Metabolic and Bariatric Surgery Outcomes in African American Patients: a Single Institution Experience.

BACKGROUND: The incidence of obesity in African Americans (AAs) is higher than in non-AA in the USA. Previous studies using large national databases report that AA patients have worse outcomes than non-AA patients. OBJECTIVES: To assess perioperative outcomes among AA patients after MBS at a center of excellence (COE) that serves a large, diverse patient population. SETTING: University Hospital METHODS: A retrospective analysis was performed on patients undergoing MBS between 2010 and 2020 at our two accredited MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program) COEs where the AA population makes up over 35% of the population. Preoperative variables were compared using unpaired t-test or chi-squared test where appropriate. Thirty-day outcomes were compared following propensity score matching (exact algorithm) of demographics and comorbidities. RESULTS: Overall, 5742 patients (AA = 2058, 36%) had Roux-en-Y gastric bypass (AA = 1028, 26%) or sleeve gastrectomy (AA = 1030, 27%). AA patients were more often female (90.2% vs. 80.2%, p < 0.001) and had higher rates of hypertension (56.3% vs. 47.8%, p < 0.001), while non-AA patients had higher rates of hyperlipidemia (27.3% vs. 20.7%, p < 0.001) and obstructive sleep apnea (41.2% vs. 37.1%, p = 0.0024). Matched data showed that AA patients had higher rates of pulmonary embolism (PE) (0.3% vs. 0.1%, p = 0.020) and more emergency department visits (7.0% vs. 5.1%, p = 0.012) but no differences in mortality, readmission, reintervention, or reoperation rates. CONCLUSIONS: In a diverse area, AA patients who underwent MBS had similar perioperative outcomes compared to non-AA patients except that they experienced higher rates of PE. They also experienced higher rates of emergency department visits but had similar readmission rates.

Safety of biliopancreatic diversion with duodenal switch in patients with body mass index less than 50 kg/m2.

INTRODUCTION: Biliopancreatic diversion with duodenal switch (BPD-DS) has often been reserved for patients with BMI > 50 kg/m2. We aim to assess the safety of BPD-DS in patients with morbid obesity (BMI 335 kg/m2 and < 50 kg/m2) using a 150-cm common channel (CC), 150-cm Roux limb, and 60-fr bougie. METHODS: A retrospective review was performed on patients with a BMI < 50 mg/k2 who underwent a BPD-DS in 2016-2019 at a single institution. Limb lengths were measured with a laparoscopic instrument with minimal tension. Sleeve gastrectomy was created with 60-fr bougie. Variables were compared using paired t test, Chi-square analysis or repeated measures ANOVA where appropriate. RESULTS: Forty-five patients underwent BPD-DS. CC lengths and Roux limb lengths were 158 ± 20 cm and 154 ± 18 cm, respectively. Preoperative BMI was 44.9 ± 2.3 kg/m2 and follow-up was 2.7 ± 1.4 years. One patient required reoperation for bleeding and died from multiorgan failure and delayed sleeve leak. There was 1 (2.2%) readmission for contained anastomotic leak and 2 ED visits (4.5%) within 30 days. There were no marginal ulcers, limb length revisions, or need for parental nutrition. Percent excess weight loss was 67.2 ± 19.7%. 88.9% (N = 8), 86.6% (N = 13), and 55.5% (N = 5) of patients had resolution or improvement of their diabetes mellitus type II, hypertension, and hyperlipidemia, respectively. 40% (N = 4) of patients had resolution of their gastroesophageal reflux disease (GERD) and 11.4% (N = 5) developed de novo GERD. 32% (N = 14) of patients had vitamin D deficiency and 25% (N = 11) experienced zinc deficiency. CONCLUSION: BPD-DS may be considered in patients with BMI < 50 kg/m2 with 150-cm CC, 150-cm Roux limb, and a 60-fr bougie sleeve gastrectomy. There was sustained weight loss and no protein calorie malnutrition, but Vitamin D and zinc deficiency remained a challenge. Careful patient selection and proper counseling of the risks and benefits are necessary.

The role of total alimentary limb length in Roux-en-Y gastric bypass: a systematic review.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is an established surgical treatment for obesity. Variations in limb length during RYGB procedures have been investigated for optimizing weight loss while minimizing nutritional deficiencies. The role of the total alimentary limb length (TALL; Roux limb plus common channel [CC]), however, is poorly defined. OBJECTIVE: Compare TALL in RYGB procedures for weight loss outcomes and malnutrition. SETTING: Systematic review. METHODS: Ovid Medline and PubMed databases were searched for entries between 1993 and 2020. Search terms included "gastric bypass" and "TALL." Two independent reviewers screened the results. RESULTS: A total of 21 studies measured TALL in RYGB. Of these, 4 of 6 reported a relationship between TALL and weight loss. Additionally, 11 studies reported that when TALL was ≤400 cm and CC <200 cm, 3.4% to 63.6% of patients required limb lengthening for protein malnutrition. CONCLUSIONS: The majority of studies on RYGB do not report TALL length. There is some evidence that weight loss is affected by shortening TALL, while a TALL ≤400 cm with CC<200 should be avoided due to severe protein malnutrition. More studies on the effect of TALL are needed.

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database.

INTRODUCTION: For patients with super obesity (BMI > 50 kg/m2), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS. MATERIALS AND METHODS: The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18 years of age, BMI > 50 kg/m2, and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes. RESULTS: There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m2, p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019). CONCLUSIONS: Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.

Less precise motor control leads to increased agonist-antagonist muscle activation during stick balancing.

Human motor control has constraints in terms of its responsiveness, which limit its ability to successfully perform tasks. In a previous study, it was shown that the ability to balance an upright stick became progressively more challenging as the natural frequency (angular velocity without control) of the stick increased. Furthermore, forearm and trunk agonist and antagonist muscle activation increased as the natural frequency of the stick increased, providing evidence that the central nervous system produces agonist-antagonist muscle activation to match task dynamics. In the present study, visual feedback of the stick position was influenced by changing where subject focused on the stick during stick balancing. It was hypothesized that a lower focal height would degrade motor control (more uncertainty in tracking stick position), thus making balancing more challenging. The probability of successfully balancing the stick at four different focal heights was determined along with the average angular velocity of the stick. Electromyographic signals from forearm and trunk muscles were also recorded. As expected, the probability of successfully balancing the stick decreased and the average angular velocity of the stick increased as subjects focused lower on the stick. In addition, changes in the level of agonist and antagonist muscle activation in the forearm and trunk was linearly related to changes in the angular velocity of the stick during balancing. One possible explanation for this is that the central nervous system increases muscle activation to account for less precise motor control, possibly to improve the responsiveness of human motor control.

Limits in motor control bandwidth during stick balancing.

Why can we balance a yardstick but not a pencil on the tip of our finger? As with other physical systems, human motor control has constraints, referred to as bandwidth, which restricts the range of frequency over which the system can operate within some tolerated level of error. To investigate control bandwidth, the natural frequency of a stick used during a stick-balancing task was modified by adjusting the height of a mass attached to the stick. The ability to successfully balance the stick with the mass positioned at four different heights was determined. In addition, electromyographic signals from forearm and trunk muscles were recorded during the trials. We hypothesized that 1) the probability of successfully balancing would decrease as mass height decreased; and 2) the level of muscle activation in both agonist and antagonist would increase as the natural frequency of the stick increased. Results showed that as the mass height decreased the probability of successfully balancing the stick decreased. Changes in the probability of success with respect to mass height showed a threshold effect, suggesting that limits in human control bandwidth were approached at the lowest mass height. Also, the level of muscle activation in both the agonist and antagonist of the forearm and trunk increased linearly as the natural frequency of the stick increased. These changes in muscle activation suggest that the central nervous system adapts muscle activation to task dynamics, possibly to improve control bandwidth.