Body Weight and Prandial Variation of Plasma Metabolites in Subjects Undergoing Gastric Band-Induced Weight Loss.

BACKGROUND: Bariatric procedures are safe and effective treatments for obesity, inducing rapid and sustained loss of excess body weight. Laparoscopic adjustable gastric banding (LAGB) is unique among bariatric interventions in that it is a reversible procedure in which normal gastrointestinal anatomy is maintained. Knowledge regarding how LAGB effects change at the metabolite level is limited. OBJECTIVES: To delineate the impact of LAGB on fasting and postprandial metabolite responses using targeted metabolomics. SETTING: Individuals undergoing LAGB at NYU Langone Medical Center were recruited for a prospective cohort study. METHODS: We prospectively analyzed serum samples from 18 subjects at baseline and 2 months after LAGB under fasting conditions and after a 1-hour mixed meal challenge. Plasma samples were analyzed on a reverse-phase liquid chromatography time-of-flight mass spectrometry metabolomics platform. The main outcome measure was their serum metabolite profile. RESULTS: We quantitatively detected over 4,000 metabolites and lipids. Metabolite levels were altered in response to surgical and prandial stimuli, and metabolites within the same biochemical class tended to behave similarly in response to either stimulus. Plasma levels of lipid species and ketone bodies were statistically decreased after surgery whereas amino acid levels were affected more by prandial status than surgical condition. CONCLUSIONS: Changes in lipid species and ketone bodies postoperatively suggest improvements in the rate and efficiency of fatty acid oxidation and glucose handling after LAGB. Further investigation is necessary to understand how these findings relate to surgical response, including long term weight maintenance, and obesity-related comorbidities such as dysglycemia and cardiovascular disease.

Prior bariatric surgery in COVID-19-positive patients may be protective.

BACKGROUND: Patients infected with novel COVID-19 virus have a spectrum of illnesses ranging from asymptomatic to death. Data have shown that age, sex, and obesity are strongly correlated with poor outcomes in COVID-19-positive patients. Bariatric surgery is the only treatment that provides significant, sustained weight loss in the severely obese. OBJECTIVES: Examine if prior bariatric surgery correlates with increased risk of hospitalization and outcome severity after COVID-19 infection. SETTING: University hospital METHODS: A cross-sectional retrospective analysis of a COVID-19 database from a single, New York City-based, academic institution was conducted. A cohort of COVID-19-positive patients with a history of bariatric surgery (n = 124) were matched in a 1:4 ratio to a control cohort of COVID-19-positive patients who were eligible for bariatric surgery (BMI ≥40 kg/m2 or BMI >35 kg/m2 with a co-morbidity at the time of COVID-19 diagnosis) (n = 496). A comparison of outcomes, including mechanical ventilation requirements and deceased at discharge, was done between cohorts using χ2 test or Fisher's exact test. Additionally, overall length of stay and duration of time in intensive care unit (ICU) were compared using Wilcoxon rank sum test. Conditional logistic regression analyses were done to determine both unadjusted (UOR) and adjusted odds ratios (AOR). RESULTS: A total of 620 COVID-19-positive patients were included in this analysis. The categorization of bariatric surgeries included 36% Roux-en-Y gastric bypass (RYGB, n = 45), 36% laparoscopic adjustable gastric banding (LAGB, n = 44), and 28% laparoscopic sleeve gastrectomy (LSG, n = 35). The body mass index (BMI) for the bariatric group was 36.1 kg/m2 (SD = 8.3), which was significantly lower than the control group, 41.4 kg/m2 (SD = 6.5, P < .0001). There was also less burden of diabetes in the bariatric group (32%) compared with the control group (48%) (P = .0019). Patients with a history of bariatric surgery were less likely to be admitted through the emergency room (UOR = .39, P = .0001), less likely to require a ventilator during the admission (UOR=.42, P = .028), had a shorter length of stay in both the ICU (P = .033) and overall (UOR = .44, P = .0002), and were less likely to be deceased at discharge compared with the control group (OR = .42, P = .028). CONCLUSION: A history of bariatric surgery significantly decreases the risk of emergency room admission, mechanical ventilation, prolonged ICU stay, and death in patients with COVID-19. Even when adjusted for BMI and the co-morbidities associated with obesity, patients with a history of bariatric surgery still have a significant decrease in the risk of emergency room admission.

First-year weight loss following gastric band surgery predicts long-term outcomes.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) continues to be a valid surgical treatment option to address severe obesity. However, outcomes are varied and can be difficult to predict. Early prediction of suboptimal weight loss following LAGB may enable adjustments to postoperative care and consequently improve surgical outcomes. Therefore, our aim is to investigate the prognostic utility of using early weight loss following LAGB to predict long-term weight outcomes. METHODS: Clinical data from patients undergoing LAGB between 2001 and 2007 at a single institution were retrospectively collected and analysed. The data was used to inform a model for predicting long-term weight loss after LAGB surgery. Percent total weight loss (%TWL) greater than 20% 1 year after surgery was considered a measurement of success since it has been associated with the improvement of comorbidities and increased patient satisfaction. RESULTS: The average %TWL 1 year after LAGB surgery was 23.73% (n = 1524, SD = 8.68%). Weight loss of less than 10% in 1 year was a negative predictor of weight loss >20% in 8-12 years (OR = 0.449; p = 0.002; 95% CI = 0.272-0.742). Moreover, weight loss >20% in 1 year was a strong predictor of weight loss >20% in 8-12 years (OR = 5.33; p < 0.001; 95% CI = 3.17-8.97). CONCLUSION: Total body weight reduction of less than 10% 1 year after LAGB surgery suggests a lesser weight loss at 8-12 years. For these patients, targeted interventions would be appropriate to increase the chances of long-term success.

The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease.

BACKGROUND: The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. OBJECTIVE: To examine the effects of LSG on GERD symptoms. METHODS: One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7 months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). RESULTS: For the entire group, mean weight loss, %TWL, and reduction in BMI were 79 pounds, 28.1%, and 12.7 kg/m2 respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. CONCLUSION: These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.

Improving Operating Room Turnover Time in a New York City Academic Hospital via Lean.

BACKGROUND: Prolonged operating room turnover time erodes patient and employee satisfaction and value. METHODS: Lean and value stream mapping was applied to three operating room teams at an academic health center in New York City, and a solution called Performance Improvement Team (PIT Crew) was piloted. RESULTS: Overall, 10% of operating room turnover steps were considered nonvalued and were eliminated, and 25% of previously sequential steps were performed synchronously. Seven institutional dogmas were eliminated, and three hospital policies were changed. After 35 pilot turnovers, median operating room turnover time improved from 37 minutes (range, 26 to 167 minutes) in historic matched controls to 14 minutes (range, 10 to 45 minutes, p < 0.0001) for the PIT Crew. Cost of the PIT Crew was $1,298 daily, and estimated return on investment was $19,500 per day. CONCLUSIONS: Lean and value stream mapping identifies nonvalued steps in operating room turnover and affords opportunities for efficiency. Once institutional rules and dogma are changed, culture and workflow improve and turnover time substantially improves. This process adds cost but is profitable. Scalability and sustainability are under further study, as is the "halo effect" on the culture in other non-PIT Crew operating rooms.

Effects of a single subanaesthetic dose of ketamine on pain and mood after laparoscopic bariatric surgery: A randomised double-blind placebo controlled study.

BACKGROUND: When administered as a continuous infusion, ketamine is known to be a potent analgesic and general anaesthetic. Recent studies suggest that a single low-dose administration of ketamine can provide a long-lasting effect on mood, but its effects when given in the postoperative period have not been studied. OBJECTIVE: We hypothesised that a single low-dose administration of ketamine after bariatric surgery can improve pain and mood scores in the immediate postoperative period. DESIGN: We performed a randomised, double-blind, placebo-controlled study to compare a single subanaesthetic dose of ketamine (0.4 mg kg) with a normal saline placebo in the postanaesthesia care unit after laparoscopic gastric bypass and gastrectomy. SETTING: Single-centre, tertiary care hospital, October 2014 to January 2018. PATIENTS: A total of 100 patients were randomised into the ketamine and saline groups. INTERVENTION: Patients in the ketamine group received a single dose of ketamine infusion (0.4 mg kg) in the postanaesthesia care unit. Patients in the placebo groups received 0.9% saline. OUTCOME MEASURES: The primary outcome was the visual analogue pain score. A secondary outcome was performance on the short-form McGill's Pain Questionnaire (SF-MPQ). RESULTS: There were no significant differences in visual analogue pain scores between groups (group-by-time interaction P = 0.966; marginal group effect P = 0.137). However, scores on the affective scale of SF-MPQ (secondary outcome) significantly decreased in the ketamine group as early as postoperative day (POD) 2 [mean difference = -2.2 (95% bootstrap CI -2.9 to 1.6), Bonferroni adjusted P < 0.001], compared with placebo group in which the scores decreased only by POD 7. Scores on the total scale of SF-MPQ for the ketamine group were smaller compared with the placebo group (P = 0.034). CONCLUSION: Although there was no significant difference between ketamine and placebo for the primary outcome measure, patients who received ketamine experienced statistically and clinically significant improvement in their comprehensive evaluation of pain, particularly the affective component of pain, on POD 2. However, future studies are needed to confirm the enduring effects of ketamine on the affective response to postoperative pain. CLINICAL TRIAL REGISTRATION: NCT02452060. : This article is accompanied by the following Invited Commentaries:Mion G. Ketamine stakes in 2018. Right doses, good choices. Eur J Anaesthesiol 2019; 36:1-3.Robu B, Lavand'homme, P. Targeting the affective component of pain with ketamine. A tool to improve the postoperative experience? Eur J Anaesthesiol 2019; 36:4-5.

Gastric band conversion to Roux-en-Y gastric bypass shows greater weight loss than conversion to sleeve gastrectomy: 5-year outcomes.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are often used as revisional surgeries for a failed laparoscopic adjustable gastric band (LAGB). There is debate over which procedure provides better long-term weight loss. OBJECTIVE: To compare the weight loss results of these 2 surgeries. SETTING: University hospital, United States. METHODS: A retrospective review was conducted of all LAGB to RYGB and LAGB to LSG surgeries performed at a single institution. Primary outcomes were change in body mass index (BMI), percent excess BMI lost, and percent weight loss. Secondary outcomes included 30-day complications and reoperations. RESULTS: The cohort included 192 conversions from LAGB to RYGB and 283 LAGB to LSG. The baseline age and BMI were similar in the 2 groups. Statistical comparisons made between the 2 groups at 24 months postconversion were significant for BMI (RYGB = 32.93, LSG = 38.34, P = .0004), percent excess BMI lost (RYGB = 57.8%, LSG = 29.3%, P < .0001), and percent weight loss (RYGB = 23.4%, LSG = 12.6%, P < .0001). However, the conversion to RYGB group had a higher rate of reoperation (7.3% versus 1.4%, P = .0022), longer operating room time (RYGB = 120.1 min versus LSG = 115.5 min, P < .0001), and longer length of stay (RYGB = 3.33 d versus LSG = 2.11 d, P < .0001) than the LAGB to LSG group. Although not significant, the conversion to RYGB group had a higher rate of readmission (7.3% versus 3.5%, P = .087). CONCLUSION: Weight loss is significantly greater for patients undergoing LAGB conversion to RYGB than LAGB to LSG. However, those undergoing LAGB conversion to RYGB had higher rates of reoperation and readmission. Patients looking for the most effective weight loss surgery after failed LAGB should be advised to have RYGB performed, while also understanding the increased risks of the procedure.

Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass.

BACKGROUND: Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure. OBJECTIVE: To investigate long-term results of salvage gastric banding. SETTING: University Hospital, New York, United States. METHODS: Data were prospectively collected with retrospective review. Baseline characteristics were evaluated and weights at multiple time intervals (before RYGB, before LAGB, each year of follow-up). Additional data included approach (open or laparoscopic), operative time, hospital length of stay, and postoperative complications. RESULTS: A total of 168 patients underwent statistical analysis with 86 patients meeting inclusion for RYGB failure. The mean body mass index before RYGB was 48.9 kg/m2. Before LAGB, patients had an average body mass index of 43.7 kg/m2, with 10.4% total weight loss and 21.4% excess weight loss after RYGB. At 5-year follow-up, patients (n = 20) had a mean body mass index of 33.6 kg/m2 with 22.5% total weight loss and 65.9% excess weight loss. The long-term reoperation rate for complications related to LAGB was 24%, and 8% of patients ultimately had their gastric bands removed. CONCLUSION: The results of our study have shown that LAGB had good long-term data as a revisionary procedure for weight loss failure after RYGB.

Lack of Diagnosis of Pneumoperitoneum in Perforated Duodenal Ulcer After RYGB: a Short Case Series and Review of the Literature.

Perforated duodenal ulcer following RYGB is an unusual clinical situation that may be a diagnostic challenge. Only 23 cases have previously been reported. We present five cases. The hallmark of visceral perforation, namely pneumoperitoneum, was not seen in three of the four cases that underwent cross sectional imaging. This is perhaps due to the altered anatomy of the RYGB that excludes air from the duodenum. Our cases had more free fluid than expected. The bariatric surgeon should not wait for free intraperitoneal air to suspect duodenal perforation after RYGB.

Factor VIII elevation may contribute to portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy: a multicenter review of 40 patients.

BACKGROUND: Portomesenteric vein thrombosis (PMVT) has been increasingly reported after laparoscopic sleeve gastrectomy (LSG). Factor VIII (FVIII) is a plasma sialoglycoprotein that plays an essential role in hemostasis. There is increasing evidence that FVIII elevation constitutes a clinically important risk factor for venous thrombosis. OBJECTIVES: To report the prevalence of FVIII elevation as well as other clinical characteristics in a multicenter series of patients who developed PMVT after LSG. SETTING: University hospitals. METHODS: A retrospective review was conducted of all patients that developed PMVT after laparoscopic bariatric surgery from 2006 to 2016 at 6 high-volume bariatric surgery centers. RESULTS: Forty patients who developed PMVT postoperatively, all after LSG, were identified. During this timeframe, 25,569 laparoscopic bariatric surgery cases were performed, including 9749 LSG (PMVT incidence after LSG = .4%). Mean age and body mass index were 40 years (18-65) and 43.4 kg/m2 (35-59.7), respectively. Abdominal pain was the most common (98%) presenting symptom. Of patients, 92% had a hematologic abnormality identified, and of these, FVIII elevation was the most common (76%). The vast majority (90%) was successfully managed with therapeutic anticoagulation alone. A smaller number of patients required small bowel resection (n = 2) and surgical thrombectomy (n = 1). There were no mortalities. CONCLUSIONS: A high index of clinical suspicion and prompt diagnosis/treatment of PMVT usually leads to favorable outcomes. FVIII elevation was the most common (76%) hematologic abnormality identified in this patient cohort. Further studies are needed to determine the prevalence of FVIII elevation in patients seeking bariatric surgery.

The safety of laparoscopic sleeve gastrectomy among diabetic patients.

AIMS: Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric procedure. Although bariatric surgery is becoming increasingly recognized as a treatment option for diabetes, there remain concerns about the operative risks faced by diabetic patients. This study's objective was to determine the safety of bariatric surgery in diabetic patients, specifically the type 2 diabetic (T2DM) population. METHODS: Patients over 18 years of age with a body mass index (BMI) ≥ 35 kg/m2 who underwent LSG in 2012 in the ACS-NSQIP database were identified. Emergency cases were excluded from analysis. Data included patient demographics, comorbidities, length of stay, and 30-day complications. The primary outcome was 30-day overall complication rate, and secondary outcomes included major complications and reoperation rates. RESULTS: There were 6399 LSG in the NSQIP database in 2012. Three hundred and twenty-two patients were excluded for BMI < 35, and 15 cases were deemed emergencies and excluded. Of the 6062 LSG who met the study criteria, 4726 (78 %) of patients were non-diabetic, 941 (15.5 %) had T2DM, and 395 (6.5 %) had T1DM. T2DM patients were more likely to be male (28.9 vs. 19.3 %, p < 0.001), were older (47.6 years vs. 42.5 years, p < 0.001), and had a higher BMI (46.4 vs. 45.7 kg/m2, p = 0.027) compared with non-diabetics. The overall 30-day complication rate did not differ between groups (6.5 % T2DM vs. 5.6 % non-diabetic, p = 0.292). After controlling for possible confounders, T2DM remained at no increased risk of 30-day complications (OR 1.16, 95 % CI 0.87-1.55, p = 0.301). In sub-analyses of specific complications, T2DM had a slightly higher rate of blood transfusions (1.8 vs. 1.0 %, p = 0.037). Other postoperative complications did not differ between groups. The 30-day complication rate for type 1 diabetics was greater than for T2DM (9.9 vs. 6.5 %, p = 0.031) and non-diabetics (9.9 vs. 5.6 %, p < 0.001). CONCLUSION: Laparoscopic sleeve gastrectomy is a safe procedure for type 2 diabetics with regard to early postoperative complications.

Long-term outcomes after biliopancreatic diversion with and without duodenal switch: 2-, 5-, and 10-year data.

BACKGROUND: There are minimal long-term data on biliopancreatic diversion (BPD) with or without duodenal switch (BPD/DS). OBJECTIVES: To investigate the long-term weight loss, co-morbidity remission, complications, and quality of life after BPD and BPD/DS. SETTING: An academic, university hospital in the United States. METHODS: We conducted a retrospective review of patients who underwent BPD or BPD/DS between 1999 and 2011. Outcomes included weight loss measures at 2, 5, and 10-15 years postoperatively; co-morbidity remission; long-term complications; nutritional deficiencies; and patient satisfaction. RESULTS: One hundred patients underwent BPD (34%) or BPD/DS (64%). Mean preoperative body mass index (BMI) was 50.2 kg/m2. Mean follow up was 8.2 years (range: 1-15 yr) with 72% of eligible patients in active follow up at 10-15 years postoperatively. Excess weight loss (EWL) was 65.1% at 2 years, 63.8% at 5 years, and 67.9% at 10-15 years. Approximately 10% higher %EWL was achieved for those with preoperative BMI<50 kg/m2 versus≥50 kg/m2 and patients who underwent BPD/DS versus BPD. Although co-morbidities improved, 37% of patients developed long-term complications requiring surgery. There were no 30-day mortalities; however, there was one mortality from severe malnutrition. Nutritional deficiencies in fat-soluble vitamins, anemia, and secondary hyperparathyroidism were common. Overall, 94% of patients reported satisfaction with their choice of surgery. CONCLUSION: This clinical experience supports the long-term positive safety profile and efficacy of BPD and BPD/DS at a single U.S. center. Higher levels of excess weight loss are achieved by patients with a lower preoperative BMI and BPD/DS. Although nutritional deficiencies and postoperative complications are common, patient satisfaction remains high.

Reducing complications with improving gastric band design.

BACKGROUND: Adjustable gastric bands have undergone significant design changes since their introduction. Band diameter, balloon volume, and shape have been modified to create high balloon fill volumes but lower and more evenly distributed pressure on the upper stomach. There have been few comparative studies on complication rates with different band types. OBJECTIVES: To compare complication rates among different types of adjustable gastric bands at a single institution. SETTING: University-affiliated hospital, United States. METHODS: We performed a retrospective cohort study of adult patients with a body mass index ≥ 35.0 kg/m(2) who underwent laparoscopic adjustable gastric banding from January 1, 2001 to December 31, 2007 and were followed for at least 5 years. Primary outcomes of the analysis were complications requiring operative management at our institution within the first 5 years after initial band placement. Reoperative procedures included diagnostic laparoscopy, hiatal hernia repair, band repositioning, replacing the band, removing the band, and converting to another bariatric procedure. RESULTS: For this study, 2711 patients met the inclusion criteria-1827 (67.4%) women and 884 (32.6%) men. Bands initially implanted included first-generation bands, LAP-BAND™ 9.75 cm (24.0%), 10 cm (33.9%) and Vanguard (24.8%) and second-generation bands, AP standard (9.5%) and AP large (7.9%). Four hundred and eighty-five patients experienced complications requiring reoperation. The 5-year follow-up rate was 63.3%. In the first 5 postoperative years there were significantly fewer complications with second-generation bands (10.0% versus 19.5%, P<.0001). Smaller, older bands had the highest complication rates (LAP-BAND 9.75 cm, 28.2%) and complication rates decreased with each successive model. Rates of band removal were not different between first- and second-generation bands. The rate of multiple complications was low at 1.5%. CONCLUSION: First-generation bands are associated with higher complication rates. Our study found that complication rates decreased with each successive model. We can expect that future design modifications will continue improve the performance with the adjustable gastric band.

The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study.

BACKGROUND: Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG. METHODS: A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls. RESULTS: Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score ≥9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028]. CONCLUSIONS: Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2-3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.

Thirty-Day Readmission After Laparoscopic Sleeve Gastrectomy­a Predictable Event?

BACKGROUND: Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG). METHODS: We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission. RESULTS: Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) ≥3 days (OR 2.54, CI = [1.19, 5.40]), intraoperative drain placement (OR 3.11, CI = [1.58, 6.13]), postoperative complications (OR 8.21, CI = [2.33, 28.97]), and pain at discharge (OR 8.49, CI = [2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR 72.4, CI = [15.8, 330.5]). CONCLUSIONS: The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.

Long-term outcomes after Roux-en-Y gastric bypass: 10- to 13-year data.

BACKGROUND: Short- and mid-term data on Roux-en-Y gastric bypass (RYGB) indicate sustained weight loss and improvement in co-morbidities. Few long-term studies exist, some of which are outdated, based on open procedures or different techniques. OBJECTIVES: To investigate long-term weight loss, co-morbidity remission, nutritional status, and complication rates among patients undergoing RYGB. SETTING: An academic, university hospital in the United States. METHODS: Between October 2000 and January 2004, patients who underwent RYGB≥10 years before study onset were eligible for chart review, office visits, and telephone interviews. Revisional surgery was an endpoint, ceasing eligibility for study follow-up. Outcomes included weight loss measures and rates of co-morbidity remission, complications, and nutritional deficiencies. RESULTS: RYGB was performed in 328 patients with a mean preoperative body mass index of 47.5 kg/m(2). Of 294 eligible patients, 134 (46%) were contacted for follow-up at ≥ 10 years (10+Year follow-up). Mean percentage excess weight loss (%EWL) was 58.9% at 10+Year. Higher %EWL was achieved by non-super-obese versus super-obese (61.3% versus 52.9%, P = .034). Blood pressure, lipid panel, and hemoglobin A1c improved significantly. At 10 years, remission of co-morbidities was 46% for hypertension and hyperlipidemia and 58% for diabetes mellitus. Thirty patients (9%) had revisional surgery for weight regain. Sixty-four patients (19.5%) had long-term complications requiring surgery. All-cause mortality was 2.7%. Nutritional deficiencies were seen in 87% of patients. CONCLUSIONS: Weight loss after RYGB appears to be significant and sustainable, especially in the non-super-obese. Co-morbidities are improved, with a substantial number in remission a decade later. Nutritional deficiencies are almost universal.

Weight loss outcomes among patients referred after primary bariatric procedure.

BACKGROUND: Bariatric patients may not always obtain long-term care by their primary surgeon. Our aim was to evaluate weight loss outcomes in patients who had surgery elsewhere. METHODS: We conducted a retrospective analysis. Postreferral management included nonsurgical, revision, or conversion. Primary outcomes were percent excess weight loss (%EWL) overall, according to original operation, and based on postreferral management. RESULTS: Between 2001 and 2013, there were 569 patients. Mean follow-up was 3.1 years. Management was 42% nonsurgical, 41% revision, and 17% conversion. Overall, mean %EWL was 45.3%. Based on original surgery type, %EWL was 41.2% for adjustable gastric banding vs 58.3% for Roux-en-Y gastric bypass (P ≤ .0001). Management affected %EWL (41.2% nonsurgical vs 45.3% revision vs 55.1% conversion, P ≤ .0001). CONCLUSIONS: Patients referred after bariatric surgery can achieve satisfactory weight loss. This differs based on surgery type and management strategy.