Preoperative Frailty Assessment, Operative Severity Score, and Early Postoperative Loss of Independence in Surgical Patients Age 65 Years or Older.

BACKGROUND: Preoperative discussions around postoperative discharge planning have been amplified by the COVID pandemic. We wished to determine whether our preoperative frailty screen would predict postoperative loss of independence (LOI). STUDY DESIGN: This single-institutional study included demographic, procedural, and outcomes data from patients 65 years or older who underwent frailty screening before a surgical procedure. Frailty was assessed using the Edmonton Frail Scale. The Operative Severity Score was used to categorize procedures. The Hierarchical Condition Category risk-adjustment score, as calculated by the Centers for Medicare and Medicaid Services, was included. LOI was defined as an increase in support outside of the home after discharge. Univariable, multivariable logistic regressions, and adjusted postestimation analyses for predictive probabilities of best fit were performed. RESULTS: Five hundred and thirty-five patients met inclusion criteria and LOI was seen in 38 patients (7%). Patients with LOI were older, had a lower BMI, a higher Edmonton Frail Scale score (7 vs 3.0; p < 0.001), and a higher Hierarchical Condition Category score than patients without LOI. Being frail and undergoing a procedure with an Operative Severity Score of 3 or higher was independently associated with an increased risk of LOI. In addition, social dependency, depression, and limited mobility were associated with an increased risk for LOI. On multivariable modeling, frailty status, undergoing an operation with an Operative Severity Score of 3 or higher, and having a Hierarchical Condition Category score ≥1 were the most predictive of LOI (odds ratio 12.72; 95% CI, 12.04 to 13.44; p < 0.001). In addition, self-reported depression, weight loss, and limited mobility were associated with a nearly 11-fold increased risk of postoperative LOI. CONCLUSIONS: This study was novel, as it identified clear, generalizable risk factors for LOI. In addition, our findings support the implementation of preoperative assessments to aid in care coordination and provide specific targets for intervention.

Loss of Independence in Older Patients after Operation for Colorectal Cancer.

BACKGROUND: Disease-free survival is the cornerstone for colorectal cancer outcomes. Maintenance of independence may represent the preferred cancer outcome in older patients. Frailty and cognitive impairment are associated with adverse clinical outcomes after operation in patients ≥65 years. The aim of this study was to determine the impact of frailty and cognitive impairment on loss of independence (LOI) among colorectal cancer patients. STUDY DESIGN: From 2016 to 2018, patients undergoing operation for colorectal cancer and having geriatric-specific American College of Surgeons NSQIP variables recorded were included. Frailty was assessed using the modified frailty index. Loss of independence was defined by the need for assistance with activities of daily living. Complications were assessed using the Clavien-Dindo (CD) scoring system. Multivariable analyses examining LOI, length of stay (LOS), and 30-day postoperative complication and readmission were performed. RESULTS: There were 1,676 patients included. Preoperatively, 118 (7%) patients reported cognitive impairment, 388 (23%) patients used a mobility aid, and 82 (5%) patients were partially or totally dependent. Loss of independence upon discharge was seen in 344 (20.5%) patients and was independently associated with an increase in LOS (incidence rate ratio [IRR] 1.44, 95% CI 1.30 to 1.59) and major complication (odds ratio [OR] 1.86, 95% CI 1.36 to 2.53). Risk factors predictive of LOI upon discharge were increasing age, cognitive impairment, use of mobility aid, and postoperative delirium. In patients ≥80 years old, 93 (18%) had LOI at 30 days. Risk factors predictive of LOI at 30 days included a preoperative mobility aid, postoperative delirium, and the need for a new mobility aid. CONCLUSIONS: One of 5 older patients undergoing operation for colorectal cancer experience LOI, and risk factors include a decline in cognition and mobility. Future studies should evaluate risks for long-term LOI and explore interventions to optimize this patient population.

Implementation of an enhanced recovery program for bariatric surgery.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs have been successfully implemented in several surgical fields; however, there have been mixed results observed in bariatric surgery. Our institution implemented an enhanced recovery program with specific pre-, intra-, and post-operative protocols aimed at patients, nursing staff, and physicians. The aim of the study is to assess the effectiveness of the ERAS program. METHODS: Patients who underwent bariatric surgery prior to the implementation of the enhanced recovery program in the calendar year 2015 were compared to those who had surgery after implementation in 2017. Data for our institution was drawn from the Premier Hospital Database. Poisson and quantile regressions were used to examine the association between ERAS protocol and LOS and cost, respectively. Logistic regression was used to assess the impact of ERAS on 30-day complications and readmissions. RESULTS: 277 bariatric surgical procedures were performed in the pre-ERAS group, compared to 348 procedures post-ERAS. While there was a 25.6% increase in volume, there was no statistical difference between the patient populations or the type of procedure performed between the 2 years. A decrease in length of stay was observed from 2.77 days in 2015 to 1.77 days in 2017 (p < 0.001), while median cost was also cut from $11,739.03 to $9482.18 (p < 0.001). 30-day readmission rate also decreased from 7.94% to 2.86% (p = 0.011). After controlling for other factors, ERAS protocol was associated with decreased LOS (IRR 0.65, p < 0.001), cost (- $2256.88, p < 0.001), and risk of 30-day readmission (OR 0.37, p = 0.011). CONCLUSION: The implementation of a standardized enhanced recovery program resulted in reduced length of stay, cost, and 30-day readmissions. Total costs saved were greater than $800,000 in one calendar year. This study highlights that the value of an enhanced recovery program can be observed in bariatric surgery, benefiting both patients and hospital systems.

Opioid tolerance impacts compliance with enhanced recovery pathway after major abdominal surgery.

BACKGROUND: Opioid tolerant patients have been shown to have poor postoperative outcomes. Enhanced recovery pathways are evidence-based interventions that focus on optimizing recovery, and their effectiveness depends on the degree of compliance with the pathway. We wish to determine pathway compliance and its impact on postoperative outcomes in opioid tolerant patients undergoing abdominal surgery on an enhanced recovery pathway. METHODS: From December 2014 to June 2017, 646 patients undergoing major abdominal surgery on an enhanced recovery pathway were included. Patients <18 years and having emergency surgery were excluded. Compliance was measured to 14 perioperative pathway standards and high-compliance was defined as adhering to ≥75% standards. Opioid tolerance was defined as any patient taking a prescribed opioid medication equivalent to 60 mg of oral morphine per day for 1 week prior to surgery. The Colorectal Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity was used for risk-adjusted analyses. Outcomes of interest include length of stay, major complications (Clavien-Dindo ≥2), 30-day readmission rates, and mortality. RESULTS: Overall, 114 (18%) patients were opioid tolerant and 532 (82%) were not opioid tolerant. Opioid tolerant patients were less likely to be highly compliant with enhanced recovery pathway standards than non-tolerant patients (35% vs 54%; P < .001); particularly postoperative care standards. On adjusted analysis, opioid tolerance was associated with a 2-fold increase in readmissions following major abdominal surgery. Examining only those patients with opioid tolerance, adjusted analysis demonstrated that high compliance with the enhanced recovery pathway standards was independently associated with a 26% reduction in length of stay, over a 90% reduction in major complications, and mitigated the effect on readmissions. CONCLUSION: The authors provide evidence that opioid tolerance is associated with less favorable outcomes in patients undergoing major abdominal surgery on an enhanced recovery pathway, and this is likely due to a lack of pathway compliance. Establishing strategies to improve compliance in this challenging patient cohort may serve to mitigate the negative impact of opioid tolerance.

Changes in Gut Microbiome after Bariatric Surgery Versus Medical Weight Loss in a Pilot Randomized Trial.

BACKGROUND: Gut microbiota likely impact obesity and metabolic diseases. We evaluated the changes in gut microbiota after surgical versus medical weight loss in adults with diabetes and obesity. METHODS: We performed 16S rRNA amplicon sequencing to identify the gut microbial composition at baseline and at 10% weight loss in adults with diabetes who were randomized to medical weight loss (MWL, n = 4), adjustable gastric banding (AGB, n = 4), or Roux-en-Y gastric bypass (RYGB, n = 4). RESULTS: All participants were female, 75% reported black race with mean age of 51 years. At similar weight loss amount and glycemic improvement, the RYGB group had the most number of bacterial species (10 increased, 1 decreased) that significantly changed (p < 0.05) in relative abundance. Alpha-diversity at follow-up was significantly lower in AGB group compared to MWL and RYGB (observed species for AGB vs. MWL, p = 0.0093; AGB vs. RYGB, p = 0.0093). The relative abundance of Faecalibacterium prausnitzii increased in 3 participants after RYGB, 1 after AGB, and 1 after MWL. CONCLUSIONS: At similar weight loss and glycemic improvement, the greatest alteration in gut microbiota occurred after RYGB with an increase in the potentially beneficial bacterium, F. prausnitzii. Gut microbial diversity tended to decrease after AGB and increase after RYGB and MWL. Future studies are needed to determine the impact and durability of gut microbial changes over time and their role in long-term metabolic improvement after bariatric surgery in adults with type 2 diabetes. CLINICAL TRIAL REGISTRATION: NCTDK089557- ClinicalTrials.gov.

Obesity is associated with copper elevation in serum and tissues.

Copper misbalance has been linked to fat accumulation in animals and experimental systems; however, information about copper homeostasis in human obesity is limited. In this study, the copper status of obese individuals was evaluated by measuring their levels of copper and cuproproteins in serum, adipose and hepatic tissues. The analysis of serum trace elements showed significant positive and element-specific correlation between copper and BMI after controlling for gender, age, and ethnicity. Serum copper also positively correlated with leptin, insulin, and the leptin/BMI ratio. When compared to lean controls, obese patients had elevated circulating cuproproteins, such as semucarbazide-sensitive amine oxidase (SSAO) and ceruloplasmin, and higher SSAO activity and copper levels in visceral fat. Although hepatic steatosis reduces copper levels in the liver, obese patients with no or mild steatosis have higher copper content in the liver compared to lean controls. In conclusion, obese patients evaluated in this study had altered copper status. Strong positive correlations of copper levels with BMI and leptin suggest that copper and/or cuproproteins may be functionally linked to fat accumulation.

Comparative Effects of Medical Versus Surgical Weight Loss on Body Composition: a Pilot Randomized Trial.

OBJECTIVE: Bariatric surgery leads to more rapid and greater weight loss (WL) compared to medical weight loss (MWL), but the differences in body composition (BC) changes for these modalities remain unclear. Due to the known health risks associated with central adiposity, we compared the changes in regional distribution of fat mass (FM) and lean mass (LM) after surgical versus MWL. METHODS: In this 1:1:1 randomized trial among 15 persons with type 2 diabetes and body mass index (BMI) 30-39.9 kg/m2, we compared changes in BC, by dual-energy X-ray absorptiometry and abdominal computerized tomography, at time of 10%WL or 9 months after intervention (whichever came first). Participants underwent MWL, adjustable gastric banding (AGB), or Roux-en-Y gastric bypass (RYGB). Non-parametric tests evaluated BC differences (FM, LM, and visceral adipose tissue [VAT]) within and across all three arms and between pair-wise comparisons. RESULTS: Twelve female participants (75% African American) completed the study. Patient age, BMI, and baseline anthropometric characteristics were similar across study arms. AGB lost more LM (MWL - 5.2%, AGB - 10.3%, p = 0.021) and VAT (MWL + 10.9%, AGB - 28.0%, p = 0.049) than MWL. RYGB tended to lose more VAT (MWL +10.9%, RYGB - 20.2%, p = 0.077) than MWL. AGB tended to lose more LM than RYGB (AGB - 12.38%, RYGB - 7.29%, p = 0.15). CONCLUSIONS: At similar WL, AGB lost more LM and VAT than MWL; RYGB similarly lost more VAT. Given the metabolic benefits of reducing VAT and retaining LM, larger studies should confirm the changes in BC after surgical versus medical WL. CLINICAL TRIAL REGISTRATION: NCTDK089557 - ClinicalTrials.gov.

Compliance to an enhanced recovery pathway among patients with a high frailty index after major gastrointestinal surgery results in improved 30-day outcomes.

BACKGROUND: Enhanced recovery pathways have been shown to improve clinical outcomes after surgery. Concerns exist about the feasibility of implementing enhanced recovery pathways in frail patients, who are at a greater risk for adverse postoperative outcomes. This study evaluated compliance and outcomes after enhanced recovery pathway implementation in high-risk, abdominal surgery patients. METHODS: Patients entered into the American College of Surgeons National Surgical Quality Improvement Program database who underwent abdominal surgery after enhanced recovery pathway implementation at two Johns Hopkins Medical Institutions were included. Risk was assessed using the American College of Surgeons National Surgical Quality Improvement Program validated, modified 5-item frailty index. Primary outcomes included compliance with 14 enhanced recovery pathway standards and postoperative length of stay, major complications (Clavien-Dindo score II-IV), and 30-day readmission. RESULTS: This study included 646 patients who participated in our enhanced recovery pathway program and 65 patients with modified 5-item frailty index ≥ 2 before enhanced recovery pathway implementation. Overall, 325 patients (50.3%) were high compliers (>75% compliance) with enhanced recovery pathway standards, with similar proportions of patients with a modified 5-item frailty index ≥ 2 or < 2 achieving high compliance (51.6% vs 50.2%, P = .89, respectively). Examining causality for "low compliers" among patients with a high frailty score (modified 5-item frailty index ≥2) demonstrated significant less use of goal-directed therapy when compared with "high compliers" (43% vs 75%, P = .01). Low compliers were also less likely than high compliers to experience mobilization the day of surgery (43% vs 78%, P = .01), postoperative day 1 (43% vs 88%, P < .01), and postoperative day 2 (60% vs 100%, P < .01). In addition, low compliers were less likely than high compliers to have their diet advanced to solids on postoperative day 1 (17% vs 59%, P < .01) and have their Foley catheter removed on postoperative day 1 (45% vs 97%, P < .01). Comparing our pre-enhanced recovery pathway patients with our enhanced recovery pathway cohort with a high frailty score, enhanced recovery pathway patients had a significantly shorter length of stay (4.5 vs 6 days, P = .04). However, adjusted analysis demonstrated that high compliance, and not just the enhanced recovery pathway intervention among patients with a high frailty score, was independently associated with a decrease in length of stay (odds ratio 0.72, 95% confidence interval 0.63-0.82, P < .01) and a significant reduction in major complications (odds ratio 0.30, 95% confidence interval 0.14-0.65, P < .01. CONCLUSION: This study demonstrates that frail patients comply well with a robust enhanced recovery pathway protocol and subsequently experience improved outcomes. Targeted interventions that seek to maximize compliance with specific enhanced recovery pathway standards may further improve outcomes in this population.

High Compliance to an Enhanced Recovery Pathway for Patients ≥65 Years Undergoing Major Small and Large Intestinal Surgery Is Associated With Improved Postoperative Outcomes.

OBJECTIVE: This study was performed to evaluate compliance to an Enhanced Recovery Pathway (ERP) among patients ≥65 years and determine the effect of compliance on postoperative outcomes. SUMMARY BACKGROUND DATA: ERPs improve postoperative outcomes in patients undergoing major surgery. Given the inherent decline of the older surgical patient, the benefit of an ERP in this population has been questioned. METHODS: Patients undergoing major small and large intestinal surgery prior to and following ERP implementation at the Johns Hopkins Medical Institutions were entered into the ACS-NSQIP database. Outcomes included ERP compliance rates, complications, length of stay (LOS), and 30-day readmission rates were determined for older patients. RESULTS: Nine hundred seventy-four patients (693 < 65 yrs and 281 ≥ 65 yrs) were included. Of those ≥ 65 years, 142 (51%) were entered prior to and 139 (49%) were entered following ERP implementation. More ERP than pre-ERP patients underwent laparoscopic procedures (45.3% vs. 32.4%, P = 0.02), had disseminated malignancies (9.4% vs. 2.8%, P = 0.03), and smoked (14.4% vs. 4.9%, P = 0.01). Overall compliance was 74.5%, and 47% of older ERP patients achieved high compliance (≥75% compliance with ERP variables). High compliance was associated with a 30% decrease LOS (IRR: 0.7 P = 0.001) and 60% decrease in major (CD ≥ II) complications (OR: 0.4 P = 0.05). CONCLUSION: LOS and complication rates following implementation of an ERP were significantly improved in highly compliant elderly patients. Interventions to further improve outcomes should target decreasing variability by increasing individual compliance with an effective clinical pathway.

Robot-assisted versus laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: a propensity score-matched comparative analysis using the 2015-2016 MBSAQIP database.

BACKGROUND: Robotic-assisted bariatric surgery is part of the armamentarium in many bariatric centers. However, limited data correlate the robotic benefits to with clinical outcomes. This study compares 30-day outcomes between robotic-assisted and laparoscopic procedures for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). METHODS: Using the 2015-2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, patients between18- and 65-year-old were included. To adjust for potential confounders, 1:1 propensity-score matching (PSM) was performed using 22 preoperative characteristics. Second PSM analysis was performed adding operative time and conversion rate. RESULTS: 269,923 patients underwent SG (n = 190,494) or RYGB (n = 79,429). The operative time was significantly longer in the Robotic-assisted compared to laparoscopic approach either for SG (102.58 ± 46 vs. 73.38 ± 36; P < 0.001) or for RYGB (158.29 ± 65 vs. 120.17 ± 56; P < 0.001). In the SG cohort (12,877 matched cases), the robotic approach showed significant reduction of postoperative bleeding (0.16% vs. 0.43%; P < 0.001) and strictures (0.19% vs. 0.33%; P = 0.04) with similar results in the other 30-day outcomes in both analyses. Similarly, for the RYGB cohort (5780 matched cases), the robotic approach showed significantly fewer requirements for blood transfusions (0.64% vs. 1.16%; P = 0.004) with no statistically different results for the other's outcomes. Conversely, when adding operative time and conversion rate to the PSM analysis, the robotic platform showed significantly shorter length of stay (2.12 ± 1.9 vs. 2.30 ± 3.1 days; P < 0.001), reduction of anastomotic leak (0.52% vs. 0.92%; P = 0.01), renal complications (0.16% vs. 0.38%; P = 0.004), and venous thromboembolism (0.24% vs. 0.52%; P = 0.02). CONCLUSIONS: Our findings show that postoperative bleeding and blood transfusion are significantly reduced with the robotic platform, and after correcting for all factors including operative time, the robotic-assisted approach is associated with better postoperative outcomes especially for RYGB.

Cytokine, Chemokine, and Cytokine Receptor Changes Are Associated With Metabolic Improvements After Bariatric Surgery.

Context: Altered cytokine levels and chronic low-grade inflammation contribute to metabolic dysfunction in obesity. The extent of cytokine changes and their impact on metabolic improvements after bariatric surgery have not been fully explored. Objective: To compare 76 circulating cytokines, chemokines, and secreted cytokine receptors in subjects with obesity and lean subjects and determine how these cytokines are altered by bariatric surgery. Design, Setting, and Participants: A total of 37 patients with obesity and 37 lean patients in a cross-sectional study at an academic medical center. We also investigated cytokine changes in 25 patients with obesity after bariatric surgery. Intervention: Bariatric surgery (Roux-en-Y gastric bypass and vertical sleeve gastrectomy). Main Outcome Measures: Quantification of 76 circulating cytokines, chemokines, and secreted cytokine receptors. Results: A total of 13 cytokines were significantly higher, and 4 lower, in patients with obesity relative to lean controls. Soluble vascular endothelial growth factor receptor 2 (sVEGFR2), soluble TNF receptor (sTNFR) 1, and sTNFR2 were positively correlated, and soluble receptor for advanced glycation end-products was inversely correlated, with weight and body mass index. sTNFR2 was positively correlated with fasting glucose, homeostatic model assessment of insulin resistance, and hemoglobin A1c. After bariatric surgery, adiponectin increased, and leptin decreased. Elevated sVEGFR2 levels in patients with obesity were decreased (P = 0.01), whereas reduced chemokine (C-X-C motif) ligand (CXCL) 12 levels in patients with obesity increased (P = 0.03) after surgery. Patients with higher soluble interleukin receptor (sIL) 1R2 and sIL-6R levels before surgery had greater weight loss after surgery (P < 0.05). Conclusions: We demonstrate that chemokine (C-C motif) ligand (CCL) 14, sVEGFR2, and platelet-derived growth factor BB are elevated in obesity, and CXCL12, CCL11, and CCL27 are lower in obesity. We found clinically concordant directionality between lean and patients with obesity and before vs after surgery for six cytokines, suggesting that bariatric surgery shifted the cytokine profiles of patients with obesity toward that of lean controls.

The incidence and risk factors associated with developing symptoms of hypoglycemia after bariatric surgery.

BACKGROUND: Hypoglycemia after bariatric surgery is an increasingly recognized metabolic complication associated with exaggerated secretion of insulin and gut hormones. OBJECTIVE: We sought to determine the incidence of hypoglycemic symptoms (hypo-sx) after bariatric surgery and characteristics of those affected compared with those unaffected. SETTING: University hospital. METHODS: We collected retrospective survey data from the patients who underwent bariatric surgery at a single center. Based on number and severity of postprandial hypo-sx in Edinburgh hypoglycemia questionnaire postoperatively, patients without preoperative hypo-sx were grouped into high versus low suspicion for hypoglycemia. We used multivariable logistic regression to examine potential baseline and operative risk factors for the development of hypo-sx after surgery. RESULTS: Among the 1119 patients who had undergone bariatric surgery who received the questionnaire, 464 (40.6%) responded. Among the 341 respondents without preexisting hypo-sx, 29% (n = 99) had new-onset hypo-sx, and most were severe cases (n = 92) with neuroglycopenic symptoms. Compared with the low suspicion group, the high suspicion group consisted of more female patients, younger patients, patients without diabetes, and those who underwent Roux-en-Y gastric bypass with a longer time since surgery and more weight loss. In multivariate analysis, factors independently associated with incidence of hypo-sx after bariatric surgery were female sex (P = .003), Roux-en-Y gastric bypass (P = .001), and absence of preexisting diabetes (P = .011). CONCLUSIONS: New onset postprandial hypoglycemic symptoms after bariatric surgery are common, affecting up to a third of those who underwent bariatric surgery. Many affected individuals reported neuroglycopenic symptoms and were more likely to be female and nondiabetic and to have undergone Roux-en-Y gastric bypass.

Endoscopic Management of Recalcitrant Marginal Ulcers by Covering the Ulcer Bed.

BACKGROUND: Management options for marginal ulcers (MU) vary from medical therapy to revision surgery. Medical therapy is often ineffective and revision surgery is associated with a high morbidity and possible recurrence. AIMS: To evaluate technical feasibility, efficacy, and safety of endoscopic management of MU by covering the ulcer bed using oversewing and/or deploying a fully covered self-expandable metallic stent (FCSEMS). METHODS: Medical records of consecutive patients who underwent endoscopic suturing and/or FCSEMS deployment for recalcitrant MU between August 2016 and June 2017 at a single academic center were reviewed. Recalcitrant MU was defined as an ulcer that persists after 6 to 8 weeks despite maximal medical therapy (open capsule PPI, 40 mg bid as well as sucralfate qid), cessation of smoking and nonsteroidal anti-inflammatory drugs (NSAIDs), and Helicobacter pylori eradication. RESULTS: Eleven patients (age range 31-60; all females) with mean BMI of 27.72 ± 5.93 kg/m2 underwent endoscopic suturing and/or stent deployment for recalcitrant MU with abdominal pain at a median of 50 months (range 3-120) post-Roux-en-Y gastric bypass (RYGB). Seven patients were managed by oversewing, two were managed by FCSEMS, and two patients required both. Technical success was 100%. All patients reported resolution of abdominal pain at 1 week. Surveillance endoscopy performed in 10/11 (90.9%) patients at 8 weeks revealed complete ulcer healing in 9/10 (90%). No adverse events were reported. CONCLUSION: Endoscopic management is an effective and safe method to treat MU and should be considered an alternative to surgical revision. It appears effective for perforated and recalcitrant MU.

The Role of Laboratory Testing in Differentiating Type 1 Diabetes from Type 2 Diabetes in Patients Undergoing Bariatric Surgery.

BACKGROUND: It may be difficult to distinguish between adults with type 1 diabetes and type 2 diabetes by clinical assessment. In patients undergoing bariatric surgery, it is critical to correctly classify diabetes subtype to prevent adverse perioperative outcomes including diabetic ketoacidosis. This study aimed to determine whether testing for C-peptide and islet cell antibodies during preoperative evaluation for bariatric surgery could improve the classification of type 1 versus type 2 diabetes compared to clinical assessment alone. METHODS: This is a retrospective analysis of the Improving Diabetes through Lifestyle and Surgery trial, which randomized patients with clinically diagnosed type 2 diabetes and BMI 30-40 kg/m2 to medical weight loss or bariatric surgery; one participant was discovered to have type 1 diabetes after experiencing postoperative diabetic ketoacidosis. Using blood samples collected prior to study interventions, we measured islet cell antibodies and fasting/meal-stimulated C-peptide in all participants. RESULTS: The participant with type 1 diabetes was similar to the 11 participants with type 2 diabetes in age at diagnosis, adiposity, and glycemic control but had the lowest C-peptide levels. Among insulin-treated participants, fasting and stimulated C-peptide correlated strongly with the C-peptide area-under-the-curve on mixed meal tolerance testing (R = 0.86 and 0.88, respectively). Three participants, including the one with type 1 diabetes, were islet cell antibody positive. CONCLUSIONS: Clinical characteristics did not correctly identify type 1 diabetes in this study. Preoperative C-peptide testing may improve diabetes classification in patients undergoing bariatric surgery; further research is needed to define the optimal C-peptide thresholds.

Inversion Technique for the Removal of Partially Covered Self-Expandable Metallic Stents.

BACKGROUND AND AIMS: Partially covered self-expandable metallic stents (PCSEMS), although an effective treatment for anastomotic/staple line leaks and strictures, can be difficult to remove. This study examines the effectiveness of the inversion technique for the removal of PCSEMS in the treatment of leaks and strictures that occurred post-sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). METHODS: Consecutive patients who underwent PCSEMS removal for a leak and/or stricture post-SG or RYGB between July 2013 and December 2016 at the Johns Hopkins Medical Institutions were reviewed. All PCSEMS removals were first attempted via the inversion technique, which involves grasping the distal end of the stent and inverting it through itself. RESULTS: Fourteen patients (four males) underwent PCSEMS removal via the inversion technique for an anastomotic/staple line leak (50%), stricture (29%) or both (21%) post-SG (79%) or RYGB (21%). Technical success (successful removal of the stent) was achieved in one endoscopic session for 13 of the 14 PCSEMS (93%). One PCSEMS required the use of the stent-in-stent technique for removal. The median dwell time was 47 days (range 5-72). A distal partial occlusion developed in five patients (35%) due to tissue overgrowth and one PCSEMS (7%) migrated, necessitating premature removal. Eight patients (57%) experienced clinical success at follow-up, and six patients (43%) required subsequent treatment due to persistence or recurrence of the pathology. CONCLUSIONS: The inversion technique is a safe, effective, and efficient method of removing PCSEMS placed to correct anastomotic/staple line leaks and strictures post-SG and RYGB.

Weight regain in patients with symptoms of post-bariatric surgery hypoglycemia.

BACKGROUND: Weight regain (WR) and symptoms of post-bariatric surgery hypoglycemia (PBSH) are metabolic complications observed in a subset of postbariatric patients. Whether hypoglycemic symptoms are an important driver of increased caloric intake and WR after bariatric surgery is unknown. OBJECTIVE: This study aims to determine whether patients with PBSH symptoms have greater odds for WR. SETTING: Tertiary academic hospital. METHODS: Patients who underwent Roux-en-Y gastric bypass or sleeve gastrectomy at our tertiary academic hospital from August 2008 to August 2012 were mailed a survey, from which weight trajectory and PBSH symptoms were assessed. Percent WR was calculated as 100×(current weight-nadir weight)/(preoperative weight-nadir weight) and was compared between dates of survey completion and bariatric surgery. The primary outcome was WR≥10%, as a reflection of the median WR among respondents. Multivariable logistic regression was used to determine clinical factors that indicate greater odds for WR≥10% at the P<.05 level. RESULTS: Of 1119 potential patients, 428 respondents (40.6%) were eligible for analysis. WR was observed in 79.2% (n = 339), while 20.8% (n = 89) experienced either weight loss or no WR at a mean of 40.6±14.5 months. Median WR was 10.8% (interquartile range, 5.6-19.4). Odds of WR≥10% was significantly increased in those who experienced PBSH symptoms (odds ratio [OR] = 1.66; 95% confidence interval [CI]: 1.04-2.65), reported less adherence to nutritional guideline (OR = 2.36; 95% CI: 1.52-3.67), and had a longer time since surgery (OR = 1.05; 95% CI: 1.03-1.07). CONCLUSIONS: We found evidence that the presence of PBSH symptoms was associated with WR. Future studies should elucidate the role of hypoglycemia among other factors in post-bariatric surgery WR.

Outcomes of Partnered Individuals Undergoing Bariatric Surgery Together: A Single Institution Case Series.

There exists marked variation in weight loss among the 200,000 annual bariatric patients, and many of these patients struggle with weight regain. Several studies have suggested that positive social support may significantly impact bariatric surgery outcomes, leading to more excess weight loss and maintenance of this weight loss through appropriate lifestyle changes. We sought to understand this by assessing clinical and behavioral outcomes among married couples whereby both spouses underwent bariatric surgery at our institution. In our case series, we found evidence that married couples meet or exceed postoperative weight loss milestones at 12, 18, and 24 months and did not show signs of weight regain as a group at 18 or 24 months. Among partners who underwent the same clinical pathway at our single institution, women tended to lose more weight than men at 12 months. Additionally, while there was significant variation in postoperative follow-up among patients, we found that partners within couples typically exhibited the same behavior with respect to postoperative visits when they had their surgeries within a year of each other. This case series suggests that partnered patients undergoing bariatric surgery can meet or exceed weight loss outcomes and may practice similar follow-up adherence.

Endoscopic Suturing for Massively Bleeding Marginal Ulcer 10 days Post Roux-en-Y Gastric Bypass.

BACKGROUND: Marginal ulceration post Roux-en-Y gastric bypass (RYGB) with associated bleeding, although infrequently encountered, can be challenging to treat. Flexible endoscopic therapy is preferred over surgery due to its minimally invasive nature. Bleeding ulcers have traditionally been treated endoscopically by injecting epinephrine, bipolar hemostasis, or clips. Here, we describe our treatment with endoscopic suturing for a massively bleeding marginal ulcer after RYGB. METHODS: A 56-year-old female 10 days post RYGB underwent her fourth endoscopy for investigation and management of hematemesis and was found to have a large bleeding anastomotic ulcer. A Rothnet was utilized to remove large blood clots which obstructed endoscopic visualization. Two marginal ulcers were noted, and these were successfully oversewn with endoscopic suturing. The multimedia video (7 min) demonstrates the management of massively bleeding marginal ulcer after RYGB by endoscopic suturing. RESULTS: Patient had no further bleeding and tolerated diet the subsequent day. She was discharged home with no further episodes of hematemesis, and follow-up at 6 weeks showed well-healed ulcer on endoscopy. CONCLUSION: Endoscopic suturing of a bleeding marginal ulcer appears technically feasible and safe. It should be considered in the treatment algorithm prior to emergency surgery.

CTRP7 deletion attenuates obesity-linked glucose intolerance, adipose tissue inflammation, and hepatic stress.

Chronic low-grade inflammation and cellular stress are important contributors to obesity-linked metabolic dysfunction. Here, we uncover an immune-metabolic role for C1q/TNF-related protein 7 (CTRP7), a secretory protein of the C1q family with previously unknown function. In obese humans, circulating CTRP7 levels were markedly elevated and positively correlated with body mass index, glucose, insulin, insulin resistance index, hemoglobin A1c, and triglyceride levels. Expression of CTRP7 in liver was also significantly upregulated in obese humans and positively correlated with gluconeogenic genes. In mice, Ctrp7 expression was differentially modulated in various tissues by fasting and refeeding and by diet-induced obesity. A genetic loss-of-function mouse model was used to determine the requirement of CTRP7 for metabolic homeostasis. When fed a control low-fat diet, male or female mice lacking CTRP7 were indistinguishable from wild-type littermates. In obese male mice consuming a high-fat diet, however, CTRP7 deficiency attenuated insulin resistance and enhanced glucose tolerance, effects that were independent of body weight, metabolic rate, and physical activity level. Improved glucose metabolism in CTRP7-deficient mice was associated with reduced adipose tissue inflammation, as well as decreased liver fibrosis and cellular oxidative and endoplasmic reticulum stress. These results provide a link between elevated CTRP7 levels and impaired glucose metabolism, frequently associated with obesity. Inhibiting CTRP7 action may confer beneficial metabolic outcomes in the setting of obesity and diabetes.

Vitamin D status and supplementation before and after bariatric surgery: a comprehensive literature review.

BACKGROUND: Bariatric surgery is the most effective long-term weight loss method. The most common procedures are Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG). Bariatric patients are at high risk of vitamin D deficiency (VDD) and insufficiency (VDI), which are associated with skeletal and nonskeletal ailments. There is no consensus regarding the optimal treatment for VDD/VDI in bariatric patients. OBJECTIVES: To critically examine the literature on vitamin D status (serum 25[OH]D concentrations) pre- and postbariatric surgery as well as supplementation regimens currently used. METHODS: We searched PubMed, Embase, and Cochrane from inception to May 2015 for articles relating to vitamin D, RYGB, and VSG. Of 208 citations retrieved, 30 were included. RESULTS: Preoperative VDD (<20 ng/mL) ranged from 13% to 90%, while VDI (<30 ng/mL) was found in up to 98%. Prevalence remained similar postoperatively and was highest after RYGB. Most studies found dosages<800 IU daily insufficient postbariatric surgery. Other studies examined the effectiveness of dosages between 1000 and 5000 IU daily, reaching similar conclusions. Several studies suggested using 50,000 IU weekly plus a daily dose. No studies reported optimization. CONCLUSIONS: It is widely accepted that serum 25(OH)D concentrations above 30 ng/mL are optimal; however, current postbariatric vitamin D supplementation fails to raise 25(OH)D above that level universally. This review highlights both the great need and the lack of consensus on the optimal supplementation regimen (dosage and frequency) for pre- and postbariatric patients. Future studies should investigate multiple regimens and attempt to identify methods for personalizing these regimens if found necessary.