Use of GLP-1 agonists in high risk patients prior to bariatric surgery: a cohort study.

INTRODUCTION: Body mass index (BMI) > 50 kg/m2 is associated with relatively increased morbidity and mortality with bariatric surgery (BS). There is reluctance to consider these patients operative candidates without preoperative weight loss. Glucagon-like peptide-1 (GLP-1) agonists have demonstrated effective weight loss in the post-BS setting. This study aims to determine the safety and efficacy of GLP-1 agonists in the pre-habilitation of patients with BMI > 50 kg/m2. METHODS: This is a retrospective review of bariatric surgery patients with BMI > 50 kg/m2 from a single bariatric center. Patients were compared by preoperative GLP-1 therapy status. All patients received medical, surgical, psychiatric, and nutritional evaluation and counseling. Preoperative BMI, change in weight from program intake until surgery, time to surgery, and perioperative complications were evaluated. RESULTS: 31 patients were included in the analysis. 18 (58%) received a GLP-1 agonist preoperatively. GLP-1 agonist use was associated with a 5.5 ± 3.2-point reduction in BMI compared to 2.9 ± 2.4 amongst controls (p = 0.026). There was no difference in the mean length of time in the bariatric program prior to surgery between groups (p = 0.332). There were no reported complications related to GLP-1 use in the preoperative setting and no difference in perioperative complications between groups (p = 0.245). DISCUSSION: GLP-1 agonist use in patients with a BMI > 50 kg/m2 results in significantly more weight loss prior to bariatric surgery, without increased time to surgery or complication rate. Further study is required to evaluate the long-term impact of preoperative GLP-1 agonist use prior to bariatric surgery. This therapy may improve perioperative and long-term outcomes in the very high-risk BMI population.

National usage of bariatric surgery for class I obesity: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

BACKGROUND: National and international consensus statements, as well as the National Institutes of Health (NIH), support the use of bariatric surgery for the treatment of class I obesity. Despite this, most payors within the United States limit reimbursement to the outdated 1991 NIH guidelines or a similar adaptation. OBJECTIVES: This study aimed to determine the safety of bariatric surgery in patients with lower BMI compared with standard patients, as well as determine U.S. utilization of bariatric surgery in class I obesity in 2015-2019. SETTING: A retrospective analysis was performed of the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass patients were divided into body mass index cohorts: class I obesity (<35 kg/m2) and severe obesity (≥35 kg/m2). Differences in preoperative patient selection and postoperative outcomes were established, and frequency trends were delineated. RESULTS: Analysis included 760,192 surgeries with 8129 (1%) for patients with class I obesity. The patients with class I obesity were older, more commonly female, and with lower American Society of Anesthesiologists (ASA) class, but with higher rates of type 2 diabetes, hyperlipidemia, and gastroesophageal reflux disease (P < .05). Variation was found for operative time, length of stay, 30-day readmission, and composite morbidity. Minimal annual variation was found for bariatric surgeries performed for patients with class I obesity. CONCLUSIONS: The short-term safety of bariatric surgery in patients with class I obesity was corroborated by this study. Despite consensus statements and robust support, rates of bariatric surgery in patients with class I obesity have failed to increase and remain limited to 1%. This demonstrates the impact of the outdated 1991 NIH guidelines regarding access to care for these potentially life-saving surgeries.

Medical student preparation for the operating room.

BACKGROUND: This study examines student perceptions of preparedness for the operating room (OR), resources used, and time spent in preparation. METHODS: Third-year medical and second-year physician assistant students across two campuses at a single academic institution were surveyed to assess perceptions of preparedness, time spent in preparation, resources used, and perceived benefits of preparation. RESULTS: 95 responses (response rate 49%) were received. Students reported being most prepared to discuss operative indications and contraindications (73%), anatomy (86%), and complications (70%), but few felt prepared to discuss operative steps (31%). Students spent a mean of 28 min preparing per case, citing UpToDate and online videos as the most used resources (74%; 73%). On secondary analysis, only the use of an anatomic atlas was weakly correlated with improved preparedness to discuss relevant anatomy (p = 0.005); time spent, number of resources or other specific resources were not associated with increased preparedness. CONCLUSION: Students felt prepared for the OR, though there is room for improvement and a need for student-oriented preparatory materials. Understanding the deficits in preparation, preference for technology-based resources, and time constraints of current students can be used to inform optimisation for medical student education and resources to prepare for operating room cases.

Effect of obesity on outcomes after breast reconstruction surgery, an analysis of national surgical quality improvement program.

BACKGROUND: Obesity is a risk factor for breast cancer and may affect the incidence, and outcomes of surgical treatment for breast cancer, including breast reconstruction. OBJECTIVE: This study aimed to evaluate outcomes of breast reconstruction in patients with obesity. METHODS: In a retrospective review of the NSQIP 2013-2018, adult patients who underwent breast reconstruction were included. Procedures were categorized to with or without an implant. Obesity was considered as body mass index(BMI)≥30 kg/m2. We made composite variables for 30-day any complication, wound complications, and major complications. Regression analysis was used to identify the independent effect of obesity on outcomes. RESULTS: A total of 46,042 patients were included(mean age 51.4 ± 11.1 years, 99.8% female). There were 3134(6.8%) patients with any complication, 2429(5.3%) with major, and 2772(6%) with wound complications, 2795 patients(6.1%) with unplanned re-operation, and 3 deaths. Obesity was an independent predictor of any complication, major complications, and wound complications(OR:1.83-1.87), and unplanned re-operation(OR:1.52). Wound complication was lower in the implant group(3.7% vs 10.9%) but obesity had a higher odds of wound complications in the implant group(2 vs 1.4). There was an increase in the odds of complications as BMI rises. CONCLUSION: Patients with a BMI>30 kg/m2 have a significantly higher risk of developing surgical complications following breast reconstruction with both implant and tissue reconstruction. Weight loss strategies should be considered in patients who need breast reconstruction surgeries and this may decrease the risk of postoperative wound complication and the need for reoperation.

Postoperative sepsis after primary bariatric surgery: an analysis of MBSAQIP.

BACKGROUND: Identifying patients at higher risk of postoperative sepsis (PS) may help to prevent this life-threatening complication. OBJECTIVES: This study aimed to identify the rate and predictors of PS after primary bariatric surgery. SETTING: An analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015-2017. METHODS: Patients undergoing elective sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were included. Exclusion criteria were revisional, endoscopic, and uncommon, or investigational procedures. Patients were stratified by the presence or absence of organ/space surgical site infection (OS-SSI), and patients who developed sepsis were compared with patients who did not develop sepsis in each cohort. Logistic regression was used to identify independent predictors of PS. RESULTS: In total, 438,752 patients were included (79.4% female, mean age 44.6±12 years). Of those, 661 patients (.2%) developed PS of which 245 (37.1%) developed septic shock. Out of 892 patients with organ/space surgical site infections (OS-SSI), 298 (45.1%) developed sepsis (P <.001). Patients who developed PS had higher mortality (8.8% versus .1%, P < .001), and this was highest in patients without OS-SSI (11.8% versus 5%, P = .002). The main infectious complications associated with PS in patients without OS-SSI were pneumonia and urinary tract infection. Independent predictors of PS in OS-SSI included RYGB versus SG (OR, 1.8), and age ≥50 years (OR, 1.4). Independent predictors of PS in patients without OS-SSI were conversion to other approaches (OR, 6), operation length >2 hours (OR, 5.7), preoperative dialysis (OR, 4.1), preoperative therapeutic anticoagulation (OR, 2.8), limited ambulation most or all of the time (OR, 2.4), preoperative venous stasis (OR, 2.4), previous nonbariatric foregut surgery (OR, 2), RYGB versus SG (OR, 2), hypertension on medication (OR, 1.5), body mass index ≥50 kg/m2(OR, 1.4), age ≥50 years (OR, 1.3), obstructive sleep apnea (OR, 1.3). CONCLUSION: Development of OS-SSI after primary bariatric surgery is associated with sepsis and increased 30-day mortality. Patients without OS-SSI who develop PS have a significantly higher mortality rate compared with patients with OS-SSI who develop PS. Early identification and intervention in patients with PS, including those without OS-SSI, may improve survival in this high-risk group.

Early cardiac complications after bariatric surgery: does the type of procedure matter?

BACKGROUND: Major adverse cardiac events (MACE) can be a cause of postoperative mortality. This is specifically important in bariatric surgery due to obesity-related cardiovascular risk factors. OBJECTIVE: To assess postoperative cardiac adverse events after bariatric surgery and its independent predictors. SETTING: A retrospective analysis of 2011-2015 Healthcare Cost and Utilization Project-National Inpatient Sample. METHODS: Data on patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were retrieved. MACE was identified as a composite variable including myocardial infarction, acute ischemic heart disease without myocardial infarction, and acute heart failure. Dysrhythmia (excluding premature beats) was identified as a separate outcome. Multivariate regression analysis for MACE was performed using demographic factors, co-morbidities, and type of surgery. RESULTS: The analysis included 108,432 patients (SG: 54.6%, RYGB: 45.4%). MACE was found in 116 patients (.1%), and dysrhythmia occurred in 3670 patients (3.4%). Median length of stay in patients with MACE was 4.5 versus 2 days in others (P < .001). There were 43 deaths overall, and 31 were in patients with MACE or dysrhythmia (P < .001). Age ≥ 50 years, male sex, congestive heart failure, chronic pulmonary disease, ischemic heart disease, history of pulmonary emboli, and fluid or electrolyte disorders were independent predictors of MACE based on multivariate analysis. Type of surgery (SG versus RYGB) was not an independent predictor for MACE (odds ratio 1.41, 95% confidence interval: .77-2.55). CONCLUSIONS: While cardiac complications are rare after bariatric surgery, their occurrence is associated with increased length of stay, hospital charges, and mortality. Older age, male sex, cardiopulmonary co-morbidities, and fluid or electrolyte disorders are predictive of MACE. RYGB does not increase the risk of MACE compared with SG.

Mortality in open abdominal aortic surgery in patients with morbid obesity.

BACKGROUND: Open abdominal aortic surgery is among procedures with high morbidity and mortality. Adverse postoperative complications may be more common in morbidly obese patients. OBJECTIVES: This study compared the outcomes of open abdominal aortic surgeries in patients with and without morbid obesity. SETTING: A retrospective analysis of 2007-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. METHODS: We included patients who underwent open abdominal aortic aneurysm (AAA) repair or open aorta-iliac-femoral (AIF) bypass. Demographic factors, morbid obesity, co-morbidities, and emergent versus elective surgery were considered for univariate and multivariate analyses. RESULTS: A total of 29,340 patients (13,443 AAA repair and 15,897 AIF bypass) were included (age 66.3 ± 10.8 years, 65.7% male). The mortality was 9.1% in 536 patients with morbid obesity compared with 7.1% in patients without morbid obesity. Based on multivariate analysis, age, existing co-morbidities, emergent versus elective setting, and morbid obesity were found to be independent predictors of mortality. Patients with morbid obesity had an odds ratio of 3.61 (95% CI, 1.50-8.68; P = .004) for mortality, longer mean length of stay (11.2 versus 9.3 days, P < .001), and higher total hospital charges ($99,500 versus $73,700, P < .001). CONCLUSIONS: Morbid obesity is an independent risk factor of mortality in patients undergoing open AAA repair and AIF bypass. Weight loss strategies should be considered for morbidly obese patients with an anticipation of open abdominal aortic procedures.

Predictors of mortality after elective ventral hernia repair: an analysis of national inpatient sample.

PURPOSE: Deciding between surgery and non-operative management of a non-obstructive ventral hernia (VH) in a high-risk patient often poses a clinical challenge. The aim of this study is to evaluate a national series of open and laparoscopic ventral hernia repair (VHR), and to assess predictors of mortality after elective VHR. METHODS: A retrospective analysis of 2008-2014 data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample was performed. All patients with a primary diagnosis of abdominal wall hernia were included. Inguinal, femoral, or diaphragmatic hernias were excluded. Patients were stratified by elective versus emergent repair. Factors associated with mortality after elective VHR were analyzed. RESULTS: 103,635 patients were studied, including 14,787 (14.3%) umbilical, 63,685 (61.5%) incisional, and 25,163 (24.3%) other ventral hernias. Operative procedures included 59,993 (57.9%) elective and 43,642 (42.1%) emergent VHR. 21.3% elective VHRs were laparoscopic versus 13% in emergent cases (P < 0.001). Mesh was used in 52,642 (87.7%) elective versus 27,734 (63.5%) emergent VHR (P < 0.001). Median (interquartile range) length of stay was 2(3) days in laparoscopic and 3(3) days in open group (P < 0.001). Mortality was 0.2% (n = 135) in elective and 0.6% (n = 269) in emergent group (P < 0.001). In elective group, mortality rates were equal among laparoscopic and open VHR (0.2%), while in emergent group, it was lower in laparoscopic VHR (0.4% vs 0.6%, P = 0.028). Multivariate analysis of elective VHR showed that the following factors were associated with mortality during hospitalization: age > 50 years [Odds ratio (OR) = 1.96], male gender (OR = 2.37), congestive heart failure (OR = 2.15), pulmonary circulation disorders (OR = 5.26), coagulopathy (OR = 3.93), liver disease (OR = 1.89), fluid and electrolyte disturbances (OR = 8.66), metastatic cancer (OR = 4.66), neurological disorders (OR = 2.31), and paralysis (OR = 5.29). CONCLUSIONS: VHR has a low mortality, especially when performed laparoscopically. In patients undergoing elective VHR, higher age and some comorbidities are predictors of mortality. These include congestive heart failure, pulmonary circulation disorders, coagulopathy, liver disease, metastatic cancer, neurological disorders, and paralysis. Conservative management should be considered for these high-risk subgroups in context of the overall clinical presentation.

Predictors of discharge destination in patients with major traumatic injury: Analysis of Oklahoma Trauma Registry.

BACKGROUND: The ability to predict the need for discharge of trauma patients to a facility may help shorten hospital stay. This study aimed to determine the predictors of discharge to a facility and develop and validate a predictive scoring model, utilizing the Oklahoma Trauma Registry (OTR). METHODS: A multivariate analysis of the OTR 2005-2013 determined independent predictors of discharge to a facility. A scoring model was developed, and positive and negative predictive values (PPV and NPV) were evaluated for 2014 patients. RESULTS: 101,656 patients were analyzed. The scoring model included age≥50 years, lower extremity fracture, ICU stay≥5 days, pelvic fracture, intracranial hemorrhage, congestive heart failure, cardiac dysrhythmia, history of CVA or TIA, and ISS≥15, spine fracture, diabetes mellitus, hypertension, ischemic heart disease, and chronic obstructive pulmonary disease. Applying the model to 2014 patients, PPV for predicting discharge to a facility was 84.9% for scores≥15, and NPV was 90.5% for scores<8. CONCLUSION: A scoring model including age, trauma severity, types of injury, and comorbidities could predict discharge of trauma patients to a facility. Further studies are needed to refine the efficacy of the model.