Outcomes of SADI and OAGB Compared to RYGB from the Metabolic and Bariatric Surgery Quality Improvement Program: The North American Experience.

BACKGROUND: Rapid adoption of sleeve gastrectomy (SG) in the last decade aptly reflects the desire of patients and surgeons for alternatives to RYGB and DS. While SG provides good outcomes, other options that address specific patient needs are warranted. Recently approved by ASMBS, SADI, and OAGB have garnered increasing interest due to their single anastomosis technique. METHODS: Using the Metabolic and Bariatric Surgery Quality Improvement Program database, we examined laparoscopic and robotic cases from 2018 to 2021 to understand the percentage of primary bariatric surgery cases that are SADI and OAGB. We used coarsened exact matching to match patients who underwent SADI or OAGB to patients who underwent Roux-en-Y gastric bypass (RYGB). We examined outcomes of matched patients using logistic regression. RESULTS: Of the 667,979 patients that underwent bariatric-metabolic surgery, 1326 (0.2%) underwent SADI, and 2541 (0.4%) underwent OAGB. SADI was not identified in the database until 2020. In 2020, there were 487 SADI procedures compared to 839 in 2021. From 2018 to 2021, OAGBs went from 149 to 940. Compared with RYGB, SADI was associated with higher rates of anastomotic or staple line leak (OR 2.21 (95% CI 1.08-4.53)) and sepsis (OR 3.62 (95% CI 1.62-8.12)). Compared with RYGB, OAGB was associated with lower rates of gastrointestinal bleeding (OR 0.29 (95% CI 0.12-0.71)) and bowel obstruction (OR 0.10 (95% CI 0.02-0.39)). Of note, there were no differences between these procedures and RYGB for 30-day mortality. CONCLUSION: More SADIs and OAGBs are being performed. However, there were higher complication rates associated with the SADI procedure. Further studies will be needed to better understand the key drivers for these outcomes.

The Degree of Preoperative Hypoalbuminemia Is Associated with Risk of Postoperative Complications in Metabolic and Bariatric Surgery Patients.

BACKGROUND: The incidence and impact of hypoalbuminemia in bariatric surgery patients is poorly characterized. We describe its distribution in laparoscopic sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) patients undergoing primary or revision surgeries and assess its impact on postoperative complications. METHODS: The Metabolic and Bariatric Surgery Quality Improvement Program Database (2015 to 2021) was analyzed. Hypoalbuminemia was defined as Severe (< 3 g/dL), Moderate (3 ≤ 3.5 g/dL), Mild (3.5 ≤ 4 g/dL), or Normal (≥ 4 g/dL). Multivariable logistic regression was performed to calculate odds ratios of postoperative complications compared to those with Normal albumin after controlling for procedure, age, gender, race, body mass index, functional status, American Society of Anesthesia class, and operative length. RESULTS: A total of 817,310 patients undergoing Primary surgery and 69,938 patients undergoing Revision/Conversion ("Revision") surgery were analyzed. The prevalence of hypoalbuminemia was as follows (Primary, Revision): Severe, 0.3%, 0.6%; Moderate, 5.2%, 6.5%; Mild, 28.3%, 31.4%; Normal, 66.2%, 61.4%. Primary and Revision patients with hypoalbuminemia had a significantly higher prevalence (p < 0.01) of several co-morbidities, including hypertension and insulin-dependent diabetes. Any degree of hypoalbuminemia increased the odds ratio of several complications in Primary and Revision patients, including readmission, intervention, and reoperation. In Primary patients, all levels of hypoalbuminemia also increased the odds ratio of unplanned intubation, intensive care unit admission, and venous thromboembolism requiring therapy. CONCLUSION: Over 30% of patients present with hypoalbuminemia. Even mild hypoalbuminemia was associated with an increased rate of several complications including readmission, intervention, and reoperation. Ensuring nutritional optimization, especially prior to revision surgery, may improve outcomes in this challenging population.

The role of preoperative toxicology screening in patients undergoing bariatric surgery.

BACKGROUND: Some programs and insurers may require patients to undergo toxicology screening despite lack of evidence that this practice affects postoperative outcomes. OBJECTIVES: To understand the prevalence of screening positive on toxicology testing in the bariatric surgical population and to examine the association between testing positive and important surgical outcomes. METHODS: We performed a retrospective review of patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from an academic health system from 2017-2020. We described the rate of preoperative toxicology positivity as determined by serum and urine testing. We examined the association between toxicology positivity and outcomes of preoperative length, 30-day complications (bleeding, venous thromboembolism, leak, wound infection, pneumonia, urinary tract infection, and myocardial infarction), readmissions, and 1-year weight loss using chi-square and t-test analysis. RESULTS: Of 1057 patients, there were 134 patients (12.7%) who had positive toxicology testing. Of these, 37 (28%) were positive for opiates and 21 (16%) were positive for cotinine. Mean preoperative length was 381.8 days (standard deviation [SD], 222.5) for patients with positive testing versus 287.8 days (SD, 151.5; P = 1.00) for negative testing. Toxicology positivity was not associated with readmissions (5.2% versus 4.3%, X2 = 0.22; P = .64). The loss to follow-up at 1 year was 32.5%. There was no association with 1-year mean change in body mass index (mean of loss 12.23kg/m2 [SD, 5.61]) versus mean of loss 12.74 (SD, 6.44; P = .20)]. CONCLUSIONS: Our study is the first to describe preoperative toxicology positivity rates. We found no association between toxicology positivity and preoperative length, readmissions, or weight loss. Given its lack of impact on outcomes, toxicology testing prior to bariatric surgery may be an unnecessary burden on patients and healthcare, with regard to cost and wait times.

Intraoperative Blood Pressure Lability Is Associated with Postoperative Hemorrhage after Uncomplicated Bariatric Surgery.

BACKGROUND: Postoperative hemorrhage is a rare complication in bariatric surgery. We aim to determine if differences in blood pressure or perioperative medication administration contribute to postoperative bleeding in patients who were hemodynamically stable intraoperatively. METHODS: This was a retrospective case-control study of all bariatric surgery patients from 2014 to 2017 at a high volume academic center. We identified controls based on age, gender, ethnicity, type of procedure, and pre-operative blood pressure. RESULTS: Patients with postoperative hemorrhage had a significantly lower MAP during the portion of the surgery in which the abdominal contents were inspected for leaks and bleeds. The timing of enoxaparin or ketorolac administration was not associated with bleeding. CONCLUSION: Blood pressure lability, but not enoxaparin or ketorolac administration, is associated with postoperative hemorrhage.

Technical Feasibility of a Murine Model of Sleeve Gastrectomy with Ileal Transposition.

BACKGROUND: Sleeve gastrectomy with ileal transposition has been shown to be superior to sleeve gastrectomy alone for promoting weight loss in rat and porcine models. The absence of a mouse model for this procedure has impeded efforts to understand the molecular physiology underlying its efficacy. This study demonstrates the long-term survivability of sleeve gastrectomy with ileal transposition in mice. MATERIALS AND METHODS: In this study of technical feasibility, a sleeve gastrectomy with ileal transposition (SGIT), sleeve gastrectomy (SG), or sham surgery (SH) was performed on 7- to 8-week-old C57Bl/6J mice (n = 8 for each). To evaluate long-term survivability, mice were placed on an obesogenic diet and weighed weekly for 10 weeks. The intestinal identity of the transposed segment was assessed with gene expression analysis of duodenal-, jejunal-, and ileal-specific hormones using quantitative polymerase chain reaction. RESULTS: Overall, SGIT better prevented weight gain than the SG or sham procedures (10-week post-operative weight: SH 45.3 ± 1.0 g, SG 41.25 ± 1.6 g, SGIT 35.4 ± 0.8 g). Gene expression pattern analysis of three markers of intestinal identity (gastrin, cholecystokinin, and peptide YY) suggests that the ileal identity of the transposed segment is maintained 10 weeks after transposition. CONCLUSIONS: We demonstrate for the first time a reproducible mouse model of sleeve gastrectomy with ileal transposition. Future studies utilizing this model will expand our understanding of the molecular pathways through which the hindgut regulates satiety.

Impact of preoperative wait time due to insurance-mandated medically supervised diets on weight loss after sleeve gastrectomy. Are patients losing momentum?

BACKGROUND: Few studies have examined whether preoperative period length, as defined by the amount of time from enrollment in a surgical weight loss program to the day of surgery, affects postoperative weight loss. OBJECTIVES: To identify associations between preoperative period length and postoperative weight loss. SETTING: Single surgeon at an academic medical center in the United States. METHODS: Retrospective chart review in 109 consecutive patients undergoing sleeve gastrectomy from 2014-2015. RESULTS: When patients were grouped based on postoperative percentage of total weight loss, greater weight loss was associated with shorter preoperative wait time. During the preoperative period, 72.2% of our patients achieved a net weight loss, but 34.6% had gained net weight until they started the preoperative "liver-shrinking" diet; 71.4±8.3% of the total preoperative weight loss occurred after initiating the preoperative diet, which accounted for approximately 15% of the whole preoperative period length. There was no correlation between the length of the preoperative diet and preoperative weight loss. CONCLUSIONS: Shorter preoperative periods and earlier initiation of liver reduction diets may increase postoperative weight loss, although ultimately there may be a limit to the weight loss that patients can achieve while adhering to highly restrictive lifestyle modifications.