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BACKGROUND: Bariatric surgery has been shown to improve and resolve diabetes. However, limited literature about its impact on end-organ complications of diabetes is available. The aim of this study was to examine the long-term effect of bariatric surgery on albuminuria. METHODS: We studied 101 patients with pre-operative diabetes and albuminuria [defined as urine albumin:creatinine ratio (uACR) > 30 mg/g] who underwent bariatric surgery at an academic center from 2005 to 2014. RESULTS: Fifty-seven patients (56%) were female with a mean age of 53 (± 11) years. The mean pre-operative BMI and glycated hemoglobin (HbA1c) were 43.1 (± 7.6) kg/m2 and 8.4 (± 1.8)%, respectively. The median pre-operative uACR was 80.0 (45.0-231.0) mg/g. Bariatric procedures included Roux-en-Y gastric bypass (n = 75, 74%) and sleeve gastrectomy (n = 26, 26%). The mean follow-up period was 61 (± 29) months. At last follow-up, the mean BMI was 33.8 (± 8.3) kg/m2. The overall glycemic control improved after bariatric surgery. At last follow-up, 73% had good glycemic control (HbA1c < 7%) and 27% met diabetes remission criteria. The mean HbA1c at last follow-up was 6.7 (± 1.0)% and the median uACR was 30 (IQR 7-94) mg/g. Albuminuria improved in 77% and resolved in 51% of patients at long-term. CONCLUSIONS: Bariatric surgery has a significantly positive impact on albuminuria in patients with obesity and type 2 diabetes. Our data showed almost an 80% improvement in albuminuria at the short- and long-term period after bariatric surgery.
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Albuminúria/prevenção & controle , Cirurgia Bariátrica , Nefropatias Diabéticas/prevenção & controle , Hemoglobinas Glicadas/metabolismo , Obesidade Mórbida/cirurgia , Adulto , Idoso , Albuminas/análise , Albuminúria/etiologia , Cirurgia Bariátrica/métodos , Creatinina/urina , Diabetes Mellitus Tipo 2/complicações , Feminino , Gastrectomia/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Redução de PesoRESUMO
BACKGROUND: Perioperative pulmonary complications are frequent in patients with interstitial lung diseases (ILD). Limited literature exists regarding the safety of bariatric procedures in patients with ILD. This study aims to assess the safety, feasibility, and outcomes of patients with ILD who underwent bariatric surgery at our institution. METHODS: After IRB approval, all patients with preoperative diagnosis of ILD who had bariatric surgery at an academic center between 2004 and 2014 were retrospectively reviewed. RESULTS: A total of 25 patients with ILD underwent bariatric surgery: Roux-en-Y gastric bypass (n = 17, 68%), sleeve gastrectomy (n = 7, 28%), and adjustable gastric banding (n = 1, 4%). Twenty-one patients (84%) were females. The median age and preoperative body mass index (BMI) were 53 (IQR 42-58) years and 39 (IQR 37-44) kg/m2, respectively. The median operative time and length of stay was 137 (IQR 110-187) min and 3 (IQR 2-5) days, respectively. The 30-day complications were reported in four patients (16%) but there was no pulmonary complication or unplanned admission to the intensive care unit. At 1-year follow-up (85%), the median BMI and excess weight loss were 30 (IQR 25-36) kg/m2 and 67% (IQR 45-100), respectively. Compared to preoperative values, there was significant improvement in the pulmonary function test (PFT) variables at 1 year with respect to forced vital capacity (62% vs 74%; n = 13, p = 0.003), and diffusing capacity of the lungs for carbon monoxide (53% vs 66%; n = 10, p = 0.003). Six out of the seven potential lung transplant candidates became eligible for transplantation after weight loss, and one of them had successful lung transplant at 88 months after bariatric surgery. CONCLUSION: In our experience, bariatric patients with ILD achieved significant weight loss and improvement in PFT. Bariatric surgery in these higher risk ILD patients appears relatively safe with acceptable perioperative morbidity and improved candidacy for lung transplantation.
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Cirurgia Bariátrica , Doenças Pulmonares Intersticiais/epidemiologia , Índice de Massa Corporal , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Doenças Pulmonares Intersticiais/cirurgia , Transplante de Pulmão , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Testes de Função Respiratória , Estudos Retrospectivos , Redução de PesoRESUMO
Metabolic surgery is an essential option in the treatment of obese patients with type 2 diabetes (T2D). Despite its known advantages, this surgery still needs to be introduced in Malaysia. In this prospective study, the pathophysiological mechanisms at the molecular level will be studied and the metabolomics pathways of diabetes remission will be explored. The present study aims to evaluate the changes in the anthropometric measurements, body composition, phase angle, diet intake, biochemistry parameters, adipokines, microRNA, and metabolomics, both pre- and post-surgery, among obese diabetic patients in Malaysia. This is a multicenter prospective cohort study that will involve obese patients (n = 102) with a body mass index (BMI) of ≥25 kg/m2 (Asian BMI categories: WHO/IASO/IOTF, 2000) who will undergo metabolic surgery. They will be categorized into three groups: non-diabetes, prediabetes, and diabetes. Their body composition will be measured using a bioimpedance analyzer (BIA). The phase angle (PhA) data will be analyzed. Venous blood will be collected from each patient for glycated hemoglobin (HbA1c), lipids, liver, renal profile, hormones, adipokines, and molecular and metabolomics analyses. The serum microRNA will be measured. A gene expression study of the adipose tissue of different groups will be conducted to compare the groups. The relationship between the 1HNMR-metabolic fingerprint and the patients' lifestyles and dietary practices will be determined. The factors responsible for the excellent remission of T2D will be explored in this study.
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This review is aimed at synthesizing the mechanisms and outcomes of metabolic surgery on the endocrine system, microbiome, metabolomics, and at the molecular level. We review the hormonal, adipokine, microbiota, microRNA, and metabolomic changes in human and animal models following metabolic surgery for the treatment of obesity and diabetes. The most relevant studies in this area over the past 17 years have been considered for this review. In most cases, metabolic procedures, especially those that include intestinal bypass components, showed the remission of type 2 diabetes. This involves a variety of weight-independent mechanisms to improve glucose homeostasis, improving insulin sensitivity and secretion, gut microbiota, and bile acid cross-talk.
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BACKGROUND AND AIMS: Bariatric surgery has been proven to be the most effective weight loss treatment for patients with morbid obesity. However, the alteration in the anatomy of the gastrointestinal structure, food aversion, and non-compliance to recommended dietary advice after bariatric surgery may cause food intolerance, which may affect the nutritional status and health-related quality of life (HRQOL). This study aims to determine the effects of bariatric surgery on food tolerance, nutritional status, and HRQOL among patients with morbid obesity in Malaysia. METHODS: This prospective observational study screened a total of 97 patients with morbid obesity. Data on socio-demographic characteristic, food tolerance, nutritional status and HRQOL were collected and assessed at baseline, one month and three months after bariatric surgery. Food tolerance was evaluated using a validated quality of alimentation questionnaire. The anthropometry measurements, including the body mass index (BMI) and percent excess weight loss (EWL), were evaluated, and the dietary intake was collected using a three-day food record. The HRQOL was assessed using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire. RESULTS: This study recruited 90 patients with morbid obesity who underwent bariatric surgery with a response rate of 100%. There were 62 females (68.9%) and 28 male (31.1%) patients, with 50% of the patient age less than 40. The EWL one month and three months after surgery was 14.1% and 31.6%, respectively. There was a significant decrease in the total food tolerance score from 26.4 (SD = 0.8) at baseline to 17.7 (SD = 4.7) one month after bariatric surgery, but a gradual rise in the score to 21.7 (SD = 4.3) was observed three months after surgery. A similar pattern is seen in the dietary intake assessment where a significant reduction in the total energy from 1842 kcal (SD = 445) at baseline to 570 kcal (SD = 180) one month and an increase to 731 kcal (SD = 185) three months after bariatric surgery. The HRQOL of the study patients showed a statistically significantly increase in the domain of physical health (t = -7.253, p = < 0.001), psychological (t = -7.692, p < 0.001), social relationship (t = -5.767, p < 0.001) and environment (t = -4.208, p < 0.013) three months after bariatric surgery. CONCLUSION: The present study showed that bariatric surgery effectively reduces weight and improves overall HRQOL domains among patients with morbid obesity despite reduced food tolerance and energy intake after bariatric surgery. Future longitudinal studies or randomized controlled trial with a larger sample size is recommended to determine the cause and effect mechanism between food tolerance, weight loss, dietary intake, HRQOL and bariatric surgery in Malaysia.
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Cirurgia Bariátrica , Obesidade Mórbida , Feminino , Humanos , Masculino , Estado Nutricional , Obesidade Mórbida/cirurgia , Qualidade de Vida , Redução de PesoRESUMO
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.
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Cirurgia Bariátrica , Tromboembolia Venosa , Anticoagulantes , Índice de Massa Corporal , Enoxaparina , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controleRESUMO
Gastrectomy and gastric bypass improve type 2 diabetes (T2DM), potentially through alterations in intestinal hormones and the microbiome. The aim of this study was to analyze whether colorectal resections result in improvement of T2DM. A total of 171 patients with T2DM who underwent colectomy for benign diseases were studied with a median postoperative follow-up of 3 years (interquartile range [IQR] 1-5). The median BMI and glycated hemoglobin (HbA1c) at baseline and post-colectomy were 30.3 kg/m2 (IQR 26.6-34.6) versus 30.4 kg/m2 (IQR 26.2-35) (p = 0.1), and 6.7% (IQR 6.2-7.5) versus 6.5% (IQR 6.5-7.1) (p = 0.5), respectively. The proportion of patients taking diabetes medications at baseline versus post-colectomy did not differ significantly. Changes in BMI, HbA1c, and status of diabetes medications were not statistically different between the subtypes of colorectal resection. Our experience suggests that colectomy for benign colorectal diseases is not associated with long-term changes in body weight or glycemic control.
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Diabetes Mellitus Tipo 2 , Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Glicemia , Índice de Massa Corporal , Colectomia , Diabetes Mellitus Tipo 2/cirurgia , Gastrectomia , Hemoglobinas Glicadas , Humanos , Obesidade Mórbida/cirurgia , Resultado do Tratamento , Redução de PesoRESUMO
OBJECTIVE: To characterize the status of cardiometabolic risk factors after late relapse of type 2 diabetes mellitus (T2DM) and to identify factors predicting relapse after initial diabetes remission following bariatric surgery to construct prediction models for clinical practice. RESEARCH DESIGN AND METHODS: Outcomes of 736 patients with T2DM who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at an academic center (2004-2012) and had ≥5 years' glycemic follow-up were assessed. Of 736 patients, 425 (58%) experienced diabetes remission (HbA1c <6.5% [48 mmol/mol] with patients off medications) in the 1st year after surgery. These 425 patients were followed for a median of 8 years (range 5-14) to characterize late relapse of diabetes. RESULTS: In 136 (32%) patients who experienced late relapse, a statistically significant improvement in glycemic control, number of diabetes medications including insulin use, blood pressure, and lipid profile was still observed at long-term. Independent baseline predictors of late relapse were preoperative number of diabetes medications, duration of T2DM before surgery, and SG versus RYGB. Furthermore, patients who relapsed lost less weight during the 1st year after surgery and regained more weight afterward. Prediction models were constructed and externally validated. CONCLUSIONS: While late relapse of T2DM is a real phenomenon (one-third of our cohort), it should not be considered a failure, as the trajectory of the disease and its related cardiometabolic risk factors is changed favorably after bariatric surgery. Earlier surgical intervention, RYGB (compared with SG) and more weight loss (less late weight regain) are associated with less diabetes relapse in the long-term.
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Cirurgia Bariátrica , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/patologia , Diabetes Mellitus Tipo 2/cirurgia , Adulto , Cirurgia Bariátrica/estatística & dados numéricos , Glicemia/metabolismo , Diabetes Mellitus Tipo 2/diagnóstico , Feminino , Seguimentos , Gastrectomia/estatística & dados numéricos , Derivação Gástrica/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Falha de Tratamento , Redução de Peso/fisiologiaRESUMO
BACKGROUND: Laparoscopic loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG) is a new metabolic procedure. Our initial data on type 2 diabetes (T2D) remission after LDJB-SG were promising. OBJECTIVES: The aim of this study was to look at our intermediate outcomes after LDJB-SG. SETTING: An academic medical center. METHODS: A prospective analysis of T2D patients who underwent LDJB-SG between October 2011 and October 2014 was performed. Data collected included baseline demographic, body mass index, fasting blood glucose, glycosylated hemoglobin, C-peptide, resolution of co-morbidities, and postoperative complications. RESULTS: A total of 163 patients with minimum of follow-up >1 year were enrolled in this study (57 men and 106 women). The mean age and body mass index were 47.7 (±10.7) years and a 30.2 (±5.1) kg/m2, respectively. There were 119 patients on oral hypoglycemic agents only, 29 patients were on oral hypoglycemic agents and insulin, 3 patients were on insulin only, and the other 12 patients were not on diabetic medication. Mean operation time and length of hospital stay were 144.7 (± 45.1) minutes and 2.4 (± 1.0) days, respectively. Seven patients (3.6%) needed reoperation due to bleeding (nâ¯=â¯1), anastomotic leak (nâ¯=â¯2), sleeve strictures (nâ¯=â¯2), and incisional hernia (nâ¯=â¯2). At 2 years of follow-up, there were 56 patients. None of the patients were on insulin and only 20% of patients were on oral hypoglycemic agents. Mean body mass index significantly dropped to 22.9 (±5.6) kg/m2 at 2 years. The mean preoperative fasting blood glucose, glycosylated hemoglobin, and C-peptide levels were 174.7 mg/dL (± 61.0), 8.8% (±1.8), and 2.6 (±1.7) ng/mL, respectively. The mean fasting blood glucose, glycosylated hemoglobin, and C-peptide at 2 years were 112.5 (±60.7) mg/dL, 6.4% (±2.0), and 1.5 (±0.6) ng/mL, respectively. No patient needed revisional surgery because of dumping syndrome, marginal ulcer, or gastroesophageal reflux disease at the last follow up period. CONCLUSION: At 2 years, LDJB-SG is a relatively safe and effective metabolic surgery with significant weight loss and resolution of co-morbidities.
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Diabetes Mellitus Tipo 2/cirurgia , Duodeno/cirurgia , Gastrectomia/métodos , Jejuno/cirurgia , Laparoscopia/métodos , Índice de Massa Corporal , Feminino , Hemoglobinas Glicadas/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Indução de Remissão , Redução de PesoRESUMO
BACKGROUND: There is limited data in the literature evaluating outcomes of bariatric surgery in severely obese patients with left ventricular assist device (LVAD) as a bridge to make them acceptable candidates for heart transplantation. This study aims to assess the safety and effectiveness of laparoscopic sleeve gastrectomy (LSG) in patients with previously implanted LVAD at our institution. METHODS: All the patients with end-stage heart failure (ESHF) and implanted LVAD who underwent LSG from2013 to January 2017 were studied. RESULTS: Seven patients with end stage heart failure (ESHF) and implanted LVAD were included. The median age and median preoperative BMI were 39 years (range: 26-62) and 43.6 kg/m2 (range 36.7-56.7), respectively. The median interval between LVAD implantation and LSG was 38 months (range 15-48). The median length of hospital stay was 9 days (rang: 6-23) out of which 4 patients had planned postoperative ICU admission. Thirty-day complications were noted in 5 patients (3 major and 2 minor) without any perioperative mortality. The median duration of follow-up was 24 months (range 2-30). At the last available follow-up, the median BMI, %EWL, and %TWL were 37 kg/m2, 47%, and 16%, respectively. The median LVEF before LSG and at the last follow-up point (before heart transplant) was 19% (range 15-20) and 22% (range, 16-35), respectively. In addition, the median NYHA class improved from 3 to 2 after LSG. Three patients underwent successful heart transplantations. CONCLUSION: Patients with morbid obesity, ESHF, and implanted LVAD constitute a high-risk cohort. Our results with 7 patients and result from other studies (19 patients) suggested that bariatric surgery may be a reasonable option for LVAD patients with severe obesity. Bariatric surgery appears to provide significant weight loss in these patients and may improve candidacy for heart transplantation.
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Cirurgia Bariátrica/métodos , Gastrectomia/métodos , Insuficiência Cardíaca/complicações , Coração Auxiliar , Obesidade Mórbida/cirurgia , Adulto , Cirurgia Bariátrica/efeitos adversos , Índice de Massa Corporal , Estudos de Coortes , Feminino , Gastrectomia/efeitos adversos , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Transplante de Coração , Humanos , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Obesidade Mórbida/fisiopatologia , Complicações Pós-Operatórias , Estudos Retrospectivos , Volume Sistólico/fisiologia , Resultado do Tratamento , Redução de PesoRESUMO
INTRODUCTION: While bariatric surgery leads to significant prevention and improvement of type 2 diabetes, patients may rarely develop diabetes after bariatric surgery. The aim of this study was to determine the incidence and the characteristic of new-onset diabetes after bariatric surgery over a 17-year period at our institution. METHODS: Non-diabetic patients who underwent bariatric surgery at a single academic center (1997-2013) and had a postoperative glycated hemoglobin (HbA1c) ≥ 6.5%, fasting blood glucose (FBG) ≥ 126 mg/dl, or positive glucose tolerance test were identified and studied. RESULTS: Out of 2263 non-diabetic patients at the time of bariatric surgery, 11 patients had new-onset diabetes in the median follow-up time of 9 years (interquartile range [IQR], 4-12). Bariatric procedures performed were Roux-en-Y gastric bypass (n = 7), adjustable gastric banding (n = 3), and sleeve gastrectomy (n = 1). The median interval between surgery and diagnosis of diabetes was 6 years (IQR, 2-9). At the last follow-up, the median HbA1c and FBG values were 6.3% (IQR, 6.1-6.5) and 95 mg/dl (IQR, 85-122), respectively. Possible etiologic factors leading to diabetes were weight regain to baseline (n = 6, 55%), steroid-induced after renal transplantation (n = 1), pancreatic insufficiency after pancreatitis (n = 1), and unknown (n = 3). CONCLUSION: De novo diabetes after bariatric surgery is rare with an incidence of 0.4% based on our cohort. Weight regain was common (> 50%) in patients who developed new-onset diabetes suggesting recurrent severe obesity as a potential etiologic factor. All patients had good glycemic control (HbA1c ≤ 7%) in the long-term postoperative follow-up.
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Cirurgia Bariátrica , Gastrectomia , Obesidade Mórbida , Adulto , Cirurgia Bariátrica/métodos , Glicemia , Estudos de Coortes , Diabetes Mellitus Tipo 2/cirurgia , Feminino , Seguimentos , Gastrectomia/métodos , Derivação Gástrica/métodos , Hemoglobinas Glicadas , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgia , Resultado do Tratamento , Redução de PesoRESUMO
BACKGROUND: Bariatric surgery can improve renal dysfunction associated with obesity and diabetes. However, acute kidney injury (AKI) can complicate the early postoperative course after bariatric surgery. The long-term consequences of early postoperative AKI on renal function are unknown. METHODS: Patient undergoing bariatric surgery from 2008 to 2015 who developed AKI within 60 days after surgery were studied. Patients on dialysis before surgery were excluded. RESULTS: Out of 4722 patients, 42 patients (0.9%) developed early postoperative AKI after bariatric surgery of whom five had chronic kidney disease (CKD) preoperatively including CKD stage 3 (n = 2), stage 4 (n = 2), and stage 5 (n = 1). Etiologies of AKI included prerenal in 37 and renal in 5 patients. Nine patients (21%) underwent hemodialysis in early postoperative period for AKI. The median duration of follow-up was 28 months (interquartile range, 4-59). Of the 40 patients eligible for follow-up, 36 patients (90%) returned to their baseline renal function. However, four patients (10%) had worsening of renal function at follow-up. CONCLUSIONS: The incidence of early postoperative AKI after bariatric surgery is about 1%. The most common causes of AKI after bariatric surgery are dehydration and infectious complications. In our series, 10% of patients who developed AKI in early postoperative period had worsening of renal function in long-term follow-up. In the absence of severe sepsis and severe underlying kidney dysfunction (CKD stages 4 and 5), full recovery is expected after postoperative AKI.
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Injúria Renal Aguda , Cirurgia Bariátrica , Complicações Pós-Operatórias , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/fisiopatologia , Injúria Renal Aguda/terapia , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/estatística & dados numéricos , Humanos , Rim/fisiopatologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Diálise Renal , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/fisiopatologia , Estudos RetrospectivosRESUMO
BACKGROUND: Some patients do not achieve optimal weight loss or regain weight after bariatric surgery. In this study, we aimed to determine the effectiveness of adjuvant weight loss medications after surgery for this group of patients. SETTING: An academic medical center. METHODS: Weight changes of patients who received weight loss medications after bariatric surgery from 2012 to 2015 at a single center were studied. RESULTS: Weight loss medications prescribed for 209 patients were phentermine (n = 156, 74.6%), phentermine/topiramate extended release (n = 25, 12%), lorcaserin (n = 18, 8.6%), and naltrexone slow-release/bupropion slow-release (n = 10, 4.8%). Of patients, 37% lost>5% of their total weight 1 year after pharmacotherapy was prescribed. There were significant differences in weight loss at 1 year in gastric banding versus sleeve gastrectomy patients (4.6% versus .3%, P = .02) and Roux-en-Y gastric bypass versus sleeve gastrectomy patients (2.8% versus .3%, P = .01).There was a significant positive correlation between body mass index at the start of adjuvant pharmacotherapy and total weight loss at 1 year (P = .025). CONCLUSION: Adjuvant weight loss medications halted weight regain in patients who underwent bariatric surgery. More than one third achieved>5% weight loss with the addition of weight loss medication. The observed response was significantly better in gastric bypass and gastric banding patients compared with sleeve gastrectomy patients. Furthermore, adjuvant pharmacotherapy was more effective in patients with higher body mass index. Given the low risk of medications compared with revisional surgery, it can be a reasonable option in the appropriate patients. Further studies are necessary to determine the optimal medication and timing of adjuvant pharmacotherapy after bariatric surgery.
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Fármacos Antiobesidade/uso terapêutico , Cirurgia Bariátrica , Obesidade/tratamento farmacológico , Quimioterapia Adjuvante , Terapia Combinada , Preparações de Ação Retardada , Dieta , Terapia por Exercício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/cirurgia , Cuidados Pós-Operatórios/métodos , Estudos Retrospectivos , Prevenção Secundária , Resultado do Tratamento , Aumento de Peso/efeitos dos fármacos , Redução de Peso/efeitos dos fármacosRESUMO
BACKGROUND: Literature directly looking at post-bariatric surgery hypoglycemia consists mostly of small case series. The rate, severity, and outcomes of treatment in a large bariatric population are less characterized. OBJECTIVE: To determine the rate of post-bariatric surgery hypoglycemia, its clinical features and management outcomes over a 13-year period at our institution. SETTING: An academic center in the United States. METHODS: Patients who underwent bariatric surgery at a single academic center between 2002 and 2015 and had a postdischarge glucose level of ≤70 mg/dL were studied. RESULTS: Of 6024 patients who underwent bariatric procedure, 118 patients (2.0%) had a postoperative glucose level ≤70 mg/dL. Eighty-three patients (1.4%) had symptomatic hypoglycemia. The known underlying causes of symptomatic hypoglycemia included postprandial hyperinsulinemic hypoglycemia (n = 32, 38%), infection (n = 8, 10%), diabetic medications (n = 8, 10%), and poor oral intake (n = 8, 10%). Overall, 9 patients required intervention for nutritional supplementation including enteral (n = 9) and intermittent parenteral (n = 2) nutrition. No patients required reversal of their bariatric surgeries or pancreatic resection for management of hypoglycemia. The majority of the symptomatic patients had resolution of their symptoms (n = 76, 92%). Thirty-two patients had postprandial hypoglycemia with a median onset of hypoglycemia after bariatric surgery of 790 days (interquartile range 388-1334). All 32 patients with postprandial hypoglycemia had dietary adjustment and 53% received pharmacotherapy, which resulted in complete resolution of hypoglycemia (n = 29, 91%) and resolution with minimal disability (n = 3, 9%). CONCLUSION: The rate of symptomatic hypoglycemia and postprandial hypoglycemia after bariatric surgery were 1.4% and .5%. The majority of patients were successfully managed with dietary counseling, nutritional intervention, and occasionally pharmacotherapy. No surgical reversal or pancreatic procedures were performed.
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Cirurgia Bariátrica/efeitos adversos , Hipoglicemia/epidemiologia , Hipoglicemia/etiologia , Obesidade Mórbida/cirurgia , Adulto , Cirurgia Bariátrica/estatística & dados numéricos , Glicemia/análise , Diabetes Mellitus Tipo 2 , Feminino , Humanos , Hipoglicemia/fisiopatologia , Hipoglicemia/terapia , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/epidemiologia , Período Pós-Prandial , Estudos RetrospectivosRESUMO
BACKGROUND: Warfarin dosing after bariatric surgery may be influenced by alterations in gastrointestinal pH, transit time, absorptive surface area, gut microbiota, food intake, and adipose tissue. OBJECTIVES: The aim of this study was to describe trends in warfarin dosing after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). SETTING: Single academic center. METHODS: All patients chronically on warfarin anticoagulation before RYGB or SG were retrospectively identified. Indications for anticoagulation, history of bleeding or thrombotic events, perioperative complications, and warfarin dosing were collected. RESULTS: Fifty-three patients (RYGB n = 31, SG n = 22) on chronic warfarin therapy were identified (56.6% female, mean 54.4 ± 11.7 yr of age). Of this cohort, 34.0% had prior venous thromboembolic events, 43.4% had atrial fibrillation, and 5.7% had mechanical cardiac valves. Preoperatively, the average daily dose of warfarin was similar in the RYGB group (8.3 ± 4.1 mg) and SG group (6.9 ± 2.8 mg). One month after surgery, mean daily dose of warfarin was reduced 24.1% in the RYGB group (P<.001) and 23.2% in the SG group (P = .002). At 12 months postoperatively, the required daily warfarin dose compared with baseline remained statistically different (RYGB: 6.8 ± 3.8 mg; SG: 6.1 ± 2.0 mg). CONCLUSIONS: The warfarin dose is expected to be decreased by approximately 25% from preoperative levels after both RYGB and SG. Lower dose requirement within the first month after bariatric surgery is followed by a trend toward increased warfarin dose requirements, but remain less than baseline. Because dose requirements change constantly over time, frequent postoperative monitoring of the international normalized ratio is recommended.
Assuntos
Anticoagulantes/administração & dosagem , Cirurgia Bariátrica/métodos , Laparoscopia/métodos , Varfarina/administração & dosagem , Fibrilação Atrial/complicações , Esquema de Medicação , Feminino , Gastrectomia/métodos , Derivação Gástrica/métodos , Próteses Valvulares Cardíacas , Hemorragia/complicações , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Tromboembolia Venosa/complicaçõesRESUMO
PURPOSE: This study aims to characterize complications, metabolic improvement, and change in ambulation status for patients with impaired mobility undergoing bariatric surgery. MATERIAL AND METHODS: Individuals undergoing primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from February 2008 to December 2015 were included. Impaired mobility (WC) was defined as using a wheelchair or motorized scooter for at least part of a typical day. The WC group was propensity score matched to ambulatory patients (1:5 ratio). Comparisons were made for 30-day morbidity and mortality and 1-year improvement in weight-related comorbidities. RESULTS: There were 93 patients in the WC group matched to 465 ambulatory controls. The median operative time (180 vs 159 min, p = 0.003) and postoperative length of stay (4 vs 3 days, p ≤ 0.001) was higher in the WC group. There were no differences in readmission or all-cause morbidity within 30 days. The median percent excess weight loss (%EWL) at 1 year was similar (WC group, 65% available, 53% EWL vs AMB group, 73% available, 54% EWL); however, patients with impaired mobility were less likely to experience improvement in diabetes (76 vs 90%, p = 0.046), hypertension (63 vs 82%, p < 0.005), and obstructive sleep apnea (53 vs 71%, p < 0.001). Within the WC group, 62% had improvement in their mobility status, eliminating dependence on wheelchair or scooter assistance. CONCLUSION: Patients with both obesity and impaired mobility experience similar rates of perioperative morbidity and weight loss at 1 year compared to ambulatory controls. However, improvement in weight-related comorbidities may be less likely with impaired mobility.
Assuntos
Gastrectomia/estatística & dados numéricos , Derivação Gástrica/estatística & dados numéricos , Limitação da Mobilidade , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Cirurgia Bariátrica , Comorbidade , Diabetes Mellitus/cirurgia , Feminino , Gastrectomia/efeitos adversos , Derivação Gástrica/efeitos adversos , Humanos , Hipertensão , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Obesidade/cirurgia , Obesidade Mórbida/metabolismo , Ohio/epidemiologia , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Apneia Obstrutiva do Sono/cirurgia , Resultado do Tratamento , Caminhada , Redução de PesoRESUMO
BACKGROUND: With the worldwide epidemic of obesity, an increasing number of bariatric operations and antireflux fundoplications are being performed. Despite low morbidity of the primary foregut surgery, completion gastrectomy may be necessary as a definitive procedure for complications of prior foregut surgery; however, the literature evaluating outcomes after completion gastrectomy with esophagojejunostomy (EJ) for benign diseases is limited. We present our experience of completion gastrectomy with Roux-en-Y EJ in the setting of benign disease at a single tertiary center. METHODS AND PROCEDURES: All patients who underwent total, proximal, or completion gastrectomy with EJ for complications of benign foregut surgery from January 2006 to December 2015 were retrospectively identified. All cancer operations were excluded. RESULTS: There were 23 patients who underwent gastrectomy with EJ (13 laparoscopic EJ [LEJ] and 10 open EJ). The index operations included 12 antireflux, 9 bariatric, and 2 peptic ulcer disease surgeries. Seventy-eight percent of patients had surgical or endoscopic interventions before EJ, with a median of one prior intervention and a median interval from the index operation to EJ of 25 months (interquartile range 9-87). The 30-day perioperative complication rate was 30% with 17% classified being major (Clavien-Dindo ≥ III) and no 30-day perioperative mortality. Comparing laparoscopic and open approaches showed similar operative times, estimated blood loss, and overall complication rate. LEJ was associated with a shorter length of stay (LOS) (P < .001), fewer postoperative ICU days (P = .002), fewer 6-month complication rates (P < .007), and decreased readmission rate (P = .024). CONCLUSION: Our series demonstrates that EJ is a reasonable option for reoperative foregut surgery. The laparoscopic approach appears to be associated with decreased LOS and readmissions.
Assuntos
Anastomose em-Y de Roux/métodos , Cirurgia Bariátrica/efeitos adversos , Fundoplicatura/efeitos adversos , Gastrectomia/métodos , Complicações Pós-Operatórias/cirurgia , Adulto , Idoso , Anastomose em-Y de Roux/efeitos adversos , Esôfago/cirurgia , Feminino , Gastrectomia/efeitos adversos , Humanos , Jejuno/cirurgia , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Estômago/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) increases the risk of liver cirrhosis and hepatocellular carcinoma and is also strongly correlated with extrahepatic diseases, including cardiovascular disease and type 2 diabetes. This risk of NAFLD among obese individuals who are otherwise metabolically healthy is not well characterized. OBJECTIVES: To determine the prevalence and characteristics of NAFLD in individuals with metabolically healthy obesity. SETTING: A tertiary, academic, referral hospital. METHODS: All patients who underwent bariatric surgery with intraoperative liver biopsy from 2008 to 2015 were identified. Patients with preoperative hypertension, dyslipidemia, or prediabetes/diabetes were excluded to identify a cohort of metabolically healthy obesity patients. Liver biopsy reports were reviewed to determine the prevalence of NAFLD. RESULTS: A total of 270 patients (7.0% of the total bariatric surgery patients) met the strict inclusion criteria for metabolically healthy obesity. The average age was 38 ± 10 years and the average body mass index was 47 ± 7 kg/m2. Abnormal alanine aminotransferase (>45 U/L) and asparate aminotransferase levels (>40 U/L) were observed in 28 (10.4%) and 18 (6.7%) patients, respectively. A total of 96 (35.5%) patients had NAFLD with NALFD Activity Scores 0 to 2 (n = 61), 3 to 4 (n = 25), and 5 to 8 (n = 10). A total of 62 (23%) patients had lobular inflammation, 23 (8.5%) had hepatocyte ballooning, 22 (8.2%) had steatohepatitis, and 12 (4.4%) had liver fibrosis. CONCLUSION: Even with the use of strict criteria to eliminate all patients with any metabolic problems, a significant proportion of metabolically healthy patients had unsuspected NAFLD. The need and clinical utility of routine screening of obese patients for fatty liver disease and the role of bariatric surgery in the management of NAFLD warrants further investigation.
Assuntos
Cirurgia Bariátrica , Obesidade Metabolicamente Benigna/cirurgia , Adulto , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/cirurgia , Feminino , Humanos , Achados Incidentais , Resistência à Insulina/fisiologia , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico por imagem , Cirrose Hepática/cirurgia , Masculino , Hepatopatia Gordurosa não Alcoólica/complicações , Hepatopatia Gordurosa não Alcoólica/diagnóstico , Hepatopatia Gordurosa não Alcoólica/cirurgia , Obesidade Metabolicamente Benigna/complicações , Estudos RetrospectivosRESUMO
BACKGROUND: Bariatric surgery has been shown to be safe and effective in patients aged 60-75 years; however, outcomes in patients aged 75 or older are undocumented. METHODS: Patients aged 75 years and older who underwent bariatric procedures in two academic centers between 2006 and 2015 were studied. RESULTS: A total of 19 patients aged 75 years and above were identified. Eleven (58%) were male, the median age was 76 years old (range 75-81), and the median preoperative body mass index (BMI) was 41.4 kg/m2 (range 35.8-57.5). All of the bariatric procedures were primary procedures and performed laparoscopically: sleeve gastrectomy (SG) (n = 11, 58%), adjustable gastric band (AGB) (n = 4, 21%), Roux-en-Y gastric bypass (RYGB) (n = 2, 11%), banded gastric plication (n = 1, 5%), and gastric plication (n = 1, 5%). The median operative time was 120 min (range 75-240), and the median length of stay was 2 days (range 1-7). Three patients (16%) developed postoperative atrial fibrillation which completely resolved at discharge. At 1 year, the median percentage of total weight loss (%TWL) was 18.4% (range 7.4-22.0). The 1-year %TWL varied among the bariatric procedures performed: SG (21%), RYGB (22%), AGB (7%), and gastric plication (8%). There were no 30-day readmissions, reoperations, or mortalities. CONCLUSION: Our experience suggests that bariatric surgery in selected patients aged 75 years and older would be safe and effective despite being higher risk. Age alone should not be the limiting factor for selecting patients for bariatric surgery.
Assuntos
Cirurgia Bariátrica , Obesidade Mórbida/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Cirurgia Bariátrica/mortalidade , Cirurgia Bariátrica/estatística & dados numéricos , Índice de Massa Corporal , Feminino , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Laparoscopia/mortalidade , Laparoscopia/estatística & dados numéricos , Masculino , Mortalidade , Obesidade Mórbida/epidemiologia , Obesidade Mórbida/mortalidade , Duração da Cirurgia , Readmissão do Paciente/estatística & dados numéricos , Seleção de Pacientes , Período Pós-Operatório , Reoperação/mortalidade , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Redução de Peso/fisiologiaRESUMO
The term metabolic surgery describes bariatric surgical procedures used primarily to treat type 2 diabetes and related metabolic conditions. Originally, bariatric surgery was used as an alternative weight-loss therapy for patients with severe obesity, but clinical data revealed its metabolic benefits in patients with type 2 diabetes. Metabolic surgery is more effective than lifestyle or medical management in achieving glycemic control, sustained weight loss, and reducing diabetes comorbidities. Perioperative adverse events are similar to other gastrointestinal surgeries. New guidelines for type 2 diabetes expand use of metabolic surgery to patients with a lower body mass index.