European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea.

Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear-nose-throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.

The effect of postoperative CPAP use on anastomotic and staple line leakage after bariatric surgery.

PURPOSE: Almost two-thirds of the population undergoing bariatric surgery (BS) suffers from obstructive sleep apnea (OSA). Continuous positive airway pressure (CPAP) is the standard treatment for moderate to severe OSA and is recommended in patients undergoing BS perioperatively. A severe and dreaded complication after BS is anastomotic leakage. There is theoretical concern that perioperative CPAP use may result in increased distension of the gastrointestinal tract and increase the risk of developing an anastomotic leakage. The aim of this study was to evaluate the effect of postoperative CPAP use on the risk of developing anastomotic leakages after BS. METHODS: Retrospectively, all patients from a single bariatric center who underwent BS from November 2007 to August 2019 were included. Presence and severity of OSA were determined using poly(somno)graphy. To evaluate the effect of postoperative CPAP use on anastomotic leakage, a multivariable logistic regression analysis was performed. RESULTS: A total of 4052 patients were included, with OSA being diagnosed in 62%. Overall, 970 patients (24%) used CPAP after BS. Anastomotic leakage occurred in 64 (1.6%) patients after BS. Leakage rate was 1.3% in non-CPAP group versus 2.5% in CPAP group (p = 0.01). CPAP use was associated with anastomotic leakage; however, after adjustment, CPAP use was not an independent predictor (OR = 1.40, 95% CI 0.60-3.28, p = 0.44). CONCLUSION: There is no independent relation between postoperative CPAP use and anastomotic leakage after BS. Only revision surgery was an independent predictor of anastomotic leakage.

Protocol of a multicentre, prospective cohort study that evaluates cost-effectiveness of two perioperative care strategies for potential obstructive sleep apnoea in morbidly obese patients undergoing bariatric surgery.

INTRODUCTION: Despite the high prevalence of obstructive sleep apnoea (OSA) in obese patients undergoing bariatric surgery, OSA is undiagnosed in the majority of patients and thus untreated. While untreated OSA is associated with an increased risk of preoperative and postoperative complications, no evidence-based guidelines on perioperative care for these patients are available. The aim of the POPCORN study (Post-Operative Pulse oximetry without OSA sCreening vs perioperative continuous positive airway pressure (CPAP) treatment following OSA scReeNing by polygraphy (PG)) is to evaluate which perioperative strategy is the most cost-effective for obese patients undergoing bariatric surgery without a history of OSA. METHODS AND ANALYSIS: In this multicentre observational cohort study, data from 1380 patients who will undergo bariatric surgery will be collected. Patients will receive either postoperative care with pulse oximetry monitoring and supplemental oxygen during the first postoperative night, or care that includes preoperative PG and CPAP treatment in case of moderate or severe OSA. Local protocols for perioperative care in each participating hospital will determine into which cohort a patient is placed. The primary outcome is cost-effectiveness, which will be calculated by comparing all healthcare costs with the quality-adjusted life-years (QALYs, calculated using EQ-5D questionnaires). Secondary outcomes are mortality, complications within 30 days after surgery, readmissions, reoperations, length of stay, weight loss, generic quality of life (QOL), OSA-specific QOL, OSA symptoms and CPAP adherence. Patients will receive questionnaires before surgery and 1, 3, 6 and 12 months after surgery to report QALYs and other patient-reported outcomes. ETHICS AND DISSEMINATION: Approval from the Medical Research Ethics Committees United was granted in accordance with the Dutch law for Medical Research Involving Human Subjects Act (WMO) (reference number W17.050). Results will be submitted for publication in peer-reviewed journals and presented at (inter)national conferences. TRIAL REGISTRATION NUMBER: NTR6991.

Perioperative Care of Patients With Obstructive Sleep Apnea Undergoing Upper Airway Surgery: A Review and Consensus Recommendations.

IMPORTANCE: To date, no consensus exists regarding optimal perioperative care of patients with obstructive sleep apnea (OSA) undergoing upper airway (UA) surgery. These patients are at risk related to anesthesia and postoperative analgesia, among other risks associated with difficult airway control, and may require intensified perioperative management. OBJECTIVE: To provide a consensus-based guideline by reviewing available literature and collecting expert opinion during an international consensus meeting with experts from relevant speciliaties. EVIDENCE REVIEW: In a consensus meeting conducted on April 4, 2018, a total of 47 questions covering preoperative, intraoperative, and postoperative care were formulated by 12 international experts with extensive clinical experience in the field of UA surgery for OSA. Systematic literature searches were performed by an independent information specialist and 6 researchers according to the Oxford and GRADE systems, and 164 articles published on or before December 31, 2011, were included in the analysis. Two moderators chaired the meeting according to the Amsterdam Delphi Method, including iteration of literature conclusions, expert discussion, and voting rounds. Consensus was reached when there was 70% or more agreement among experts. FINDINGS: Of 47 questions, 35 led to a recommendation or statement. The remaining 12 questions provided no additional information and were excluded in the judgment of experts. Consensus was reached for 32 recommendations. For 1 question there was less than 70% agreement among experts; therefore, consensus was not achieved. Highlights of these recommendations include (1) postoperative bleeding is a complication described for all types of UA surgery; (2) OSA is a relative risk factor for difficult mask ventilation and intubation, and plans for difficult airway management should be considered and implemented; (3) safe perioperative care should be provided, with aspects such as OSA severity, adherent use of positive airway pressure, type of surgery, and comorbidities taken into account; (4) although there is no direct evidence to date, in patients undergoing UA surgery, preoperative treatment with positive airway pressure may reduce the risk of postoperative airway complications; and (5) alternative pain management options perioperatively to reduce opioid use should be considered. CONCLUSIONS AND RELEVANCE: This consensus contains 35 recommendations and statements on the perioperative care of patients with OSA undergoing UA surgery and may be used as a guideline in daily practice.

Diagnostic value of computed tomography for detecting anastomotic or staple line leakage after bariatric surgery.

BACKGROUND: Postbariatric anastomotic or staple line leakage (ASLL) is a dreaded complication with an incidence up to 1.6% and a leak-associated mortality of 5.0% to 16.7%. Feared low sensitivity of abdominal computed tomography (CT) for detecting ASLL is causing surgeons to omit CT and directly perform a diagnostic laparoscopy in patients with suspected ASLL. OBJECTIVES: To evaluate the diagnostic value of CT in case of suspected ASLL after bariatric procedures and to identify reliable CT characteristics predicting the presence of ASLL. SETTING: A large teaching hospital and bariatric center of excellence. METHODS: All CT scans performed for suspected ASLL after bariatric surgery in the period November 2007 until August 2016 were independently reevaluated by abdominal radiologists. The diagnostic value of CT by means of sensitivity, specificity, and positive and negative predictive value was analyzed comparing results of reevaluation to a standard of reference. Multivariable regression was performed to identify reliable CT characteristics for the presence of ASLL. RESULTS: A total of 66 CT scans were performed because of suspected leakage. Reevaluation of CT scans revealed a sensitivity of 89% to 100%, a specificity of 69% to 78%, a positive predictive value of 39% to 50%, and a negative predictive value of 97% to 100% of CT for detecting ASLL after bariatric surgery. Multivariable logistic regression of ASLL characteristics on CT revealed 'air near the anastomosis/staple line' as the only independent predictor for the presence of ASLL. CONCLUSION: With a sensitivity of 89% to 100% and negative predictive value of 97% to 100%, a negative CT can rule out ASLL in patients with a lower suspicion of ASLL.

Patients' preferences for information in bariatric surgery.

BACKGROUND: The decision to undergo bariatric surgery is multifactorial and made both by patient and doctor. Information is of the utmost importance for this decision. OBJECTIVE: To investigate the bariatric surgery patient's preferences regarding information provision in bariatric surgery. SETTING: A teaching hospital, bariatric center of excellence in Amsterdam, the Netherlands. METHODS: All patients who underwent a primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between September 2013 and September 2014 were approached by mail to participate. A questionnaire was used to elicit patient preferences for the content and format of information. Sociodemographic characteristics, clinicopathologic factors, and psychologic factors were explored as predictors for specific preferences. RESULTS: Of the 356 eligible patients, 112 (31.5%) participated. The mean age was 49.2 (±10.7) years, and 91 (81.3%) patients were female. Patients deemed the opportunity to ask questions (96.4%) the most important feature of the consult, followed by a realistic view on expectations-for example, results of the procedure (95.5%) and information concerning the consequences of surgery for daily life (89.1%). Information about the risk of complications on the order of 10% was desired by 93% of patients; 48% desired information about lower risks (.1%). Only 25 patients (22.3%) desired detailed information concerning their weight loss after surgery. CONCLUSION: Bariatric patients wished for information about the consequences of surgery on daily life, whereas the importance of information concerning complications decreased when their incidence lessened.

Influence of continuous positive airway pressure on postoperative leakage in bariatric surgery.

BACKGROUND: Obstructive sleep apnea (OSA) affects two third of morbidly obese individuals undergoing bariatric surgery. Perioperative usage of continuous positive airway pressure (CPAP) is advised for moderately and severe OSA to avoid respiratory failure and cardiac events. CPAP increases the air pressure in the upper airway, but also may elevate the air pressure in the esophagus and stomach. Concern exists that this predisposes to mechanical stress resulting in suture or staple line disruption (further referred to as suture line disruption). OBJECTIVES: To evaluate whether perioperative CPAP usage is associated with an increased risk of suture line disruption after bariatric surgery. SETTING: Obesity Center Amsterdam, OLVG-west, Amsterdam, the Netherlands. METHODS: All patients who underwent bariatric surgery including a suture line were eligible for inclusion. Only patients with information regarding OSA severity as defined by the apnea-hypopnea-index and postoperative CPAP usage were included. RESULTS: From November 2007 to August 2016, postoperative CPAP status was documented in 2135 patients: 497 (23.3%) used CPAP postoperatively, whereas 1638 (76.7%) used no CPAP. Mean body mass index was 44.1 kg/m2 (standard deviation 6.6). Suture line disruption occurred in 25 patients (1.2%). The leakage rate was not associated with CPAP usage (8 [1.6%] in CPAP group versus 17 [1%] in non-CPAP group, P = .300). CPAP was no risk factor for suture line disruption in multivariable analysis as well. CONCLUSION: Postoperative CPAP does not appear to increase the risk of suture line disruption in bariatric surgery. CPAP is recommended in all patients with moderate or severe OSA who undergo bariatric surgery.

Obstructive sleep apnea and bariatric surgical guidelines: summary and update.

PURPOSE OF REVIEW: Increasing numbers of bariatric surgical procedures and the high prevalence of obstructive sleep apnea (OSA) in this population have resulted in a growing interest in the perioperative management of OSA in bariatric surgery. This review provides a summary of the first consensus guideline on this topic as well as an update of the newest literature available. RECENT FINDINGS: All bariatric patients should be screened for OSA and obesity hypoventilation syndrome (OHS) to reduce the risk of perioperative complications. Intraoperative precautions are preoxygenation, induction and intubation in ramped position, continuous positive airway pressure (CPAP) and positive end-expiratory pressure during induction, maintenance of low tidal volumes during surgery, multimodal anesthesia and analgesia with avoidance of opioids and extubation when patients are free of neuromuscular blockage. CPAP therapy and continuous monitoring with a minimum of pulse oximetry is recommended in the early postoperative period. SUMMARY: Multiple precautions exist to minimize the risk of cardiopulmonary complications and to enhance recovery after surgery. A combination of these procedures seems to provide optimal perioperative care of OSA patients undergoing bariatric surgery. Nearly 75% of recommendations are based on low quality of evidence, indicating the high value of experts' opinion and potential for future research.

Unexplained abdominal pain in morbidly obese patients after bariatric surgery.

BACKGROUND: There is an overall complication rate of 6.3%-10% after bariatric surgery. After ruling out anatomic/physical causes, there is a substantial group of patients who develop unexplained postsurgical abdominal pain. OBJECTIVES: To inventory the prevalence of unexplained abdominal pain after laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy and to determine predictive factors for unexplained abdominal pain. SETTING: Obesity Center Amsterdam, Amsterdam, the Netherlands. METHODS: A retrospective study in a prospective database was performed. Baseline characteristics and postoperative course were evaluated. RESULTS: A total of 1788 patients underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between November 2007 and April 2015. The average follow-up consisted of 33.5 months, without loss to follow-up. Abdominal pain was presented in 387 patients (21.6%). The study population consisted of 337 women (87.1%) and 50 men (12.9%); the mean age was 43.3 years (standard deviation 10.1) and the median preoperative body mass index was 43.7 kg/m². An explanation for abdominal pain was found in 246 of 387 patients (63.6%), whereas no explanation was found in 133 patients (34.4%). Revisional surgery was a significant predictor for unexplained pain (odds ratio 1.7; confidence interval 1.0-2.8; P = 0.037). CONCLUSION: A total of 133 patients (7.4%) experienced unexplained abdominal pain after laparoscopic bariatric surgery. Revisional surgery was found to be a significant predictive factor for this outcome. Present study results suggest that postoperative unexplained abdominal pain is a significant morbidity and should be part of the informed consent. More research is needed regarding further diagnosis and management and treatment.

Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline.

BACKGROUND: The frequency of metabolic and bariatric surgery (MBS) is increasing worldwide, with over 500,000 cases performed every year. Obstructive sleep apnea (OSA) is present in 35%-94% of MBS patients. Nevertheless, consensus regarding the perioperative management of OSA in MBS patients is not established. OBJECTIVES: To provide consensus based guidelines utilizing current literature and, when in the absence of supporting clinical data, expert opinion by organizing a consensus meeting of experts from relevant specialties. SETTING: The meeting was held in Amsterdam, the Netherlands. METHODS: A panel of 15 international experts identified 75 questions covering preoperative screening, treatment, postoperative monitoring, anesthetic care and follow-up. Six researchers reviewed the literature systematically. During this meeting, the "Amsterdam Delphi Method" was utilized including controlled acquisition of feedback, aggregation of responses and iteration. RESULTS: Recommendations or statements were provided for 58 questions. In the judgment of the experts, 17 questions provided no additional useful information and it was agreed to exclude them. With the exception of 3 recommendations (64%, 66%, and 66% respectively), consensus (>70%) was reached for 55 statements and recommendations. Several highlights: polysomnography is the gold standard for diagnosing OSA; continuous positive airway pressure is recommended for all patients with moderate and severe OSA; OSA patients should be continuously monitored with pulse oximetry in the early postoperative period; perioperative usage of sedatives and opioids should be minimized. CONCLUSION: This first international expert meeting provided 58 statements and recommendations for a clinical consensus guideline regarding the perioperative management of OSA patients undergoing MBS.

Predicting postoperative complications after bariatric surgery: the Bariatric Surgery Index for Complications, BASIC.

BACKGROUND: Around 20% of bariatric surgery patients develop a short- or long-term complication. OBJECTIVE: Aim of this study was to develop a risk model predicting complications: the Bariatric Surgery Index for Complications (BASIC). SETTING: The Obesity Center Amsterdam, located in a large teaching hospital, in Amsterdam, The Netherlands. METHODS: A prospective consecutive database including patients operated between November 2007 and February 2015 was used. For the BASIC, analysis according to the TRIPOD statement was performed to identify risk factors for complications. Class I included patients with zero to one risk factor, class II patients with two risk factors, and class III patients with three or more risk factors. RESULTS: Of 1709 analyzed patients, mean age was 45 years (±SD 10.7), 1393 (81.5%) were female; mean body mass index was 44.5 kg/m2 (6.8). Overall, 271 (15.9%) patients developed a complication of which 197 (72.5%) occurred within 30 days. Predictors in multivariable analysis were use of anticoagulants (odd's ratio (OR) 1.5); chronic obstructive pulmonary disease (OR 2.3); dyslipidemia (OR 1.4); gender (OR 1.4); psychiatric history (OR 1.3); and revisional surgery (OR 1.5). In class I, 13.5% (181 out of 1338) experienced complications, in class II 58 (21.6%) of the 269 patients and in class III 32 (31.4%) of the 102 patients, respectively. There was a significant difference (p < 0.001) in both overall and 30 day complications. CONCLUSION: The BASIC uses six preoperative variables to classify patients in a low-, intermediate-, or high-risk group for postoperative complications after bariatric surgery.

Are routine preoperative liver function tests in patients with uncomplicated symptomatic gallstone disease necessary?

BACKGROUND: The aim of this study was to evaluate the value of preoperative liver function tests (LFTs) in patients with uncomplicated gallstone disease and scheduled for laparoscopic cholecystectomy. METHODS: All 1112 patients who underwent a laparoscopic cholecystectomy for symptomatic gallstone disease during a 6-year cohort were retrospectively reviewed. Only patients who presented with uncomplicated disease were selected. Preoperative LFTs, pre-, and postoperative endoscopic retrograde cholangio pancreaticographies (ERCPs) and postoperative complications were collected. RESULTS: A total of 697 patients were included. There were 629 (90.2%) patients with (group I) and 68 (9.8%) patients without (group II) preoperative LFTs. The incidence of ERCPs, ERCPs positive for bile duct stones, and postoperative complications were not significantly different between groups. Second, Group I patients were divided into four groups: 360 patients with normal LFTs (I-A1), 269 patients with at least one LFT > normal value (I-A2), 531 patients with all LFTs <2× normal (I-B1), and 98 patients with at least one LFT >2× normal (I-B2). More ERCPs were performed in group I-A2 (10%) than in group I-A1 (2.2%) and more in group I-B2 (18.4%) than I-B1 (3.2%), as a consequence of significantly more ERCPs performed preoperatively. No differences were detected between groups regarding ERCPs positive for bile duct stones or postoperative complications. CONCLUSIONS: Preoperative LFTs do not influence the occurrence of postoperative complications nor the total rate of ERCPs in patients undergoing cholecystectomy for uncomplicated gallstone disease. Preoperative determination of LFTs seems to cause a slight shift from post- to preoperative ERCPs without further clinical consequences.

Value of routine polysomnography in bariatric surgery.

BACKGROUND: Obstructive sleep apnea (OSA), present in 60-70 % of bariatric surgery patients, is a potentially life-threatening condition when not detected and managed appropriately. The best available method to identify the severity of OSA is polysomnography. However, routine polysomnography measurements have not been accepted as standard modality in bariatric surgery. We report our experience with routine polysomnography in a cohort of patients undergoing bariatric surgery to determine the true prevalence of OSA with respect to the different severity levels as determined by the apnea-hypopnea index (AHI). METHODS: AHI data were retrospectively collected from all patients who underwent bariatric surgery from 2012 onward, when the performance of preoperative polysomnography became mandatory. Mild, moderate and severe OSA were defined as an AHI ≥5, ≥15 and ≥30/h, respectively. Prevalence and number needed to screen (NNS) were calculated for all OSA severity levels. RESULTS: A total of 1358 patients were included. OSA was detected in 813 (59.9 %; NNS: 2) patients. Moreover, 405 (29.8 %; NNS: 4) patients were diagnosed with an AHI ≥15/h and 213 (15.7 %; NNS: 7) with severe OSA (AHI ≥30/h). Extreme AHI thresholds of ≥60 and ≥90/h were detected in 79 (5.8 %; NNS: 18) and 17 (1.3 %; NNS: 77) patients, respectively. CONCLUSION: One-third of the bariatric surgery patients have an AHI ≥15/h and would benefit from continuous positive airway pressure therapy. In order to increase perioperative safety and avoid the preventable risk of perioperative complications, we recommend mandatory P(S)G prior to bariatric surgery.

Complications of banded laparoscopic Roux-en-Y gastric bypass in a 33-week pregnant woman.

Women desiring pregnancy might fail to conceive due to their obesity. Bariatric surgery has shown to reduce this infertility up to 58% and is therefore considered a successful strategy for morbidly obese infertile women. Nevertheless, when pregnancy has succeeded, surgery-related complications might occur.Banded laparoscopic Roux-en-Y gastric bypass (B-LRYGB) is a relatively new technique in which a band is placed around the small gastric pouch. We report a case of a 30-year-old woman who succeeded to become pregnant after weight loss due to B-LRYGB, but presented with acute abdominal pain in Week 33 of her pregnancy.

Evaluation of the obesity surgery mortality risk score for the prediction of postoperative complications after primary and revisional laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The Obesity Surgery Mortality Risk Score (OS-MRS) is a validated instrument for mortality risk prediction in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures classifying patients into low risk (class A), intermediate risk (class B), and high risk (class C). OBJECTIVES: The primary aim of this study was to evaluate the accuracy of the OS-MRS in predicting postoperative complications after LRYGB. Secondarily, the postoperative complication rate between primary and revisional LRYGB was systematically analyzed. SETTING: The Obesity Center Amsterdam, located in a large teaching hospital, in Amsterdam, The Netherlands. METHODS: The OS-MRS was applied to a consecutive database of patients who underwent LRYGB from November 2007 onwards. Postoperative complications were scored according to the Clavien-Dindo classification. Revisional LRYGB was separately analyzed. RESULTS: LRYGB was performed in 1667 patients either as a primary (81.5%) or revisional (18.5%) procedure. The majority (n = 1371, 82.2%) were female, mean age 44.6 (standard deviation 14.4) years and mean body mass index 44.2 (6.5) kg/m2. Nine hundred and four (54.2%) were OS-MRS class A, 642 class B (38.5%), and 121 (7.3%) class C. Complications occurred in 143 (10.5%) and 44 (14.2%) patients after primary and revisional surgery, respectively. In both primary and revisional LRYGB, there was no association between complications and the OS-MRS classification. Subanalysis comparing primary with revisional LRYGB found a significant association between revisional surgery and the development of severe complications (Clavien-Dindo≥3) (P = .003) and mortality (P = .017). CONCLUSION: The OS-MRS was not an accurate predictor for postoperative complications in patients who underwent primary or revisional LRYGB. As in other studies, revisional surgery is an independent risk factor for the development of severe complications.

Persistent moderate or severe obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass: which patients?

BACKGROUND: Patients with severe obesity and obstructive sleep apnea (OSA) might decide to undergo bariatric surgery to improve this disease or, more specifically, to become independent of continuous positive airway pressure (CPAP) therapy, which is generally indicated in case of moderate and severe OSA. Knowledge of this topic is important for patient education on expectations of surgical outcome. OBJECTIVES: To evaluate the prevalence and phenotypes of patients with persistent moderate to severe OSA after bariatric surgery. SETTING: Obesity Center Amsterdam, Amsterdam, the Netherlands. METHODS: Patients who underwent a laparoscopic Roux-en-Y gastric bypass, had a preoperative apnea-hypopnea index (AHI)≥15/hr, and of whom a follow-up AHI/hr was available were included. RESULTS: Out of 437 patients, 205 underwent pre- and postoperative polysomnography; 232 (53.1%) were lost to follow-up. Median AHI was 32.3/hr (range, 15-138) and mean body mass index was 46 (standard deviation 7.2) kg/m2. A postoperative AHI<15/hr was achieved in 152 patients (74.1%), whereas 53 (25.9%) still had moderate or severe disease 8.6 (standard deviation 4.8) months postoperatively. Predictive factors for persistent moderate to severe disease were age≥50 years, preoperative AHI≥30/hr, excess weight loss (EWL)<60%, and hypertension (area under the curve: .772). CONCLUSION: After bariatric surgery, around three quarters of the moderate to severe OSA patients had no or mild OSA, whereas one quarter (25.9%) still had moderate to severe OSA. Age≥50 years, preoperative AHI≥30/hr, EWL<60%, and hypertension were predictive factors for this persistent postoperative AHI≥15/hr.

Is fear for postoperative cardiopulmonary complications after bariatric surgery in patients with obstructive sleep apnea justified? A systematic review.

BACKGROUND: To evaluate the influence of obstructive sleep apnea (OSA) on postoperative cardiopulmonary complications in bariatric surgery patients. METHODS: PubMed, Embase, and the Cochrane central register databases were searched. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used for reviewing. RESULTS: Thirteen studies were included (n = 98,935). OSA was documented in 36,368 (37%) patients. The cardiopulmonary complication rate varied between .0% and 25.8%; no clear association with OSA was found (rate .0% to 18%), possibly because of optimized situations such as continuous positive airway pressure. OSA appeared to be no independent risk factor for intensive care unit (ICU) admission, death, or longer length of stay in most studies. CONCLUSIONS: Overall, presented data showed no clear association of OSA with cardiopulmonary morbidity, ICU admissions, mortality, and length of stay after bariatric surgery. Although this questions the justification of admitting OSA patients to the ICU, future studies are required investigating the effect of monitoring strategies and optimizing treatments including continuous positive airway pressure use.

Trocar Port Hernias After Bariatric Surgery.

BACKGROUND: Laparoscopic bariatric surgery is increasingly being performed worldwide. It is estimated that trocar port hernias occur more often in obese patients due to their obesity and because the ports are not closed routinely. The aim of the present study was to analyze the incidence, risk factors, and management of patients with trocar port hernias after laparoscopic bariatric surgery. METHODS: All patients who were operated between 2006 and 2013 were included. During the study period, the trocar ports were not closed routinely. All patients who had any symptomatic abdominal wall hernia during follow-up were included. RESULTS: Overall, 1524 laparoscopic bariatric procedures were performed. There were 1249 female (82 %) and 275 male (18 %) patients. The mean age was 44 years, and median body mass index was 43 kg/m(2). Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 859), laparoscopic adjustable gastric banding (LAGB) (n = 364), laparoscopic sleeve gastrectomy (LSG) (n = 68), revisional surgery (n = 226), and other procedures (n = 7). Three hundred and one patients (20 %) had one or more postoperative complications and the overall mortality was 0.3 % (four patients). There were 14 patients (0.9 %) with an abdominal wall hernia, of which eight (0.5 %) had a trocar port hernia, three (0.2 %) an incisional hernia from other previous surgery, and three (0.2 %) an umbilical hernia. Gender, age, BMI, smoking, type II diabetes, procedure type, complications, and weight loss were not associated with the occurrence of abdominal wall hernias. CONCLUSIONS: Trocar port hernias after bariatric surgery occur seldom if the trocar port is not routinely closed.

Predictive Factors for Insufficient Weight Loss After Bariatric Surgery: Does Obstructive Sleep Apnea Influence Weight Loss?

BACKGROUND: Important endpoints of bariatric surgery are weight loss and improvement of comorbidities, of which obstructive sleep apnea (OSA) is the highest accompanying comorbidity (70%). This study aimed to evaluate the influence of OSA on weight loss after bariatric surgery and to provide predictive factors for insufficient weight loss (defined as ≤50% excess weight loss (EWL)) at 1 year follow-up. METHODS: All consecutive patients, who underwent primary laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between 2006 and 2014 were retrospectively reviewed. Patients with data on preoperative apnea-hypopnea index (AHI) and pre- and postoperative body mass index (BMI) were included. After surgery, the percentage excess weight loss (%EWL) and BMI changes were compared between preoperatively diagnosed OSA-, subdivided in mild, moderate, and severe OSA, and non-OSA patients. Multivariable logistic regression analysis evaluated predictive factors for ≤50% EWL. RESULTS: A total of 816 patients, 522 (64%) with and 294 (36%) without OSA, were included. After 1 year, OSA patients achieved less %EWL than non-OSA patients (65.5 SD 20.7 versus 70.3 SD 21.0; p < 0.01). The lowest %EWL was seen in severe OSA patients (61.7 SD 20.2). However, when adjusted for waist circumference, BMI, and age, no effect of OSA was seen on %EWL or changes in BMI. Although AHI, gender, age, BMI, type of surgery, and type II diabetes were predictive factors for ≤50% EWL (area under the curve 0.778), the AHI as variable was of little importance. CONCLUSIONS: The presence of OSA does not individually impair weight loss after bariatric surgery.

Positional obstructive sleep apnea in bariatric surgery patients: risk factor for postoperative cardiopulmonary complications?

BACKGROUND: Up to 80 % of the bariatric surgery (BS) patients suffer from obstructive sleep apnea (OSA). BS patients with moderate to severe OSA (apnea-hypopnea index (AHI) ≥15) are usually treated with continuous positive airway pressure (CPAP). This is not indicated in mild OSA patients (AHI <15). However, >50 % of patients with mild OSA have positional OSA (POSA); their AHI is at least twice as high in supine sleeping position than in other positions. Since many patients sleep in supine position for surgical safety reasons after BS, evaluating the AHI in this position might be more relevant in this group. The aim of this study is to evaluate the postoperative cardiopulmonary complication rate in mild OSA patients with and without POSA. Secondary aim is to evaluate predictive factors for POSA. METHODS: A single-institute retrospective analysis was achieved with all consecutive patients who underwent primary laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between 2006 and 2014. All patients with an AHI between 5 and 15 were included. Postoperative complications were compared between POSA and non-POSA patients. Predictive factors were evaluated through univariate and multivariable logistic regression analysis. RESULTS: A total of 277 patients, 153 with and 124 without POSA, were included. After BS, three patients (1.1 %) experienced severe cardiopulmonary complications. No significant difference was found between POSA and non-POSA patients. In multivariate analysis, age and BMI were found to be negative predictors for POSA. CONCLUSION: In terms of 30-day postoperative cardiopulmonary outcome, CPAP therapy is not indicated in mild (P)OSA patients scheduled for BS.