ± 31.8 mL, respectively. Eight patients (17%) required one additional trocar. Two cases (4.4%) had an intraoperative complication (staple line bleeding and splenic capsule laceration). Two (4.4%) postoperative complications were encountered (wound infection and axillary vein thrombosis). The mean LOS was 2.7 (range 2-7) days. At a mean follow-up of 5 (range 0.4-11.7) months, the cohort had a mean BMI of 40.0 ± 9.26 kg/m(2), which corresponded to a mean excess weight loss of 36.0% ± 18.1%. There were no trocar site hernias. All patients were highly satisfied with the final cosmetic result. CONCLUSION: Laparoscopic 3PSG appears to be a safe and feasible technique for performing sleeve gastrectomy. While further long-term research is needed, it appears to have significant benefits, mainly patient satisfaction and potentially less pain.


Subject(s)
Gastrectomy/methods , Laparoscopes , Laparoscopy/instrumentation , Obesity, Morbid/surgery , Surgical Stapling/instrumentation , Body Mass Index , Equipment Design , Female , Humans , Length of Stay , Male , Middle Aged , Patient Satisfaction , Retrospective Studies , Treatment Outcome , Weight Loss
18.
Surg Obes Relat Dis ; 12(2): 392-7, 2016 Feb.
Article in English | MEDLINE | ID: mdl-26483069

ABSTRACT

BACKGROUND: It remains unclear if patients undergoing revisional surgery for inadequate weight loss/recidivism can achieve improvement of refractory metabolic syndrome (MetS). OBJECTIVE: We aimed to evaluate metabolic outcomes after reoperative bariatric surgery for unsatisfactory weight loss in patients with refractory MetS. SETTING: Academic Hospital. METHODS: We retrospectively reviewed all revisional bariatric surgery cases performed for inadequate weight loss/recidivism at our center and analyzed all cases in which the patient had ongoing uncontrolled diabetes or MetS. RESULTS: In total, 121 reoperative bariatric cases for inadequate weight loss/recidivism were identified. Of those, 31.4% (N = 38) had MetS and 33.9% (N = 41) were diabetic at the time of primary bariatric surgery. At revisional surgery, 15 (39.5%) patients still met criteria for MetS and 7 (17.1%) had hemoglobin A1c (HbA1c)≥6.0%. Of those with refractory MetS (N = 15) at revisional surgery, a mean percent excess weight loss (%EWL) of 59.4±21.2% at mean 40.1±29.9 months follow-up corresponded to a mean decrease in triglyceride of 65.2 mg/dL, mean increase in high-density lipoprotein cholesterol (HDL) of 12.1 mg/dL, and mean decrease in plasma glucose of 58.8 mg/dL. Mean percent total weight loss was 27.3%. One patient still met criteria for MetS. Of those with HbA1c≥6.0% at reoperative surgery (N = 7), a mean %EWL of 63.0±22.9% at mean 51.6±36.6 months follow-up corresponded to a mean decrease in HbA1c of 1.6%. Three patients still had HbA1c≥6.0%, but only 1 had HbA1c≥ 6.5%. CONCLUSION: Although further research is needed, this report suggests that revisional bariatric surgery is capable of treating both inadequate weight loss and refractory metabolic disease.


Subject(s)
Bariatric Surgery/methods , Glycated Hemoglobin/metabolism , Metabolic Syndrome/etiology , Obesity, Morbid/surgery , Weight Loss , Adult , Female , Follow-Up Studies , Humans , Male , Metabolic Syndrome/blood , Middle Aged , Obesity, Morbid/complications , Postoperative Complications , Reoperation , Retrospective Studies , Time Factors , Treatment Outcome
19.
Surg Obes Relat Dis ; 12(9): 1731-1736, 2016 Nov.
Article in English | MEDLINE | ID: mdl-26723561

ABSTRACT

BACKGROUND: As the number of patients who have undergone bariatric surgery increases, it is expected that more patients will present for body contouring procedures after weight loss. It has been reported that abdominoplasty can improve mobility, reduce skin fold complications, and improve psychosocial functioning. No previous studies have evaluated weight loss in patients who pursue plastic surgery after bariatric surgery. OBJECTIVES: The aim of this study is to evaluate weight loss outcomes in patients who choose to undergo body contouring procedures after bariatric surgery. SETTING: Academic center, United States. METHODS: Patients who underwent body contouring procedures after bariatric surgery between 2002 and 2014 were included. A comparison was made to a matched cohort based on age, gender, type of bariatric procedure, preoperative body mass index (BMI), and length of follow-up. RESULTS: In total, 186 patients had documentation of a body contouring procedure after bariatric surgery. There were 158 (84.9%) female participants in the body countering group. Mean age was 48.5±12.7 years and mean BMI was 49.8±10.4 kg/m2. Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding were performed in 157 (84.4%), 17 (9.1%), and 11 (5.9%) patients, respectively. After a matched follow-up period of 61 months, total weight loss was 43.0±22.6 kg in the body contouring group versus 33.5±21.7 kg in the control group (P<.001), percentage of total weight loss was 30.8±11.4% versus 24.0±13.2% (P<.001), percentage excess weight loss was 66.4±25% versus 52.5±30.5% (P<.001), and BMI dropped by 15.7±7.8 kg/m2 versus 12.1±7.3 kg/m2 (P<.001) in the body contouring group compared with the bariatric surgery-only group, respectively. Multivariate analysis indicated that body contouring after bariatric surgery is significantly associated with increase and durable weight loss (odds ratio 3.59, 95% confidence interval 2.04-5.14, P< .001). CONCLUSION: Patients who underwent body contouring procedures after bariatric surgery had significantly better long-term weight loss than a matched cohort of patients. This finding likely has many contributing factors, and the association between long-term weight loss and body contouring procedures after bariatric surgery requires more detailed study.


Subject(s)
Abdominoplasty/statistics & numerical data , Bariatric Surgery/methods , Postoperative Care/statistics & numerical data , Weight Loss/physiology , Body Mass Index , Case-Control Studies , Female , Humans , Male , Middle Aged , Obesity/surgery , Postoperative Care/methods , Retrospective Studies , Second-Look Surgery/methods , Time Factors , Treatment Outcome
20.
Surg Obes Relat Dis ; 12(1): 132-7, 2016 Jan.
Article in English | MEDLINE | ID: mdl-26077696

ABSTRACT

BACKGROUND: Numerous reports address bariatric outcomes in super-obese or elderly patients, but data addressing this high-risk combination is lacking. OBJECTIVE: The objective of this study was to assess outcomes of bariatric surgery in the super-obese elderly. SETTING: Academic institution, United States. METHODS: All primary bariatric cases performed on patients aged 65 years or older with a body mass index (BMI) ≥ 50 kg/m(2) were retrospectively analyzed. Surgical approaches included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). RESULTS: Thirty patients (26 female, 4 male) with a mean age of 67.1 ± 2.7 years and BMI of 55.9 ± 3.9 kg/m(2), who had LRYGB (n = 16), LSG (n = 6), or LAGB (n = 8), were identified. There were no deaths, conversions, or intraoperative complications. Three patients were lost to follow-up after the 3-month visit. The early (<30 d) major morbidity rate was 10.0%. At a median follow-up of 37 (range, 6-95) months, the cohort had a mean BMI of 42.3 ± 6.7 kg/m(2), which corresponded to a mean percent excess weight loss of 44.5% ± 20.5% and mean percent total weight loss of 24.4% ± 12.2%. The most percent excess weight loss was achieved after LRYGB (54.1% ± 19.4%), followed by LSG (48.3% ± 10.2%) and then LAGB (26.2% ± 14.4%). Diabetic medication reduction in number and/or dosage was observed in 40% (6/15) patients, and 33% (5/15) of patients were completely off antidiabetic agents. CONCLUSIONS: Although further research is needed, the present data suggest that successful weight loss and metabolic improvement can be achieved safely in the high-risk population of super-obese elderly.


Subject(s)
Bariatric Surgery/methods , Body Mass Index , Laparoscopy/methods , Metabolic Syndrome/complications , Obesity, Morbid/surgery , Weight Loss , Aged , Female , Follow-Up Studies , Humans , Male , Metabolic Syndrome/metabolism , Obesity, Morbid/complications , Obesity, Morbid/metabolism , Retrospective Studies , Treatment Outcome
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