Treatment of esophageal adenocarcinoma in patients with a history of bariatric surgery.

BACKGROUND: The relationship among obesity, bariatric surgery, and esophageal adenocarcinoma (EAC) is complex, given that some bariatric procedures are thought to be associated with increased incidence of reflux and Barrett's esophagus. Previous bariatric surgery may complicate the use of the stomach as a conduit for esophagectomy. In this study, we presented our experience with patients who developed EAC after bariatric surgery and described the challenges encountered and the techniques used. METHODS: We conducted a retrospective review of our institutional database to identify all patients at our institution who were treated for EAC after previously undergoing bariatric surgery. RESULTS: In total, 19 patients underwent resection with curative intent for EAC after bariatric surgery, including 10 patients who underwent sleeve gastrectomy. The median age at diagnosis of EAC was 63 years; patients who underwent sleeve gastrectomy were younger (median age, 56 years). The median time from bariatric surgery to EAC was 7 years. Most patients had a body mass index (BMI) score of >30 kg/m2 at the time of diagnosis of EAC; approximately 40% had class III obesity (BMI score > 40 kg/m2). Six patients (32%) had known Barrett's esophagus before undergoing a reflux-increasing bariatric procedure. Sleeve gastrectomy patients underwent esophagectomy with gastric conduit, colonic interposition, or esophagojejunostomy. Only 1 patient had an anastomotic leak (after esophagojejunostomy). CONCLUSION: Endoscopy should be required both before (for treatment selection) and after all bariatric surgical procedures. Resection of EAC after bariatric surgery requires a highly individualized approach but is safe and feasible.

A second chance for a new heart? The role of metabolic and bariatric surgery in patients with end-stage heart failure.

BACKGROUND: Obesity is an independent risk factor for heart failure (HF). Substantial weight loss has been shown to reverse obesity-related cardiomyopathy. This study aimed to report our institution's experience with laparoscopic sleeve gastrectomy (LSG) in patients with morbid obesity and end-stage HF. METHODS: Between 2018 and 2022, 26 patients with end-stage HF were referred for LSG. Of 26 patients, 16 underwent an operation, and 10 did not. After institutional review board approval, a retrospective electronic medical record review was performed to evaluate (i) age, (ii) preoperative weight, (iii) decrease in body mass index (BMI) score, (iv) whether the patient underwent heart transplantation, and (v) mortality. Data analysis was performed using Stata/SE (version 17.0; StataCorp). The Wilcoxon rank-sum test was used to compare continuous variables between the cohorts, and the Pearson chi-square test was used for binary variables with Bonferroni correction applied. RESULTS: The LSG and non-LSG cohorts had comparable ages (P = .088) and starting BMI score (P = .918), and a proportion of patients had a ventricular assist device (P = .191). Patients who underwent LSG lost significantly more weight than the patients who did not, with an average decrease in BMI score of 8.9 kg/m2 (SD, ±6.13) and 1.1 kg/m2 (SD, ±4.10), respectively (P = .040). Of note, 6 patients (37.5%) who underwent LSG eventually underwent transplantation, compared with 2 patients (20.0%) from the matched cohort (P = .884). Of the 26 patients, there were 6 deaths: 2 (12.5%) in the LSG cohort and 4 (40.0%) in the non-LSG cohort (P = .525). CONCLUSION: LSG may be safe and effective for weight loss in patients with HF. This operation may provide patients affected by obesity with end-stage HF the lifesaving opportunity to achieve transplant candidacy.

First national analysis of severe obesity hospitalizations in Italy: insights from discharge card database.

Background: Obesity is associated with numerous severe diseases necessitating intensive healthcare for diagnosis and treatment. Most patients with obesity, especially in its severe form, require at least one hospitalization. However, few studies in Italy have assessed the burden of obesity on the National Health System. This study aims to routinely estimate the 'disease burden' by analyzing hospital admissions related to severe obesity. Subjects: We analyzed the medical records of the Italian national hospital discharge database, including all patients older than 18 years discharged with the diagnosis of 'severe obesity'.' We included patients who underwent bariatric surgery, even without an explicit obesity code, such as laparoscopic restrictive gastric procedures, other stomach operations, and high gastric bypass. Special focus was given to those who underwent abdominal reshaping surgery. The cross-sectional survey PASSI in Italy served as an additional data source to estimate. The phenomenon was described using appropriate indicators, including rates and ratios between rates. Linear regression was employed to analyze trends in standardized rates over time. Results: Between 2014 and 2021, a total of 243,325 patients were discharged with a severe obesity code in Italy. Among these patients, 36.8% underwent at least one bariatric surgery procedure. We investigated the types of bariatric surgery procedures performed. The most frequent procedure was "other operations on the stomach," where sleeve gastrectomy is included which also appears to be steadily increasing during the study period together with the gastric bypass, while the gastric bondage is decreasing over time. Conclusion: These findings underscore the significant burden of severe obesity on Italy's healthcare system, a burden that is progressively increasing. The growing utilization of bariatric surgery suggests an escalating trend toward adopting drastic solutions to combat this health issue.

Risk factors for bariatric surgery in patients over 65 years of age-a multicenter retrospective cohort study.

PURPOSE: Societies are aging, life expectancy is increasing, and as a result, the percentage of elderly people in the population is constantly increasing. When qualifying patients over 65 years of age for bariatric surgery, the benefits and risks should be carefully assessed. Weighing risk factors against each other to improve the quality of life and better control of obesity-related diseases. The study aimed to determine risk factors for bariatric surgery among patients over 65 years of age. METHODS: A multicenter, retrospective analysis of patients undergoing laparoscopic bariatric procedures from 2008 to 2022. The patients were divided into two groups: complicated (C) and uncomplicated (UC). Uni- and multivariate logistic regression analysis was performed to obtain significant, independent risk factors. RESULTS: There were 20 (7.0%) patients in C group and 264 (93.0%) patients in UC group. The most common complication was intraperitoneal bleeding (8, 2.8). There was no postoperative mortality. The mean follow-up was 47.5 months. In a multivariate logistic regression analysis, length of stay and %EWL significantly corresponded to general complications (OR 1.173, OR 1.020). A higher weight loss before surgery lowered the risk for hemorrhagic events after surgery (OR 0.889). A longer length of stay corresponded to leak after surgery (OR 1.175). CONCLUSIONS: Bariatric and metabolic surgery appears to be a safe method of obesity treatment in patients over 65 years of age. The most common complication was intraperitoneal bleeding. A prolonged hospital stay may increase the risk of leakage, while a higher weight loss before the surgery may lower the risk of bleeding.

Comparative impact of Roux-en-Y gastric bypass, sleeve gastrectomy or diet alone on beta-cell function in insulin-treated type 2 diabetes patients.

Although bariatric surgery is an effective treatment for type 2 diabetes by inducing weight loss and augmenting gut hormone secretion, the immediate effect on beta-cell function itself remains to be elucidated in type 2 diabetes. Therefore, a prospective, randomized trial was performed in 30 patients with insulin-treated type 2 diabetes and a body mass index ≥ 35 kg/m2. Patients were randomly assigned (1:1:1) to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in combination with protein-sparing modified fast (PSMF), or to PSMF alone. Eu- and hyperglycemic clamps were performed before and 3 weeks after surgery and/or PSMF initiation. The primary outcome was the evolution of insulin sensitivity and beta-cell function after surgery, calculated using the composite measures of glucose disposal rate, insulin secretion rate, and disposition index (DI). Results revealed that markers of insulin sensitivity increased similarly in all arms (p = 0.43). A higher marker for maximal beta-cell function was observed when comparing SG to PSMF (p = 0.007). The DI showed a clear positive evolution after RYGB and SG, but not after PSMF alone. Altogether, these findings indicate that bariatric surgery results in an immediate beta-cell function recovery in insulin-treated type 2 diabetes.

Demographics and Outcomes of Glenohumeral Dislocations in Individuals With Elevated Body Mass Index.

INTRODUCTION: No specific study has investigated the characteristics and outcomes of anterior shoulder dislocations in morbidly obese individuals. The purpose of this study was to describe shoulder dislocations in patients with body mass index (BMI) greater than 40. METHODS: A retrospective review was conducted to identify patients aged 18 years and older with a BMI ≥40 who presented with a shoulder dislocation in a single institution from 2000 to 2020. Dislocation patterns, associated injuries, treatment modalities, and associated complications were recorded. RESULTS: A significant increase was noted in the number of patients with BMI greater than 40 presenting per year (r2 = -0.831, P < 0.01) over the past 20 years. A significant increase was noted in the average BMI per year in this population (r2 = 0.504, P = 0.028). Fifteen patients (19.5%) experienced at least one recurrent dislocation episode. Ten patients had a Bankart lesion that was associated with an elevated BMI (P = 0.04). Nine patients (11.7%) sustained an associated neurologic injury (no association with BMI). CONCLUSIONS: Over time, there has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations.

Banded One-Anastomosis Gastric Bypass (BOAGB) for Patients Living with Obesity and Extreme Obesity: A Single Institution's Experience.

BACKGROUND: The prevalence of patients suffering from extreme obesity (body mass index (BMI) ≥ 50) has significantly increased over the past three decades, surpassing the rise in the general population of overweight patients. Weight loss outcomes after bariatric surgery in patients suffering from extreme obesity are less favorable, with a higher incidence of weight regain. Variations of existing bariatric procedures have been proposed to address this issue. One such variation is adding a gastric band to limit the expansion of the newly created pouch. Limited data exist regarding the effectiveness of this procedure, called the banded one-anastomosis gastric bypass (BOAGB) procedure, compared to other bariatric procedures. METHOD: In this retrospective study, we compared all patients who underwent the BOAGB procedure at the Bariatric Surgery Unit in our Medical Center with a postoperative follow-up of at least 1 year with patients who underwent a one-anastomosis gastric bypass (OAGB) or sleeve gastrectomy (SG) procedures. Data collected included demographics, comorbidities, surgical outcomes, complications, and postoperative quality-of-life assessments. RESULTS: One hundred eleven patients were enlisted to our study during the relevant study period-24 patients underwent the BOAGB procedure, 43 underwent OAGB, and 44 underwent a SG. Lost to follow-up beyond 30 days was 9% (at 1-year post-surgery, we were able to establish contact with 101 patients). The pre-op BMI was significantly higher in the BOAGB group compared to the other procedures. Additionally, a higher prevalence of diabetes was observed in the BOAGB group. The duration of surgery was significantly longer for the BOAGB procedure. No significant differences were found in surgical complications. Overall, all procedures resulted in significant excess weight loss (EWL) or change in BMI, improvement in comorbidities, and improved quality of life postoperatively. CONCLUSIONS: The BOAGB procedure, like OAGB and SG, demonstrated favorable weight loss outcomes and weight maintenance 1 year postoperatively without significant differences between the procedures. The BOAGB procedure is relatively new, with good bariatric outcomes and a favorable safety profile. Long-term study is needed to evaluate these various bariatric procedures' efficacy further.

Routine Upper Gastrointestinal Series Post-bariatric Surgery: Predictors, Usage, and Utility.

OBJECTIVE: To investigate usage and utility of routine upper gastrointestinal (UGI) series in the immediate post-operative period to evaluate for leak and other complications. METHODS: Single institution IRB-approved retrospective review of patients who underwent bariatric procedure between 01/08 and 12/12 with at least 6-month follow-up. RESULTS: Out of 135 patients (23%) who underwent routine UGI imaging, 32% of patients were post-gastric bypass (127) versus 4% of sleeve gastrectomy (8). In patients post-gastric bypass, 22 were found with delayed contrast passage, 3 possible obstruction, 4 possible leak, and only 1 definite leak. In patients post-sleeve gastrectomy, 2 had delayed passage of contrast without evidence of a leak. No leak was identified in 443 patients (77%) who did not undergo imaging. The sensitivity and specificity of UGI series for the detection of leak in gastric bypass patients were 100% and 97%, respectively, and the positive and negative predictive values were 20% and 100%, respectively. On univariate and multivariate analysis, sleeve gastrectomy patients (OR 0.4 sleeve vs bypass; P < 0.01) and male patients (OR 0.4 M vs F; P 0.02) were less likely to undergo routine UGI series (OR 0.4 M vs F; P 0.02). CONCLUSION: Routine UGI series may be of limited value for the detection of anastomotic leaks after gastric bypass or sleeve gastrectomy and patients should undergo routine imaging based on clinical parameters. Gastric bypass procedure and female gender were factors increasing the likelihood of routine post-operative UGI. Further larger scale analysis of this important topic is warranted.

Predictors of Chronic Pain 6 Months and 1 Year After Bariatric Surgery.

BACKGROUND: Obesity and chronic pain (CP) represent serious, interrelated global public health concerns that have a profound impact on individuals and society. Bariatric surgery is increasing in popularity and has been proven safe and efficacious, providing long-term weight loss and improvements in many obesity-related co-morbidities. A decrease in CP is often a motivation for bariatric surgery. The purpose of this study was to investigate the changes in CP postoperatively and to examine the relationship between psychosocial measures and pain. METHODS: A total of 155 adult bariatric surgery patients were recruited and completed self-report measures for CP severity and interference, neuropathic pain, anxiety, depression, emotion regulation and perceived social support at three timepoints preoperative and 6 and 12 months postoperative. RESULTS: Pain significantly decreased between preoperative and postoperative timepoints, and preoperative pain was the most significant predictor of postoperative pain. Preoperative CP was correlated with anxiety (p < 0.05) and depression (p < 0.01) at 6 months postoperatively and perceived social support (p < 0.01) at 1 year postoperatively. However, regression analyses with psychological variables were not significant. CONCLUSION: CP decreases after bariatric surgery, but further research with larger sample sizes is needed to establish whether psychosocial characteristics impact this outcome.

Bariatric Surgery in Patients with Achondroplasia, a Feasibility Study of Two Case Studies.

BACKGROUND: Achondroplasia is a common skeletal dysplasia with a high prevalence of obesity in adulthood. Bariatric surgery has been shown to be effective in treating obesity and related comorbidities, but its feasibility and effectiveness in patients with achondroplasia have not been clearly established. OBJECTIVES: The objective of this study was to evaluate the feasibility and effectiveness of bariatric surgery in patients with achondroplasia. SETTING: This study was performed in France, and bariatric surgeons from the Société Française et Francophone de Chirurgie de l'Obésité et des Maladies Métaboliques (French Francophone Society of Surgery for Obesity or Metabolic Diseases) were asked to participate. METHODS: Two adult women with confirmed achondroplasia and a high BMI were selected for laparoscopic sleeve gastrectomy. Preoperative data were collected, including demographic information, comorbidities, and follow-up at 1, 3, and 6 months and 1 year after surgery. Complications were monitored and recorded. RESULTS: Both patients had good excess weight loss outcomes, with an average excess weight loss of 60.5% 1 year after surgery. One patient had a follow-up of 3 years and an excess weight loss of 44%. The surgery was well-tolerated, and no major complications were observed. CONCLUSIONS: Bariatric surgery is feasible and effective in patients with achondroplasia, with good outcomes for excess weight loss and related comorbidities. These findings suggest that bariatric surgery should be considered a treatment option for patients with achondroplasia and obesity.

Septic Shock After Endoscopic Sleeve Gastroplasty: A Post-procedural Complication?

BACKGROUND: ESG is a safe and effective technique in the obesity management, usually indicated in class I and II obesity. It is also an acceptable treatment in patients with class III obesity who have high surgical risk or refuse surgery. This procedure results in a significant weight loss and important improvement in metabolic comorbidities. Nevertheless, there are several procedure-related complications. Few cases of gastric perforation following ESG have been reported. We present a case of septic shock after ESG with preoperative diagnostic uncertainties. METHODS: We present the case of a 54-year-old male with a BMI of 43.6 kg/m2 who underwent ESG 7 days before in an external center. The patient came to the emergency department presenting abdominal pain, nausea, and vomiting since the day after the procedure. Physical examination revealed hemodynamic instability, altered level of consciousness, diffuse abdominal pain, and a painful umbilical lump due to a complicated umbilical hernia. Emergent surgery was decided after preoperative assessment. RESULTS: Intraoperative gastroscopy was performed, viewing a gastric ischemic ulcer covered with fibrin and a mucosal defect and suspecting a covered gastric perforation. Firstly, we performed an open approach to the complicated umbilical hernia. Subsequently, an exploratory laparoscopy was performed through the hernial ring, where a fibrin-covered area was evidenced in the anterior face of the gastric body, adhered to the round ligament by a transmural suture of the ESG. Additionally, multiple transmural sutures were observed adhered to the greater omentum and lesser sac and an intramural hematoma in the greater gastric curvature. No intra-abdominal free fluid was evidenced. A laparoscopic barbed suture of the area covered with fibrin was performed, after its release from the round ligament. The adhesions of the sutures and metallic material from the ESG were released. Finally, two abdominal drains were placed in the anterior and posterior gastric face. The patient presented superficial incisional surgical site infection and was discharged 6 days after laparoscopic surgery. CONCLUSIONS: ESG is a novel procedure, which has proven to be an effective alternative in the treatment of obesity. However, this technique may have major complications that can require urgent surgery.

A Dutch Survey on Medication Adjustments after Metabolic and Bariatric Surgery: Experiences of Bariatric Surgeons, Internists, Pharmacists, and General Practitioners.

BACKGROUND: As metabolic and bariatric surgery (MBS) can alter the pharmacokinetics of drugs, post-bariatric surgery patients may require medication adjustments and monitoring. To improve pharmacotherapy in these patients, we aimed to understand the beliefs, attitudes, knowledge, and concerns of healthcare professionals who treat these patients. METHODS: A survey by means of an online questionnaire was divided into six sections. It was sent to bariatric surgeons, internists, pharmacists, and general practitioners in the Netherlands. RESULTS: Out of 229 returned surveys, 222 were included. Virtually all respondents (98%) expected MBS to influence the effect of medication. Both reduced efficacy (23%) and more adverse events or medication-related complications (21%) were recognized. Two-thirds of the respondents felt competent to prescribe or to provide advice regarding medication in post-bariatric surgery patients. Most of the respondents (95%) believed that other healthcare professionals should be aware of the contraindication "bariatric surgery". Of the respondents, 37% indicated that they were not aware of the medication advice incorporated in the electronic health record systems. Almost half of the respondents (48%) indicated that they documented changes in drug effects. Most respondents answered that these ought to be registered in the pharmacovigilance database or national registry. CONCLUSIONS: The majority of prescribers and pharmacists believe that patients will receive better pharmacotherapy if healthcare professionals take MBS into account. However, not all prescribers think they are competent to act adequately. To improve this, information on changed drug effects after MBS should be more widely shared among healthcare professionals via resources that are easily accessible.

External Oblique Intercostal Plane Block Versus Port-Site Infiltration for Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Study.

PURPOSE: Although laparoscopic sleeve gastrectomy (LSG) is a minimally invasive surgery, postoperative pain is common. A novel block, the external oblique intercostal (EOI) block, can be used as part of multimodal analgesia for upper abdominal surgeries. The aim of our study is to investigate the effectiveness of EOI block in patients undergoing LSG. MATERIALS AND METHODS: Sixty patients were assigned into two groups either EOI or port-site infiltration (PSI). The EOI group received ultrasound-guided 30 ml 0.25% bupivacaine, while the PSI group received 5 ml of 0.25% bupivacaine at each port sites by the surgeon. Data on clinical and demographic were collected and analyzed. RESULTS: There were no statistical differences in terms of demographic details (p > 0.05). VAS scores were statistically lower during resting at PACU, 1, 2, 4, 8, and 12 h postoperatively in the EOI group than PSI group (p < 0.05), The VAS scores were also lower during active movement at PACU, 1, 2, 4, and 8 h postoperatively in the EOI group than PSI group (p < 0.05). Twenty-four-hour fentanyl consumption was lower in the EOI than in the PSI group (505.83 ± 178.56 vs. 880.83 ± 256.78 µg, respectively, p < 0.001). Rescue analgesia was higher in PSI group than EOI group (26/30 vs. 14/30, respectively, p = 0.001). CONCLUSION: EOI block can be used as a part of multimodal analgesia due to its simplicity and effective postoperative analgesia in LSG.

Weight Loss with an AI-Powered Digital Platform for Lifestyle Intervention.

BACKGROUND: Lifestyle intervention remains the cornerstone of weight loss programs in addition to pharmacological or surgical therapies. Artificial intelligence (AI) and other digital technologies can offer individualized approaches to lifestyle intervention to enable people with obesity to reach successful weight loss. METHODS: SureMediks, a digital lifestyle intervention platform using AI, was tested by 391 participants (58% women) with a broad range of BMI (20-78 kg/m2), with the aim of losing weight over 24 weeks in a multinational field trial. SureMediks consists of a mobile app, an Internet-connected scale, and a discipline of artificial intelligence called Expert system to provide individualized guidance and weight-loss management. RESULTS: All participants lost body weight (average 14%, range 4-22%). Almost all (98.7%) participants lost at least 5% of body weight, 75% lost at least 10%, 43% at least 15%, and 9% at least 20%, suggesting that this AI-powered lifestyle intervention was also effective in reducing the burden of obesity co-morbidities. Weight loss was partially positively correlated with female sex, accountability circle size, and participation in challenges, while it was negatively correlated with sub-goal reassignment. The latter three variables are specific features of the SureMediks weight loss program. CONCLUSION: An AI-assisted lifestyle intervention allowed people with different body sizes to lose 14% body weight on average, with 99% of them losing more than 5%, over 24 weeks. These results show that digital technologies and AI might provide a successful means to lose weight, before, during, and after pharmacological or surgical therapies.

Medium and Long-Term Weight Loss After Revisional Bariatric Surgery: A Systematic Review and Meta-Analysis.

Despite the current increase in revisional bariatric surgery (RBS), data on the sustainability of weight loss remain unclear. A systematic review and meta-analysis were performed to assess weight loss outcomes in adult patients undergoing RBS with follow-up > 2 years. Twenty-eight observational studies (n = 2213 patients) were included. The %TWL was 27.2 (95%CI = 23.7 to 30.6), and there was a drop in BMI of 10.2 kg/m2 (95%CI = - 11.6 to - 8.7). The %EWL was 54.8 (95%CI = 47.2 to 62.4) but with a high risk of publication bias (Egger's test = 0.003). The overall quality of evidence was very low. Our data reinforce that current evidence on RBS is mainly based on low-quality observational studies, and further higher-quality studies are needed to support evidence-based practice.

Patients who received sleeve gastrectomy have lower plasma osteopontin levels than those who did not.

BACKGROUND: The aim of this study was to compare metabolic parameters, plasma Osteopontin (OPN) and Hepatocyte Growth Factor (HGF) levels between Sleeve Gastrectomy (SG) patients in their 6th post-operation month and healthy control patients. METHODS: Height, weight, Body Mass Index (BMI) and laboratory parameters of 58 SG patients aged 18‒65 years (Group 1) and 46 healthy control patients (Group 2) were compared. In addition, preoperative and postoperative sixth-month BMI and laboratory parameters of the patients in Group 1 were compared. RESULTS: The mean age and gender distributions of the groups were similar (p > 0.05). Mean BMI was 28.9 kg/m2 in Group 1 and 27 kg/m2 in Group 2 (p < 0.01). While plasma HGF levels were similar between both groups, plasma OPN levels were higher in Group 2 (p < 0.001). Fasting plasma glucose, total cholesterol, triglyceride, fasting plasma insulin and insulin resistance values were higher in Group 1, while alanine aminotransferase and aspartate aminotransferase levels were higher in Group 2 (p < 0.05). There was a strong correlation between plasma HGF and OPN levels in Group 1, but not in Group 2 (Rho = 0.805, p < 0.001). CONCLUSION: OPN and HGF are promising biomarkers that can be used to better understand and detect problems related to obesity. The fact that patients in the early post-SG period had lower plasma OPN and similar plasma HGF compared to non-surgical patients of similar age and gender with higher BMI may be another favorable and previously unknown metabolic effect of SG.