Changes in renal blood flow after surgically induced weight loss: can bariatric surgery halt the progression of chronic kidney disease?

BACKGROUND: We previously demonstrated how kidney injury in patients with morbid obesity can be reversed by bariatric surgery (BaS). OBJECTIVE(S): Based on previous experience, we hypothesize patients' potentially reversible kidney injury might be secondary to reduction in renal blood flow (RBF), which improves following BaS. SETTING: Academic Hospital. METHODS: We conducted a retrospective analysis of patients who underwent BaS at our institution from 2002 to 2019. We identified patients with chronic kidney disease (CKD) using the estimated glomerular filtration rate (eGFR) from the CKD Epidemiology Collaboration Study (CKD-EPI) classification system. We used the BUN/Creatinine (Cr) ratio pre- and postoperatively to determine a prerenal (decreased RBF) versus intrinsic component as the responsible cause of CKD in this patient population. Decreased RBF was defined as BUN/Cr > 20 preoperatively. RESULTS: Our analysis included n = 2924 patients, of which 11% (n = 325) presented decreased RBF. From our original sample, only n = 228 patients had the complete data necessary to assess both eGFR and RBF (BUN/Cr). Patients with baseline CKD stage 2 demonstrated preoperative BUN/Cr 20.85 ± 10.23 decreasing to 14.99 ± 9.10 at 12-month follow-up (P < .01). Patients with baseline CKD stage 3 presented with preoperative BUN/Cr 23.88 ± 8.75; after 12-month follow-up, BUN/Cr ratio decreased to 16.38 ± 9.27 (P < .01). Patients with CKD stage 4 and ESRD (eGFR < 30) did not demonstrate a difference for pre- and postoperative BUN/Cr 21.71 ± 9.28 and 19.21 ± 14.58, respectively. CONCLUSION(S): According to our findings, patients with CKD stages 1-3 present improvement of their kidney function after BaS. This amelioration could be secondary to improvement of the RBF, an unstudied reversible mechanism of kidney injury in the bariatric population.

Predictors and outcomes of acute kidney injury after bariatric surgery: analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.

BACKGROUND: Acute kidney injury (AKI) after surgery increases long-term risk of kidney dysfunction. The major risk factor for AKI after bariatric surgery is having preoperative renal insufficiency. Little is known about the outcomes and risk factors for developing AKI in patients undergoing bariatric surgery with normal renal function. OBJECTIVE: We aimed to describe factors that may increase risk of AKI after primary bariatric surgery in patients without history of kidney disease. SETTING: Academic hospital, United States. METHODS: We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry for patients aged ≥18 years undergoing laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2015 to 2019. Patients with diagnosis of chronic kidney disease were excluded. The primary outcome was incidence of AKI. Secondary outcomes included 30-day complications, readmissions, reoperations, and mortality. Univariate and multivariate analyses were performed to identify differences between patients with and without AKI. RESULTS: A total of 747,926 patients were included in our analysis (laparoscopic sleeve gastrectomy = 73.1%, LRYGB = 26.8%). Mean age was 44.40 ± 11.94 years, with female predominance (79.7%). AKI occurred in 446 patients (.05%). Patients with postoperative AKI had higher rates of complications, readmissions, reoperations, and mortality. Significant predictors of AKI were male sex, history of venous thromboembolism, hypertension, limitation for ambulation, and LRYGB. High albumin levels and White race were protective factors. CONCLUSIONS: New-onset AKI was associated with adverse 30-day outcomes in patients undergoing bariatric surgery. Male sex, venous thromboembolism, hypertension, limited ambulation, and LRYGB were independent predictors of AKI. Prospective studies are needed to better describe these results.

The impact of bariatric surgery on hospitalization due to peripheral artery disease and critical limb ischemia: a nationwide analysis.

BACKGROUND: Severe obesity could be an independent risk factor for peripheral artery disease (PAD) and critical limb ischemia (CLI). Bariatric surgery reduces cardiac risk factors, decreasing cardiovascular morbidity and mortality in subjects with severe obesity. OBJECTIVES: We aimed to describe the impact of bariatric surgery on risk of hospitalization due to PAD and CLI. SETTING: Academic hospital. METHODS: The National Inpatient Sample data collected from 2010 to 2015 were examined. Patients were classified as treatment and control groups. Treatment was defined as patients with a previous history of bariatric surgery, and control was defined as patients with a body mass index ≥35 without a history of bariatric surgery. The primary outcome was hospitalization due to PAD; secondary outcomes were CLI, revascularization, major amputation, length of hospital stay (LOS), and total cost of hospitalization. Univariate and multivariate analyses were performed to assess the differences between groups. RESULTS: There were a total of 2,300,845 subjects: 2,004,804 controls and 296,041 treatment patients. Hospitalization rate for PAD was significantly lower compared to the control group (.10% versus .21%, P < .0001), which was confirmed after adjusting for covariables (control versus treatment: odds ratio= 1.20, confidence interval: 1.15-1.47). Subgroup analysis showed patients without a history of bariatric surgery had a higher prevalence of CLI (59.3% versus 52.4%, P < .0219) and a higher mean LOS (6.7 versus 5.7 days, P = .0023) and cost of hospitalization (78.756 versus 72.621$, P = .0089), with no significant differences in other outcomes. After multivariate analysis, only LOS and total costs were significantly different. CONCLUSIONS: Bariatric surgery may decrease the risk of hospitalization due to PAD, similarly to the LOS and total cost of hospitalization. Prospective studies should be performed to describe this relationship.

Impact of Rapid Weight Loss after Bariatric Surgery in Systemic Inflammatory Response and Pulmonary Hemodynamics in Severely Obese Subjects with Pulmonary Hypertension.

BACKGROUND: Pulmonary hypertension (PH) can be associated with obesity. The excessive production of proinflammatory mediators by dysfunctional adipocytes may enhance remodeling of the pulmonary vasculature and worsen pulmonary hemodynamics. This study aimed to describe the changes in pulmonary arterial pressures and systemic inflammation in patients with obesity with PH after bariatric surgery (BaS). STUDY DESIGN: In this retrospective cohort study, we compared patients with PH who underwent BaS from 2008 to 2018 at our institution (group 1) to a group of severely obese patients with PH (group 2). Echocardiographic right ventricular systolic pressure (RVSP) was used as an indirect measurement of pulmonary arterial pressures. Red blood cell distribution width (RDW) was used as a marker of systemic inflammation. RESULTS: A total of 40 patients were included, 20 per group. In group 1, the RVSP decreased from 44.69 ± 7.12 mmHg to 38.73 ± 12.81 mmHg (p = 0.041), and the RDW decreased from 15.22 ± 1.53 to 14.41 ± 1.31 (p = 0.020). In group 2, the RVSP decreased from 60.14 ± 18.08 to 59.15 ± 19.10 (0.828), and the RDW increased from 15.37 ± 1.99 to 15.38 ± 1.26 (0.983). For both groups, we found a positive correlation between RVSP and RDW changes, although the correlation was not statistically significant. CONCLUSIONS: Previous studies suggest BaS could be a safe and effective procedure to achieve weight loss in obese patients with PH, with an additional modest improvement in pulmonary hemodynamics. The results of this study reinforce this observation and suggest that such improvement could be related to a decrease in systemic inflammation. Further prospective studies with bigger samples are needed to better understand these findings.

Midterm benefits of metabolic surgery on symptom remission and medication use in patients with pseudotumor cerebri.

BACKGROUND: Pseudotumor cerebri is a serious obesity-related disorder that can result in severe complications. The aim of this study was to compare metabolic surgery with medical management of pseudotumor cerebri at a single bariatric center. METHODS: After institutional review board approval, a retrospective review was conducted of individuals with severe obesity and pseudotumor cerebri (nonbariatric group) and patients with preoperative pseudotumor cerebri (bariatric group). The variables included demographic characteristics, comorbidities, and pseudotumor cerebri-related risk factors. Symptoms, medication use, and body mass index were analyzed during a 4-year follow-up. RESULTS: A total of 86 patients with pseudotumor cerebri were included in the analysis. In the nonbariatric group (n = 77), the mean age was 34.1 ± 10.5 years and initial body mass index 37.2 ± 6.5 kg/m2. Initially, the most common symptom was headache (90.9%; n = 70), with a mean lumbar opening pressure of 341.94 ± 104.50 mm H2O. In the bariatric group (n = 9), the mean age was 36.1 ± 8.9 years and preoperative body mass index 46.1 ± 5.5 kg/m2. The most common preoperative symptom was headache (100%; n = 9), with a lumbar opening pressure of 320 ± 44.27 mm H2O. During the 4-year follow-up, both groups presented with a significant decrease in pseudotumor cerebri-related symptoms at 3 months (P < .0001). Additionally, pseudotumor cerebri medication use significantly decreased after 3 months in the bariatric group (P = .0406), whereas in the nonbariatric group decreased at 18 months (P = .023). Bariatric patients presented with a significant decrease in body mass index in ≤3 months of surgery (P = .0380), which was not observed in nonbariatric patients (P = .6644). CONCLUSION: Metabolic surgery seems to provide a greater decrease in pseudotumor cerebri symptoms and medication use in a shorter period of time compared with medical management alone.

Does bariatric surgery change the risk of acute ischemic stroke in patients with a history of transient ischemic attack? A nationwide analysis.

BACKGROUND: Stroke is the second leading cause of death worldwide and fifth in the United States, and it represents the major cause of disability in older adults. OBJECTIVE: We aimed to determine the risk of acute ischemic stroke (AIS) in individuals with obesity with a history of transient ischemic attack (TIA) compared with patients with a history of bariatric surgery. SETTING: Academic hospital, United States. METHODS: Using the Nationwide Inpatient Sample (NIS) database from 2010 to 2015, we retrospectively identified patients with obesity and past medical history of TIA and divided them into 2 groups: a treatment group of patients who underwent bariatric surgery, and a control group of patients with obesity. We compared incidence of new AIS in both groups using a univariate analysis and multivariate regression model. Covariates included were lifestyle (smoking status, alcohol habits, cocaine use), family history of stroke, co-morbidities (diabetes, hypertension, hyperlipidemia, atrial fibrillation) and long-term medical treatment (antiplatelet/antithrombotic treatment). RESULTS: A total of 91,640 patients met inclusion criteria, of which treatment patients were 12.3% (n = 11,284) and control patients 87.6% (n = 80,356). The average age of the treatment group was 62.9 ± 17.08 years, and the average of the control was 59.6 ± 12.74 years. The rate of AIS in the treatment group was significantly lower compared with the control group (2.8% versus 4.2%, P < .0001). After adjusting for covariables, the risk difference of AIS was still significant between groups (odds ratio = 1.33, P < .0001), showing that patients in the treatment group were less likely to have AIS compared with the control group. CONCLUSIONS: After analyzing nationwide information, we conclude bariatric surgery helps decrease risk of AIS in patients with a history of TIA. However, this comparison is limited by the nature of the database; further studies are needed to better understand these results.

Use of fluorescence imaging and indocyanine green during laparoscopic cholecystectomy: Results of an international Delphi survey.

BACKGROUND: Published empirical data have increasingly suggested that using near-infrared fluorescence cholangiography during laparoscopic cholecystectomy markedly increases biliary anatomy visualization. The technology is rapidly evolving, and different equipment and doses may be used. We aimed to identify areas of consensus and nonconsensus in the use of incisionless near-infrared fluorescent cholangiography during laparoscopic cholecystectomy. METHODS: A 2-round Delphi survey was conducted among 28 international experts in minimally invasive surgery and near-infrared fluorescent cholangiography in 2020, during which respondents voted on 62 statements on patient preparation and contraindications (n = 12); on indocyanine green administration (n = 14); on potential advantages and uses of near-infrared fluorescent cholangiography (n = 18); comparing near-infrared fluorescent cholangiography with intraoperative x-ray cholangiography (n = 7); and on potential disadvantages of and required training for near-infrared fluorescent cholangiography (n = 11). RESULTS: Expert consensus strongly supports near-infrared fluorescent cholangiography superiority over white light for the visualization of biliary structures and reduction of laparoscopic cholecystectomy risks. It also offers other advantages like enhancing anatomic visualization in obese patients and those with moderate to severe inflammation. Regarding indocyanine green administration, consensus was reached that dosing should be on a milligrams/kilogram basis, rather than as an absolute dose, and that doses >0.05 mg/kg are necessary. Although there is no consensus on the optimum preoperative timing of indocyanine green injections, the majority of participants consider it important to administer indocyanine green at least 45 minutes before the procedure to decrease the light intensity of the liver. CONCLUSION: Near-infrared fluorescent cholangiography experts strongly agree on its effectiveness and safety during laparoscopic cholecystectomy and that it should be used routinely, but further research is necessary to establish optimum timing and doses for indocyanine green.

Effect of Intraoperative Urinary Catheter Use on Postoperative Urinary Retention After Laparoscopic Inguinal Hernia Repair: A Randomized Clinical Trial.

Importance: Urinary catheters are commonly placed during laparoscopic inguinal hernia repair as a presumed protection against postoperative urinary retention (PUR), one of the most common complications following this operation. Data from randomized clinical trials evaluating the effect of catheters on PUR are lacking. Objective: To investigate the effect of intraoperative catheters on PUR after laparoscopic inguinal hernia repair. Design, Setting, and Participants: This 2-arm registry-based single-blinded randomized clinical trial was conducted at 6 academic and community hospitals in the US from March 2019 to March 2021 with a 30-day follow-up period following surgery. All patients who presented with inguinal hernias were assessed for eligibility, 534 in total. Inclusion criteria were adult patients undergoing laparoscopic, elective, unilateral, or bilateral inguinal hernia repair. Exclusion criteria were inability to tolerate general anesthesia and failure to understand and sign the written consent form. A total of 43 patients were excluded prior to intervention. Interventions: Patients in the treatment arm had placement of a urinary catheter after induction of general anesthesia and removal at the end of procedure. Those in the control arm had no urinary catheter placement. Main Outcomes and Measures: PUR rate. Results: Of the 491 patients enrolled, 241 were randomized to catheter placement, and 250 were randomized to no catheter placement. The median (IQR) age was 61 (51-68) years, and 465 participants (94.7%) were male. Overall, 44 patients (9.1%) developed PUR. There was no difference in the rate of PUR between the catheter and no-catheter groups (23 patients [9.6%] vs 21 patients [8.5%], respectively; P = .79). There were no intraoperative bladder injuries. In the catheter group, there was 1 incident of postoperative urethral trauma in a patient who presented to the emergency department with PUR leading to a suprapubic catheter placement. Conclusions and Relevance: Intraoperative urinary catheters did not reduce the risk of PUR after laparoscopic inguinal hernia repair. While their use did not appear to be associated with a high rate of iatrogenic complications, there may be a low rate of catastrophic complications. In patients who voided urine preoperatively, catheter placement did not appear to confer any advantage and thus their use may be reconsidered. Trial Registration: ClinicalTrials.gov Identifier: NCT03835351.

Bariatric Surgery Improves Heart Geometry and Plasticity.

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

Bariatric surgery decreases hospitalization rates of patients with obstructive lung diseases: a nationwide analysis.

BACKGROUND: Obesity can worsen outcomes in patients with chronic respiratory diseases. OBJECTIVES: The objective of the study was to determine the impact of bariatric surgery (BaS) on risk of hospitalization due to acute exacerbation (AE) of chronic obstructive lung diseases (OLDs). SETTING: Academic, University-affiliated Hospital; United States. METHODS: Nationwide Inpatient Sample data collected from 2010 to 2015 were examined. Patients were classified as treatment and control groups. Treatment subjects were defined as patients with a previous history of BaS, and control subjects, as patients with a body mass index ≥35 kg/m2 and without a history of BaS. The primary outcome was hospitalization due to AE of any OLD (chronic obstructive pulmonary disease, asthma, and bronchiectasis), and the secondary outcome was the total length of stay (LOS). Univariate analysis and multivariate regression model were performed to assess the difference in outcomes between groups. RESULTS: We included a total of 2,300,845 subjects: 2,004,804 controls and 296,041 treatments. Univariate analysis showed that the hospitalization rate was significantly lower for the treatment group than that for the control group (3.7% versus 9.8%, P < .0001), confirmed after adjusting for covariates (control versus treatment: odds ratio [OR] = 2.46, P < .0001). Subgroup analysis showed that the treatment group had a lower risk of LOS ≥3 days than controls (69.8% versus 77.4%, P < .0001), confirmed by multivariate analysis (control versus treatment: OR = 1.40, P < .0001). CONCLUSIONS: BaS-induced weight loss may decrease the risk of hospitalization due to AE in patients with OLD, also decreasing the LOS. We acknowledge that this comparison is limited by the nature of the database; hence, further prospective studies are needed to better understand these results.

Sleeve gastrectomy in patients with severe obesity and baseline chronic kidney disease improves kidney function independently of weight loss: a propensity score matched analysis.

BACKGROUND: In the last 10 years, severe obesity and the associated metabolic syndrome have reached pandemic proportions and consequently have significantly increased the prevalence of related co-morbidities such as chronic kidney disease (CKD). One in 7 people in the United States have CKD, and 90% of those are not aware of it. OBJECTIVES: Following sleeve gastrectomy (SG) in patients with severe obesity and baseline CKD stage ≥2, to determine improvement of glomerular function and analyze the relationship between kidney function and weight loss. SETTING: US Hospital, Academic Institution. METHODS: We retrospectively reviewed the charts of all patients who underwent SG at our institution from 2010 to 2019. Kidney function assessment using the Chronic Kidney Disease Epidemiology Collaboration Study (CKD-EPI) equation and classification was carried out preoperatively and postoperatively at 12-months follow-up. Propensity score matching (1:1 ratio) was used to balance the distribution of covariates between patients with a baseline estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m2 and patients with normal kidney function. RESULTS: We calculated the eGFR of 1330 bariatric patients who underwent SG. Of these patients, 18.79% (n = 250) met the criteria for CKD-EPI eGFR calculation preoperatively and at 12-months follow-up after SG. From the 250 patients included in the analysis, 42% (n = 105) were classified as CKD stage ≥2. When comparing the baseline preoperative eGFR at 12-months follow-up after SG, we observed an improvement of 8.26 ± 11.89 mL/min/1.73 m2 in CKD stage ≥2 (eGFR <90 mL/min/1.73 m2) as compared with 1.98 ± 10.25 mL/min/1.73 m2 in patients with eGFR >90 mL/min/1.73 m2 (P < .001). CONCLUSION: There is short-term improvement of the eGFR in patients with severe obesity following SG. This improvement is significant in CKD stages ≥2 and seems unrelated to weight loss.

Non-absorbable Barbed Sutures for Primary Fascial Closure in Laparoscopic Ventral Hernia Repair.

Purpose The aim of this study is to describe the safety and effectiveness of laparoscopic ventral hernia repair with intraperitoneal fascial closure using a barbed suture prior to mesh placement. Materials and methods Patients who underwent laparoscopic ventral hernia repair were included in this retrospective review. Patients were divided into two groups. In the first group, primary fascial closure was performed with a 2-polypropylene non-absorbable unidirectional barbed suture followed by fixation of the intraperitoneal mesh. In the second group, the mesh was fixed intraperitoneally using tacks without closing the fascial defect. Results A total of 148 patients who underwent laparoscopic primary ventral hernia repair were included. A total of 72 (48.6%) patients were included in the barbed suture with mesh group and 76 (51.4%) patients in the mesh-only group. The mean fascial defect size was 25 cm2 in the first group and 64 cm2 in the second group. The median suturing time for fascial closure was 15 minutes. The average surgery time was 98 minutes in the first group and 96 minutes in the second group. The mean follow-up period was 80 days for Group 1 and 135 days for Group 2. No hernia recurrence or mortality occurred in this study. Conclusion The barbed suture closure technique is a fast, safe, and effective technique for fascial closure during laparoscopic ventral hernia repair in combination with mesh placement. Further evidence to support these findings and longer follow-up periods are warranted to evaluate long-term outcomes.

Ventricular conduction improvement after pericardial fat reduction triggered by rapid weight loss in subjects with obesity undergoing bariatric surgery.

BACKGROUND: Obesity is considered a major cardiovascular risk factor. The excess of pericardial fat (PF) in patients with obesity has been associated with a variety of electrocardiographic alterations. In previous studies, we demonstrated that rapid weight loss and bariatric interventions result in decreased PF. OBJECTIVES: The aim of this study is to report the changes in PF after bariatric surgery and its effect on ventricular conduction. SETTING: US hospital, academic institution. METHODS: A linear measurement of PF thickness on computed tomography scans was obtained for 81 patients, as well as a retrospective review of electrocardiographic changes before and after bariatric surgery. We compared the changes in PF thickness and electrocardiographic components before and after procedures. Common demographics and co-morbidities were collected along with lipid profiles preoperative and postoperative. RESULTS: A total of 81 patients had electrocardiograms done before and 1 year after bariatric surgery. Females comprised 67.9% (n = 55), and the average age for our population was 55.07 ± 14.17 years. Pericardial fat thickness before surgery was 5.6 ± 1.84 and 4.5 ± 1.62 mm after surgery (P = .0001). Ventricular conduction (QT and QT corrected [QTc] intervals) showed a significant improvement from 438.7 + 29 before to 426.8 + 25.3 after bariatric surgery (P = .006). We found a statistically significant association between the decrease in PF and the decrease in QTc intervals (P = .002). CONCLUSION: Obesity is a risk factor for arrhythmias and sudden cardiac death. Bariatric surgery and its effect on PF produce an improvement in ventricular conduction, which may reduce the ventricular electrical instability in patients with obesity.

Prevalence of chronic kidney disease and end-stage renal disease in a bariatric versus nonbariatric population: a retrospective analysis of the U.S. National Inpatient Sample database.

BACKGROUND: In the past five 5 years our team has studied the effects of bariatric surgery on chronic kidney disease (CKD) at our institution. OBJECTIVES: The objective of this study was to assess the impact of bariatric surgery (BaS) on the prevalence and likelihood of CKD and end-stage renal disease (ESRD) nationwide. SETTING: Academic hospital, United States. METHODS: We conducted a retrospective analysis of the U.S. National Inpatient Sample (NIS) database for the years 2010-2015 and compared. Univariate and multivariable analysis were performed to assess the impact of BaS on the point prevalence and the probability of CKD and ESRD. Similarly, a multivariable logistic regression was conducted to measure the impact of the most important risk factors for CKD exclusively in a severely obese population. RESULTS: Data on 296,041 BaS cases and 2,004,804 severely obese controls was extracted from the NIS database and relative to controls, all baseline CKD risk factors were less common among bariatric surgery cases. Nonetheless, even after adjusting for all CKD risk factors, controls exhibited marked increases in the odds of CKD-stage III (odds ratio [OR] 3.10 [3.05-3.14], P < .0001) and modes increase for ESRD (OR 1.13 [1.09-1.18], P < .0001). Overall, even after adjusting for risk factors we observed that the rate of CKD is significantly higher in the control group, 12% when compared with 5.3% in the bariatric surgery group (P < .0001). CONCLUSION: In this retrospective, case control study of a large, representative national sample of patients with severe obesity, BaS was found to be associated with significantly reduced point-prevalence and likelihood for CKD when adjusted for baseline CKD risk factors as compared with patients with obesity who did not undergo BaS. Overall, BaS resulted in a reduced rate and a moderate decrease in the likelihood of ESRD.

Bariatric surgery decreases the number of future hospital admissions for diastolic heart failure in subjects with severe obesity: a retrospective analysis of the US National Inpatient Sample database.

BACKGROUND: Considerable evidence documents the effectiveness and efficacy of bariatric surgery (BaS) in reducing the prevalence and severity of obesity-related co-morbidities. Diastolic heart failure (DHF) is a condition with considerable morbidity and mortality, yet recalcitrant to medical therapy. OBJECTIVE: Our objectives were to assess whether BaS is associated with a decrease in hospital admissions for DHF and determine its impact upon DHF hospital admissions among patients with hypertension (HTN) and coronary artery disease (CAD). SETTING: Academic institution. METHODS: Data on 296 041 BaS cases and 2 004 804 controls with severe obesity were extracted from the US National Inpatient Sample database for the years 2010 to 2015 and compared. Univariate and multivariable analysis were performed to assess the impact of pre-2010 BaS on the rate of hospital admissions for DHF, adjusting for demographics, co-morbidities, and other risk factors associated with cardiovascular disease (CVD). RESULTS: Relative to controls, all baseline CVD risk factors were less common among BaS cases. Nonetheless, even after adjusting for all CVD risk factors, controls exhibited marked increases in the odds of DHF overall (odds ratio = 2.80; 95% confidence interval = 2.52-3.10). Controls with HTN and CAD demonstrated an almost 3-fold increase in odds of DHF admissions. Similarly, controls with no HTN demonstrated a 5-fold increase in odds of admissions for DHF when compared to the surgical group. CONCLUSIONS: In this retrospective, case control study of a large, representative national sample of patients with severely obesity, BaS was found to be associated with significantly reduced hospitalizations for DHF when adjusted for baseline CVD risk factors. It also reduced DHF incidence in high-risk patients with HTN and CAD.

Outcomes of laparoscopic sleeve gastrectomy with and without antrectomy in severely obese subjects. Evidence from randomized controlled trials.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has been proven safe and effective in achieving weight loss. However, the distance from the pylorus where resection should begin has been debated. OBJECTIVES: To compare the clinical outcomes of laparoscopic SG with antrum resection (AR) versus preservation (AP) for bariatric purposes by conducting a meta-analysis of randomized controlled trials (RCT). SETTING: Academic hospital, United States. METHODS: PubMed and Cochrane Library were queried for RCTs from establishment to August 2020. The following key search terms were used: "sleeve gastrectomy" AND ("antrectomy" OR "antrum") AND ("randomized" OR "random"). The following data were extracted: author, publication year, country, sample size, follow-up duration, and clinical outcomes, including weight-related: excess weight loss (EWL), total weight loss (TWL), body mass index (BMI), operation time, length of hospital stay, complication rates, and resolution of obesity-related comorbidities. RESULTS: A total of 9 unique RCTs including 492 AR and 385 AP patients were screened and included in the final quantitative analysis. Patients who underwent SG with AR showed higher EWL and TWL at 6 months (EWL: P < .001; TWL: P = .006), and 1 year (EWL: P = .013; P < .001) postoperatively. The BMI was also lower in the AR group 3 months (P = .013) and 6 months (P = .003) postoperatively. However, the EWL and BMI at 2 years were comparable between both groups (P = .222 and P = .908, respectively). No statistical significance was observed in terms of operating time, staple line disruption, bleeding, complications with a Clavien-Dindo Grade >III, resolution of comorbidities (hypertension, diabetes, hyperlipidemia, arthritis/back pain), and de novo gastroesophageal reflux disease (P > .05). AP was associated with a slightly shorter postoperative hospital stay (4.0 versus 3.1 days, P = .039). CONCLUSION: Laparoscopic SG with AR is associated with superior weight loss in the short-term compared with AP. However, mid-term follow-up beyond 1 year showed no significant differences in BMI or incidence of de novo gastroesophageal reflux disease.

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

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

Does Transverse Abdominis Plane Block Increase the Risk of Postoperative Urinary Retention after Inguinal Hernia Repair?

BACKGROUND AND OBJECTIVE: Postoperative urinary retention (POUR) is a common adverse event after inguinal hernia repair (IHR), with an incidence of up to 22.2%. The aim of this study is to determine if pre-operative transverse abdominis plane (TAP) block increases the incidence of POUR. METHODS: A retrospective review was performed for all patients who underwent IHR (open or laparoscopic) at this institution, from January 1, 2016 to December 31, 2017. Patients were divided into two groups: Patients that had a TAP block before surgery (group 1) and patients with no TAP block (group 2). Common demographics and comorbidities were collected along with postoperative outcomes and POUR incidence rates for every group to determine procedural influence. RESULTS: From 276 patients reviewed, 28.2% (N = 78) underwent TAP block before surgery. The patient cohort mean age was 61.1 ± 14.4 years. Most the interventions were laparoscopic (81.2%) and an overall POUR incidence rate of 7.6% (N = 21) was observed. Comparatively, common demographics and comorbidities were statistically similar for both groups, with the exception of type 2 diabetes mellitus (p = 0.049). Individually, group 1 and 2 presented POUR incidence rates of 14.1% and 5.05%, respectively. While intraoperative fluid administration, early readmission rate, and length were similar in both groups, there was a significant difference in POUR incidence rates (p = 0.01). CONCLUSION: Patients undergoing TAP block during IHR might have an increased risk of developing POUR. Further larger, prospective, and randomized controlled studies are necessary to better assess these findings.

Impact of bariatric surgery on the risk of hospitalization due to influenza virus infection.

BACKGROUND: Obesity independently increases the risk of hospitalization due to viral respiratory infections, including influenza virus and, more recently, severe acute respiratory syndrome coronavirus 2. As an independent risk factor, obesity impairs the immune response to viral infections and decreases the effectiveness of immunizations. OBJECTIVES: Using influenza as a proxy, we aimed to determine the impact of bariatric surgery (BaS) on the risk of hospitalization due to viral respiratory infections. SETTING: Academic hospital, United States. METHODS: National (Nationwide) Inpatient Sample data collected from 2010 to 2015 were examined. Patients were classified as treatment and control groups. Treatment subjects were defined as patients with a history of BaS and control subjects as patients with a body mass index ≥35 kg/m2 and without a history of BaS. Any hospitalization with influenza as a primary diagnosis was identified. Univariate analysis and multivariate regression models were performed to assess the differences between groups. RESULTS: A total of 2,300,845 subjects were reviewed, of which 2,004,804 were control subjects and 296,041 were treated patients. Univariate analysis showed that the hospitalization rate in the treatment group was significantly lower than in the control group (.007% versus .019%, P < .0001), which was confirmed after adjusting for covariables (control versus treatment: odds ratio = 2.21, P = .0010). CONCLUSIONS: BaS may decrease the risk of hospitalization due to influenza, but further prospective studies are needed to confirm these results. We also suggest that these results should be translated into the development of similar studies to determine the impact of BaS on the incidence and severity of the coronavirus disease 2019.

Trends in early postoperative major adverse cardiovascular and cerebrovascular events associated with bariatric surgery: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.

BACKGROUND: The population undergoing bariatric surgery (BaS) has many cardiovascular risk factors that can lead to significant perioperative cardiovascular morbidity. OBJECTIVES: We aimed to examine trends in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) after BaS. SETTING: Academic Hospital, United States METHODS: We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry for patients aged ≥18 years undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2015 to 2019. Data on demographics, co-morbidities, and type of procedure were collected. MACCE was defined as a composite variable including perioperative acute myocardial infarction (AMI), cardiac arrest requiring cardiopulmonary resuscitation, acute stroke, and all-cause mortality. We utilized the Cochrane-Armitage and Jonckheere-Terpstra tests to assess for significant trend changes throughout the years. RESULTS: A total of 752,722 patients were included in our analysis (LSG = 73.2%, LRYGB = 26.8%). Postoperative MACCE occurred in 1058 patients (.14%), and was more frequent in patients undergoing LRYGB (.20%). The frequency of MACCE declined from .17% to .14% (P = .053), driven by a decline in the frequency of AMI (.04% to .02%, P = .002), cardiac arrest (.05% to .04%, P = .897), and all-cause death (.11% to .08%, P = .040), but with an increase in perioperative stroke (.01% to .02%, P = .057). CONCLUSION: The overall risk of MACCE after BaS is .14% and has been declining in the last 5 years. This trend is likely multifactorial and further analysis is necessary to provide a detailed explanation.