Bariatric Surgery and the Long-Term Risk of Venous Thromboembolism: A Population-Based Cohort Study.

PURPOSE: Bariatric surgery is associated with a greater venous thromboembolism (VTE) risk in the weeks following surgery, but the long-term risk of VTE is incompletely characterized. We evaluated bariatric surgery in relation to long-term VTE risk. MATERIALS AND METHODS: This population-based retrospective matched cohort study within three United States-based integrated health care systems included adults with body mass index (BMI) ≥ 35 kg/m2 who underwent bariatric surgery between January 2005 and September 2015 (n = 30,171), matched to nonsurgical patients on site, age, sex, BMI, diabetes, insulin use, race/ethnicity, comorbidity score, and health care utilization (n = 218,961). Follow-up for incident VTE ended September 2015 (median 9.3, max 10.7 years). RESULTS: Our population included 30,171 bariatric surgery patients and 218,961 controls; we identified 4068 VTE events. At 30 days post-index date, bariatric surgery was associated with a fivefold greater VTE risk (HRadj = 5.01; 95% CI = 4.14, 6.05) and a nearly fourfold greater PE risk (HRadj = 3.93; 95% CI = 2.87, 5.38) than no bariatric surgery. At 1 year post-index date, bariatric surgery was associated with a 48% lower VTE risk and a 70% lower PE risk (HRadj = 0.52; 95% CI = 0.41, 0.66 and HRadj = 0.30; 95% CI = 0.21, 0.44, respectively). At 5 years post-index date, lower VTE risks persisted, with bariatric surgery associated with a 41% lower VTE risk and a 55% lower PE risk (HRadj = 0.59; 95% CI = 0.48, 0.73 and HRadj = 0.45; 95% CI = 0.32, 0.64, respectively). CONCLUSION: Although in the short-term bariatric surgery is associated with a greater VTE risk, in the long-term, it is associated with a substantially lower risk.

Long term outcomes of metabolic/bariatric surgery in adults.

The prevalence of obesity continues to rise around the world, driving up the need for effective and durable treatments. The field of metabolic/bariatric surgery has grown rapidly in the past 25 years, with observational studies and randomized controlled trials investigating a broad range of long term outcomes. Metabolic/bariatric surgery results in durable and significant weight loss and improvements in comorbid conditions, including type 2 diabetes. Observational studies show that metabolic/bariatric surgery is associated with a lower incidence of cardiovascular events, cancer, and death. Weight regain is a risk in a fraction of patients, and an association exists between metabolic/bariatric surgery and an increased risk of developing substance and alcohol use disorders, suicidal ideation/attempts, and accidental death. Patients need lifelong follow-up to help to reduce the risk of these complications and other nutritional deficiencies. Different surgical procedures have important differences in risks and benefits, and a clear need exists for more long term research about less invasive and emerging procedures. Recent guidelines for the treatment of obesity and metabolic conditions have been updated to reflect this growth in knowledge, with an expansion of eligibility criteria, particularly people with type 2 diabetes and a body mass index between 30.0 and 34.9.

Assessment of empiric body mass index-based thromboprophylactic dosing of enoxaparin after bariatric surgery: evidence for dosage adjustment using anti-factor Xa in high-risk patients.

BACKGROUND: Despite thromboprophylaxis, postoperative deep vein thrombosis and pulmonary embolism occur after bariatric surgery, perhaps because of failure to achieve optimal prophylactic levels in the obese population. OBJECTIVES: The aim of this study was to evaluate the adequacy of prophylactic dosing of enoxaparin in patients with severe obesity by performing an antifactor Xa (AFXa) assay. SETTING: An academic medical center METHODS: In this observational study, all bariatric surgery cases at an academic center between December 2016 and April 2017 who empirically received prophylactic enoxaparin (adjusted by body mass index [BMI] threshold of 50 kg/m2) were studied. The AFXa was measured 3-5 hours after the second dose of enoxaparin. RESULTS: A total of 105 patients were included; 85% were female with a median age of 47 years. In total, 16 patients (15.2%) had AFXa levels outside the prophylactic range: 4 (3.8%) cases were in the subprophylactic and 12 (11.4%) cases were in the supraprophylactic range. Seventy patients had a BMI <50 kg/m2 and empirically received enoxaparin 40 mg every 12 hours; AFXa was subprophylactic in 4 (5.7%) and supraprophylactic in 6 (8.6%) of these patients. Of the 35 patients with a BMI ≥50 who empirically received enoxaparin 60 mg q12h, no AFXa was subprophylactic and 6 (17.1%) were supraprophylactic. Five patients (4.8%) had major bleeding complications. One patient developed pulmonary embolism on postoperative day 35. CONCLUSION: BMI-based thromboprophylactic dosing of enoxaparin after bariatric surgery could be suboptimal in 15% of patients with obesity. Overdosing of prophylactic enoxaparin can occur more commonly than underdosing. AFXa testing can be a practical way to measure adequacy of pharmacologic thromboprophylaxis, especially in patients who are at higher risk for venous thromboembolism or bleeding.

Bariatric Enhanced Recovery Protocol: a Community Quality Perspective.

INTRODUCTION: Bariatric enhanced recovery protocols can decrease length of stay (LOS) and hospital costs without compromising patient safety. Increased data is needed to compare patient outcomes before and after application of enhanced recovery pathways. We present a bariatric enhanced recovery protocol (BERP) at a community hospital. The objectives were to decrease hospital LOS and reduce schedule II substance use (medications with a high potential for abuse, potentially resulting in psychological or physical dependence), without compromising patient safety. METHODS: This was a combined retrospective and prospective analysis of all patients undergoing bariatric surgery by two surgeons from September 2016 to April 2018. Mann-Whitney U, Pearson chi-square, and Fisher's exact tests were used to compare demographics, comorbidities, and outcomes. RESULTS: Two hundred patients were evaluated. Overall median (interquartile range) age was 43.0 (36.0-54.0) years and body mass index (BMI) was 45.0 (40.6-50.3) kg/m2. Pre-protocol mean hospital LOS was 2.3 days while enhanced recovery protocol patients mean LOS was 1.4 days (p < 0.001). Sixty-five percent of BERP patients were discharged on hospital day 1, while no patients prior to the protocol were discharged before hospital day 2. Only 9% of BERP patients were discharged with schedule II medications, compared to 100% of the pre-protocol patients (p < 0.001). Intraoperative, in-hospital, and 30-day complication rates were not statistically significant between the two groups. CONCLUSION: Community hospitals can reduce length of stay and narcotic prescribing without compromising safety-related outcomes. Significant reductions in the amount of schedule II medications can be achieved when using multimodal enhanced recovery protocol approaches.

A Structured Approach for Safely Reintroducing Bariatric Surgery in a COVID-19 Environment.

Due to the profound effect of novel coronavirus disease 2019 (COVID-19) on healthcare systems, surgical programs across the country have paused surgical operations and have been utilizing virtual visits to help maintain public safety. For those who treat obesity, the importance of bariatric surgery has never been more clear. Emerging studies continue to identify obesity and several other obesity-related comorbid conditions as major risk factors for a more severe COVID-19 disease course. However, this also suggests that patients seeking bariatric surgery are inherently at risk of suffering severe complications if they were to contract COVID-19 in the perioperative period. The aim of this protocol is to utilize careful analysis of existing risk stratification for bariatric patients, novel COVID-19-related data, and consensus opinion from multiple academic bariatric centers within our organization to help guide the reanimation of our programs when appropriate and to use this template to prospectively study this risk-stratified population in real time. The core principles of this protocol can be applied to any surgical specialty.

Bariatric surgery is associated with a lower rate of death after myocardial infarction and stroke: A nationwide study.

AIM: To assess the potential protective effect of bariatric surgery on mortality after myocardial infarction (MI) or cerebrovascular accident (CVA). MATERIALS AND METHODS: Using the National Inpatient Sample (2007-2014), 2218 patients with a principal discharge diagnosis of acute MI and 2168 patients with ischaemic CVA who also had history of prior bariatric surgery were identified. Utilizing propensity scores, these patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Control group-1 included participants with obesity (BMI ≥ 35 kg/m2 ) only and participants in control group-2 were matched according to post-surgery BMI with the bariatric surgery group. The primary and secondary endpoints were in-hospital all-cause mortality and length of hospital stay, respectively. Outcomes after MI and CVA were separately compared among groups in multivariate regression models. RESULTS: A total of 48 300 (weighted) participants were included in the analysis. The distribution of covariates was well balanced after propensity matching. Mortality rates after MI were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.85% vs 3.03%; odds ratio (OR), 0.61; 95% confidence interval (CI), 0.44-0.86; P = 0.004) and with control group-2 (2.00% vs 3.26%; OR, 0.62; 95% CI, 0.44-0.88; P = 0.008). Similarly, in-hospital mortality rates after CVA were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.43% vs 2.74%; OR, 0.54; 95% CI, 0.37-0.79; P = 0.001) and with control group-2 (1.54% vs 2.59%; OR, 0.61; 95% CI, 0.41-0.91; P = 0.015). Furthermore, length of stay was significantly shorter in the bariatric surgery group for all comparisons (P < 0.001). CONCLUSION: Prior bariatric surgery is associated with significant protective effect on survival after MI and CVA.

Midterm outcomes of sleeve gastrectomy in the elderly.

BACKGROUND: The increase in life expectancy presents health systems with a growing challenge in the form of elderly obesity. Bariatric surgery has been shown to be a safe and effective treatment for obesity with reduction of excess weight and improvement in obesity-related co-morbidities. However, only recently have surgeons begun performing these operations on elderly patients on a larger scale, making data regarding mid- and long-term outcomes scarce. The objective of this study was to evaluate the safety and midterm efficacy of laparoscopic sleeve gastrectomy (LSG) in patients aged ≥60 years. METHODS: All patients aged ≥60 years who underwent LSG between 2008 and 2014 and achieved ≥24-month follow-up were retrospectively reviewed. Demographic characteristics and perioperative data were analyzed. Weight loss parameters and co-morbidity resolution rates were compared with preoperative data. RESULTS: In total 55 patients aged ≥60 years underwent LSG. Mean patient age was 63.9 ± 3.2 years (range, 60-75.2), and mean preoperative body mass index was 43 ± 6.0 kg/m2. Perioperative morbidity included 5 cases of hemorrhage necessitating operative exploration, 2 cases of reduced hemoglobin levels treated with blood transfusion, and 1 case of portal vein thrombosis managed with anticoagulation. There were no mortalities. Mean follow-up time was 48.6 (range, 25.6-94.5) months. Mean percentage of excess weight loss was 66.4 ± 19.7, 67.5 ±1 6.4, 61.4 ± 18.3, 66.7 ± 25.6, 50.7 ± 21.4 at 12, 24, 36, 37 to 60, and 61 to 96 months, respectively. Statistically significant improvement of type 2 diabetes, hypertension, and dyslipidemia were observed at the latest follow-up (P < .01). CONCLUSION: LSG offers an effective treatment of obesity and its co-morbidities in patients aged ≥60 years, albeit with a high perioperative bleeding rate at our center; efficacy is maintained for at least 4.5 years.

Single-port Laparoscopic Appendectomy: Beyond the Learning Curve: A Retrospective Comparison With Multi-port Laparoscopic Appendectomy.

OBJECTIVES: Previous comparisons between single-port laparoscopic appendectomy (SPLA) and multi-port laparoscopic appendectomy have been conflicting and limited. We compare our single-surgeon, SPLA experience with multi-port cases performed during the same time. METHODS: A retrospective chart review of 128 single-surgeon single-port and 941 multi-port laparoscopic appendectomy cases from April 2009 to December 2014 was conducted. RESULTS: Patient demographics and preoperative laboratory values were comparable. SPLA was associated with shorter operative time (P=0.0001). There was no statistically significant difference in length of hospitalization, postoperative pain medication use, cost, postoperative complication rates (ileus, urinary retention, deep space infection), or readmission between the 2 groups. There were no postoperative incisional hernias in the single-port group. The single-port group had more postoperative oxycodone use (P=0.0110). CONCLUSIONS: Our study supports recently published metaanalyses that fail to support older studies demonstrating longer operative times, and higher hernia rates with SPLA.

Which postoperative complications matter most after bariatric surgery? Prioritizing quality improvement efforts to improve national outcomes.

BACKGROUND: National quality programs have been implemented to decrease the burden of adverse events on key outcomes in bariatric surgery. However, it is not well understood which complications have the most impact on patient health. OBJECTIVE: To quantify the impact of specific bariatric surgery complications on key clinical outcomes. SETTING: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: Data from patients who underwent primary bariatric procedures were retrieved from the MBSAQIP 2015 participant use file. The impact of 8 specific complications (bleeding, venous thromboembolism [VTE], leak, wound infection, pneumonia, urinary tract infection, myocardial infarction, and stroke) on 5 main 30-day outcomes (end-organ dysfunction, reoperation, intensive care unit admission, readmission, and mortality) was estimated using risk-adjusted population attributable fractions. The population attributable fraction is a calculated measure taking into account the prevalence and severity of each complication. The population attributable fractions represents the percentage reduction in a given outcome that would occur if that complication were eliminated. RESULTS: In total, 135,413 patients undergoing sleeve gastrectomy (67%), Roux-en-Y gastric bypass (29%), adjustable gastric banding (3%), and duodenal switch (1%) were included. The most common complications were bleeding (.7%), wound infection (.5%), urinary tract infection (.3%), VTE (.3%), and leak (.2%). Bleeding and leak were the largest contributors to 3 of 5 examined outcomes. VTE had the greatest effect on readmission and mortality. CONCLUSION: This study quantifies the impact of specific complications on key surgical outcomes after bariatric surgery. Bleeding and leak were the complications with the largest overall effect on end-organ dysfunction, reoperation, and intensive care unit admission after bariatric surgery. Furthermore, our findings suggest that an initiative targeting reduction of post-bariatric surgery VTE has the greatest potential to reduce mortality and readmission rates.

The effect of pregnancy before and/or after bariatric surgery on weight loss.

BACKGROUND: Women of childbearing age represent 31%-36% of patients undergoing bariatric surgery. However, the influence of pregnancy before or after bariatric surgery on surgery outcomes is unclear. OBJECTIVES: The aim of the present study was to compare the effect of pregnancy before and after bariatric surgery on overall weight loss. SETTING: An academic center in the United States. METHODS: All female patients who had a successful pregnancy between 2005 and 2014 were included. The window of inclusion was≤3 years, either before or after surgery. Control patients included a cohort of female patients who had not been pregnant, matched on a 2:3 ratio for age, initial body mass index, type of procedure, and duration of follow-up. RESULTS: A total of 62 patients delivered within 3 years either before or after surgery. Data were compared with a matched cohort of 92 patients who had never conceived. Mean age at surgery was 33.8 years, and mean body mass index at surgery was 48.2 kg/m(2). Laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding were performed in 75.9%, 12.9%, and in 11.0% of cases, respectively. After an average matched follow-up period of 43.9 months, percentage excess weight loss was 68.0%±26.0% in the nonpregnant group compared with 53.0%±25.0% in the pregnant group (P<.01). The percentage total weight loss was 24.0%±11.0% in the study group compared with 31.0%±12.0% in the matched cohort (P<.01). Multivariate analysis showed that pregnancy before bariatric surgery had a more negative effect on weight loss compared with patients who had never been pregnant (odds ratio: -3.8; 95% confidence interval, -6.6 to -1.0; P< .01). CONCLUSION: Pregnancy before bariatric surgery increases the likelihood of reduced weight loss after surgery. Patients wishing to conceive should be informed that weight loss outcomes may vary depending on the timing of pregnancy relative to bariatric surgery.

Factors associated with length of stay in intensive care after bariatric surgery.

BACKGROUND: Although uncommon, admission to the intensive care unit (ICU) after bariatric surgery may be necessary. This study evaluates characteristics of bariatric surgery patients that are admitted to the ICU, and identifies possible risk factors for increased ICU length of stay (LOS). SETTING: Academic hospital, United States. METHODS: A retrospective review of all ICU admissions after bariatric surgery from 2006 to 2013 was performed. Demographic characteristics and perioperative data were extracted, and risk factors for the LOS and mortality in the ICU were analyzed. RESULTS: In total, 124 out of 4398 (2.8%) patients were admitted to the ICU after bariatric surgery. The mean age of these patients was 52.7±11.8 years and included 79 female patients (64%). There were 19 nonemergent or planned admissions (15.3%) and 105 unplanned admissions (84.7%). Mean body mass index was 47.8±12.2 kg/m2, and mean American Society of Anesthesiology (ASA) score was 3.1±0.6. Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding were performed in 80 (65%), 18 (15%), and 6 (5%) patients, respectively. Revisional procedures were performed in 15 (12%) patients. Respiratory failure was the most common cause for admission, occurring in 35 (28.2%) patients. The most common surgical complications requiring ICU admission were bleeding (n = 27) and anastomotic leak (n = 21). Mean ICU LOS was 6.0±9.6 (1-65) days. Mortality occurred in 5 (4.0%) patients. Based on univariate analysis, risk factors associated with ICU LOS were conversion from laparoscopic to open approach, anastomotic leak, time from operation to ICU admission, and reoperation. Higher ASA score was a significant risk factor for mortality. CONCLUSION: ICU admission after bariatric surgery is uncommon but is associated with a significantly increased mortality. Anastomotic leak, conversions, time from operation to ICU admission, and reoperation have the greatest impact in determining the LOS in the ICU after bariatric surgery.

Weight loss is higher among patients who undergo body contouring procedures after bariatric surgery.

BACKGROUND: As the number of patients who have undergone bariatric surgery increases, it is expected that more patients will present for body contouring procedures after weight loss. It has been reported that abdominoplasty can improve mobility, reduce skin fold complications, and improve psychosocial functioning. No previous studies have evaluated weight loss in patients who pursue plastic surgery after bariatric surgery. OBJECTIVES: The aim of this study is to evaluate weight loss outcomes in patients who choose to undergo body contouring procedures after bariatric surgery. SETTING: Academic center, United States. METHODS: Patients who underwent body contouring procedures after bariatric surgery between 2002 and 2014 were included. A comparison was made to a matched cohort based on age, gender, type of bariatric procedure, preoperative body mass index (BMI), and length of follow-up. RESULTS: In total, 186 patients had documentation of a body contouring procedure after bariatric surgery. There were 158 (84.9%) female participants in the body countering group. Mean age was 48.5±12.7 years and mean BMI was 49.8±10.4 kg/m2. Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding were performed in 157 (84.4%), 17 (9.1%), and 11 (5.9%) patients, respectively. After a matched follow-up period of 61 months, total weight loss was 43.0±22.6 kg in the body contouring group versus 33.5±21.7 kg in the control group (P<.001), percentage of total weight loss was 30.8±11.4% versus 24.0±13.2% (P<.001), percentage excess weight loss was 66.4±25% versus 52.5±30.5% (P<.001), and BMI dropped by 15.7±7.8 kg/m2 versus 12.1±7.3 kg/m2 (P<.001) in the body contouring group compared with the bariatric surgery-only group, respectively. Multivariate analysis indicated that body contouring after bariatric surgery is significantly associated with increase and durable weight loss (odds ratio 3.59, 95% confidence interval 2.04-5.14, P< .001). CONCLUSION: Patients who underwent body contouring procedures after bariatric surgery had significantly better long-term weight loss than a matched cohort of patients. This finding likely has many contributing factors, and the association between long-term weight loss and body contouring procedures after bariatric surgery requires more detailed study.

Total Weight Loss as the Outcome Measure of Choice After Roux-en-Y Gastric Bypass.

BACKGROUND: Currently, there is no agreement on the best method to describe weight loss (WL) after bariatric surgery. The aim of this study is to evaluate short-term outcomes using percent of total body weight loss (%TWL). METHODS: A single-institution retrospective study of 2420 patients undergoing Roux-en-Y gastric bypass (RYGB) was performed. Suboptimal WL was defined as %TWL < 20 % at 12 months. RESULTS: Mean preoperative BMI was 46.8 ± 7.8 kg/m(2). One year after surgery, patients lost an average 14.1 kg/m(2) units of body mass index (BMI), 30.0 ± 8.5 %TWL, and 68.5 ± 22.9 %EWL. At 6 and 12 months after RYGB, mean BMI and percent excess WL (%EWL) significantly improved for all baseline BMI groups (p < 0.01, BMI; p = 0.01, %EWL), whereas mean %TWL was not significantly different among baseline BMI groups (p = 0.9). The regression analysis between each metric outcome and preoperative BMI demonstrated that preoperative BMI did not significantly correlate with %TWL at 1 year (r = 0.04, p = 0.3). On the contrary, preoperative BMI was strongly but negatively associated with the %EWL (r = -0.52, p < 0.01) and positively associated with the BMI units lost at 1 year (r = 0.56, p < 0.01). In total, 11.3 % of subjects achieved <20 %TWL at 12 months and were considered as suboptimal WL patients. CONCLUSION: The results of our study confirm that %TWL should be the metric of choice when reporting WL because it is less influenced by preoperative BMI. Eleven percent of patients failed to achieve successful WL during the in the first year after RYGB based on our definition.

Bariatric and metabolic outcomes in the super-obese elderly.

BACKGROUND: Numerous reports address bariatric outcomes in super-obese or elderly patients, but data addressing this high-risk combination is lacking. OBJECTIVE: The objective of this study was to assess outcomes of bariatric surgery in the super-obese elderly. SETTING: Academic institution, United States. METHODS: All primary bariatric cases performed on patients aged 65 years or older with a body mass index (BMI) ≥ 50 kg/m(2) were retrospectively analyzed. Surgical approaches included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). RESULTS: Thirty patients (26 female, 4 male) with a mean age of 67.1 ± 2.7 years and BMI of 55.9 ± 3.9 kg/m(2), who had LRYGB (n = 16), LSG (n = 6), or LAGB (n = 8), were identified. There were no deaths, conversions, or intraoperative complications. Three patients were lost to follow-up after the 3-month visit. The early (<30 d) major morbidity rate was 10.0%. At a median follow-up of 37 (range, 6-95) months, the cohort had a mean BMI of 42.3 ± 6.7 kg/m(2), which corresponded to a mean percent excess weight loss of 44.5% ± 20.5% and mean percent total weight loss of 24.4% ± 12.2%. The most percent excess weight loss was achieved after LRYGB (54.1% ± 19.4%), followed by LSG (48.3% ± 10.2%) and then LAGB (26.2% ± 14.4%). Diabetic medication reduction in number and/or dosage was observed in 40% (6/15) patients, and 33% (5/15) of patients were completely off antidiabetic agents. CONCLUSIONS: Although further research is needed, the present data suggest that successful weight loss and metabolic improvement can be achieved safely in the high-risk population of super-obese elderly.

MANAGEMENT OF ENDOCRINE DISEASE: Metabolic effects of bariatric surgery.

Obesity is associated with an increased risk of type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, osteoarthritis, numerous cancers and increased mortality. It is estimated that at least 2.8 million adults die each year due to obesity-related cardiovascular disease. Increasing in parallel with the global obesity problem is metabolic syndrome, which has also reached epidemic levels. Numerous studies have demonstrated that bariatric surgery is associated with significant and durable weight loss with associated improvement of obesity-related comorbidities. This review aims to summarize the effects of bariatric surgery on the components of metabolic syndrome (hyperglycemia, hyperlipidemia and hypertension), weight loss, perioperative morbidity and mortality, and the long-term impact on cardiovascular risk and mortality.

Revisional bariatric surgery can improve refractory metabolic disease.

BACKGROUND: It remains unclear if patients undergoing revisional surgery for inadequate weight loss/recidivism can achieve improvement of refractory metabolic syndrome (MetS). OBJECTIVE: We aimed to evaluate metabolic outcomes after reoperative bariatric surgery for unsatisfactory weight loss in patients with refractory MetS. SETTING: Academic Hospital. METHODS: We retrospectively reviewed all revisional bariatric surgery cases performed for inadequate weight loss/recidivism at our center and analyzed all cases in which the patient had ongoing uncontrolled diabetes or MetS. RESULTS: In total, 121 reoperative bariatric cases for inadequate weight loss/recidivism were identified. Of those, 31.4% (N = 38) had MetS and 33.9% (N = 41) were diabetic at the time of primary bariatric surgery. At revisional surgery, 15 (39.5%) patients still met criteria for MetS and 7 (17.1%) had hemoglobin A1c (HbA1c)≥6.0%. Of those with refractory MetS (N = 15) at revisional surgery, a mean percent excess weight loss (%EWL) of 59.4±21.2% at mean 40.1±29.9 months follow-up corresponded to a mean decrease in triglyceride of 65.2 mg/dL, mean increase in high-density lipoprotein cholesterol (HDL) of 12.1 mg/dL, and mean decrease in plasma glucose of 58.8 mg/dL. Mean percent total weight loss was 27.3%. One patient still met criteria for MetS. Of those with HbA1c≥6.0% at reoperative surgery (N = 7), a mean %EWL of 63.0±22.9% at mean 51.6±36.6 months follow-up corresponded to a mean decrease in HbA1c of 1.6%. Three patients still had HbA1c≥6.0%, but only 1 had HbA1c≥ 6.5%. CONCLUSION: Although further research is needed, this report suggests that revisional bariatric surgery is capable of treating both inadequate weight loss and refractory metabolic disease.