Effect of Surgical Weight Loss on Plantar Fasciitis and Health-Care Use.

BACKGROUND:: Plantar fasciitis (PF) is one of the most common causes of heel pain. Obesity is recognized as a major factor in PF development, possibly due to increased mechanical loading of the foot due to excess weight. The benefit of bariatric surgery is documented for other comorbidities but not for PF. METHODS:: A retrospective medical record review was performed for patients with PF identified from a prospectively maintained database of the Cleveland Clinic Bariatric and Metabolic Institute. Age, sex, surgery, excess weight loss, body mass index (BMI), and health-care use related to PF treatment were abstracted. Comparative analyses were stratified by surgery type. RESULTS:: Two hundred twenty-eight of 10,305 patients (2.2%) had a documented diagnosis of PF, of whom 163 underwent bariatric surgery and were included in the analysis. Eighty-five percent of patients were women, mean ± SD age was 52.2 ± 9.9 years, and mean ± SD preintervention BMI was 45 ± 7.7. Postoperatively, mean ± SD BMI and excess weight loss were 34.8 ± 7.8 and 51.0% ± 20.4%, respectively. One hundred forty-six patients (90%) achieved resolution of PF and related symptoms. The mean ± SD number of treatment modalities used for PF per patient preoperatively was 1.9 ± 1.0 ( P = .25). After surgery, the mean ± SD number of treatment modalities used per patient was reduced to 0.3 ± 0.1 ( P = .01). CONCLUSIONS:: We present new evidence suggesting that reductions in BMI after bariatric surgery may be associated with decreasing the number of visits for PF and may contribute to symptomatic improvement.

Achalasia After Bariatric Surgery.

BACKGROUND: Obesity is an epidemic on the rise. Increasing body mass index (BMI) has been associated with a number of comorbid diseases, including rarely reported motility disorders such as achalasia. Motility disorders are prevalent in obese patients, possibly more prevalent when compared to the nonobese population. Identification of motility disorders is important before bariatric surgery and may alter the planned type of procedure performed. Limited data exist regarding the development or existence of esophageal motility disorders after bariatric surgery. This study aims to characterize patients who have undergone bariatric surgery and subsequently developed or were diagnosed with achalasia. METHODS: Patients with a diagnosis of achalasia who previously underwent bariatric surgery were identified. Data collected included baseline demographics, perioperative parameters, and postoperative outcomes. Descriptive statistics were computed for all variables. RESULTS: Ten patients met the inclusion criteria. All patients had endoscopy and manometry confirming diagnosis of achalasia after previous bariatric surgery. Eight patients had undergone Roux-en-Y gastric bypass (RYGB), and two patients had vertical banded gastroplasty (VBG). Median length of time from bariatric surgery to diagnosis was 6 years. Two patients had undergone Botox(®) treatment, and five had gone through the scope esophageal dilations. All patients had a surgical intervention for achalasia, specifically Heller myotomy (HM) (n = 4 open, n = 4 laparoscopic) was performed in the eight RYGB patients, whereas near total gastrectomy and esophagectomy (n = 1), and transhiatal esophagectomy with a partial gastrectomy (n = 1), were performed in each of the patients who previously underwent VBG. These patients were considered to have end-stage achalasia. All patients showed significant decrease in BMI after bariatric surgery (11.1 ± 1.5 kg/m(2)). Six of the eight patients who underwent HM achieved resolution of achalasia symptoms at a mean time of 1.6 months and remained asymptomatic for the total follow-up of 36 months. One patient developed recurrent achalasia 2 years after HM and subsequently underwent a peroral endoscopic myotomy. One HM patient was lost to follow-up. The two patients who underwent esophagectomies were symptom free at 36 months. CONCLUSION: Although the incidence of achalasia in the bariatric population is unknown, it does coexist and should be treated when identified. Dysmotility is not uncommon and rarely is the workup completed to identify achalasia before bariatric surgery. Increasing our attention to identify motility diseases preoperatively and specifically raising awareness that achalasia can occur after bariatric surgery will result in better care for patients. Our results suggest achalasia can be effectively treated with surgical therapy after previous bariatric surgery.

The Role of the Multidisciplinary Conference in the Evaluation of Bariatric Surgery Candidates with a High-Risk Psychiatric Profile.

Background: Implementation of a multidisciplinary conference (MC) attended by medical, surgical, nutrition, bioethics, and psychology specialists may help identify treatment plans for bariatric surgery candidates with a high-risk psychiatric profile. Methods: Data were assessed for all bariatric candidates evaluated by the MC in an academic center between January 2009 and December 2010. Results: A total of 134 patients of 2798 patients assessed by four different psychologists were subsequently evaluated by the MC. The most frequent psychiatric diagnoses were mood disorders (n = 37, 27.6%), anxiety disorders (n = 24, 17.9%), and binge eating disorder (n = 19, 14.1%). More than one psychiatric diagnosis was observed in 95.6% of the cohort. Substance abuse issues were present in 25% patients. Fifteen patients (11.2%) were eventually cleared and underwent surgery, 35 (26.1%) left the program before completing their requirements, and 84 patients (62.7%) were still working toward their individualized goals in the program. For those who underwent surgery, mean preoperative management duration was 221 days (range, 111-366) with an average of 11 preoperative psychiatric visits (range, 9-15). Conclusions: Patients with a high-risk psychosocial profile seeking bariatric surgery require multiple visits and resources to determine their candidacy. The majority of these patients are either deemed ineligible for surgery or require prolonged preoperative evaluation.

Paraesophageal Hernia Repair With Partial Longitudinal Gastrectomy in Obese Patients.

BACKGROUND AND OBJECTIVES: Treatment of gastroesophageal reflux disease (GERD) with hiatal hernia in obese patients has proven difficult, as studies demonstrate poor symptom control and high failure rates in this patient population. Recent data have shown that incorporating weight loss procedures into the treatment of reflux may improve overall outcomes. METHODS: We retrospectively reviewed 28 obese and morbidly obese patients who presented from December 2007 through July 2013 with large or recurrent type 3 or 4 paraesophageal hernia. All of the patients underwent combined paraesophageal hernia repair and partial longitudinal gastrectomy. Charts were retrospectively reviewed, and the patients were contacted to determine symptomatic relief. RESULTS: Mean preoperative body mass index was 38.1 ± 4.9 kg/m(2). Anatomic failure of prior fundoplication occurred in 7 patients (25%). The remaining 21 had primary paraesophageal hernia, 3 of which were type 4. Postoperative complications included pulmonary embolism (n = 1), pulmonary decompensation (n = 2), and wound infection (n = 1). Mean hospital stay was 5 ± 3 days. Upper gastrointestinal esophagogram was performed in 21 patients with no immediate recurrence or staple line dehiscence. Mean excess weight loss was 44 ± 25%. All of the patients surveyed experienced near to total resolution of their preoperative symptoms within the first month. At 1 year, symptom scores decreased significantly. At 27 months, however, there was a mild increase in the scores. Return of severe symptoms occurred in 2 patients, both of whom underwent conversion to gastric bypass. CONCLUSIONS: Combined laparoscopic paraesophageal hernia repair with longitudinal partial gastrectomy offers a safe, feasible approach to the management of large or recurrent paraesophageal hernia in well-selected obese and morbidly obese patients. Short-term results were promising; however, intermediate results showed increasing rates of reflux symptoms that required medical therapy or conversion to gastric bypass.

Pre-operative opioid analgesia reduces clinical success of laparoscopic gastric electrical stimulation placement in patients with gastroparesis.

INTRODUCTION: Gastroparesis is a common chronic and costly disorder for which medical therapy is often unsuccessful. Gastric electrical stimulation (GES) has been used to treat refractory cases, however, response is variable and difficult to predict. This study aims to assess whether pre-operative opioid analgesics (OA) use affects clinical success of GES. METHODS: Records of 128 patients who underwent laparoscopic GES placement from March 2001 to September 2012 were analyzed retrospectively. Data collected included demographics, surgical outcomes, and clinical parameters. Pre- and post-operative opioid analgesic dosing (No = 0 morphine equivalents (ME)/day, Low = 0-40 ME/day, Mid = 41-80 ME/day, High >80 ME/day), as well as clinical symptom assessment was collected for up to 3 years post-operatively. Clinical success was defined as (1) OA reduction of >50 %, (2) maintenance of weight, or (3) symptom improvement. Descriptive statistics were computed for all factors. A p < 0.05 was considered statistically significant. RESULTS: Fifty-three patients were on OA pre-operatively compared to 69 patients who were not. Patients not on OA pre-operatively were less likely than those on OA pre-op group to be on OA post-operatively (p = 0.005); however, there were no differences in weight or symptom improvement. Sub-group analysis of the 53 patients on OA demonstrated significant improvement in clinical symptoms in the low-morphine cohort compared to the mid-morphine cohort (p = 0.02), and OA dosing post-operatively in the low-morphine cohort diminished significantly compared to mid- and high-morphine cohort (p = 0.032). There was no significant difference in weight. CONCLUSION: OA dosing pre-operatively significantly affects clinical success of GES placement. Criteria for offering GES implantation may need to take OA dosing into consideration.

Exploring the impact of bariatric surgery on high density lipoprotein.

Low HDL cholesterol is an independent cardiac risk factor. A general efficacy gradient exists for the resolution of cardiovascular risk factors after bariatric surgery (i.e., biliopancreatic diversion [BPD]>Roux-en-Y gastric bypass [RYGB]>sleeve gastrectomy [SG]>adjustable gastric banding [AGB]). However, a review of high level of evidence clinical studies shows a different hierarchy for the effect of bariatric surgery on HDL (i.e., RYGB=SG>BPD, AGB). Surgically induced weight loss effectively reverses many steps in HDL metabolism that have been altered with obesity. Furthermore, enterocytes contribute to HDL levels through the synthesis of apolipoproteins A-IV and A-I. RYGB and SG that preserve the small intestine (particularly the jejunum) lead to a significant rise in HDL. However, when the small intestinal contribution does not reinforce the weight loss dependent mechanisms (e.g., after BPD and AGB), only a modest rise in HDL occurs. Further experimental and clinical studies are required to better delineate the issue.

Acute pancreatitis in patients after bariatric surgery: incidence, outcomes, and risk factors.

BACKGROUND: The incidence of acute pancreatitis (AP) in bariatric surgery patients is not known. Ouraim was to determine the incidence, outcomes, and risk factors of AP in post-bariatric surgery patients. METHODS: An historical cohort study was conducted of all patients who underwent Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric banding, and revisional procedures at our institution from January 2004 to September 2011. Patients who developed AP were identified by review of the electronic medical record. A nested case-control study using Cox regression analysis was done to identify risk factors. RESULTS: A total of 2695 patients underwent bariatric surgery. Twenty-eight patients (1.04 %) developed AP during a median follow-up of 3.5 years (interquartile range [IQR] 1.9-5.8). One patient had severe AP, and there was one AP-related death. In the case-control study, the only baseline variable that predicted post-operative AP was a prior history of AP. Three other variables identified after surgery were associated with AP: (1) rapid weight loss as measured by percent of excess weight loss (EWL) at the first post-operative visit, (2) abnormal findings on post-operative ultrasound (stones, sludge or ductal dilation), and (3) post-operative complications of bowel leak or anastomotic stricture. CONCLUSIONS: The incidence of AP in this cohort is 1.04 %, which is higher than that reported for the general population (~17/100,000, 0.017 %). Most cases were clinically mild and managed conservatively with good outcomes. Rapid post-operative weight loss and the presence of gallstones or sludge on post-operative ultrasound were significant risk factors for AP.

Laparoscopic resection of symptomatic gastric diverticula.

Gastric diverticula are rare and usually asymptomatic. This report, however, describes two examples of symptomatic gastric diverticula successfully treated by laparoscopic resection. Both patients were male and in their sixth decade of life. One patient was relatively healthy with no past medical history, whereas the other patient had chronic pain issues and at presentation was also undergoing evaluation for hyperaldosteronism. The patients presented with gastrointestinal symptoms, including nausea, emesis, abdominal pain, and change in bowel function. In both cases, a gastric diverticulum was identified by CT scan, and precise anatomic position was determined by upper endoscopy. After discussion with the treating teams, including a gastroenterologist and surgeon, surgical treatment and resection was elected. Successful laparoscopic removal was accomplished in both patients, and they were discharged home after tolerating liquid diets. Both patients reported resolution of their abdominal symptoms at follow-up.