Combined liver transplantation and sleeve gastrectomy: Report of a brief-interval staged approach.

Pretransplantation bariatric surgery in patients with high Model for End-Stage Liver Disease (MELD) score is fraught with risks. Bariatric surgery after liver transplantation (LT) may be complicated by surgical adhesions but could have advantages if performed at the time of transplantation. We investigated a method of brief-interval staging combining LT and sleeve gastrectomy (SG). LT recipients with a body mass index (BMI) > 40 kg/m 2 received an SG during the same hospitalization as the LT (LT/SG), at the same time as a planned brief-interval return to the operating room for biliary anastomosis. Differences in intraoperative attributes of the LT (Stage 1) versus SG (Stage 2) procedures were analyzed using Wilcoxon signed-rank test with significance p < 0.05 and compared with patients with obesity having a two-stage LT without SG. A total of 14 cases {median MELD score 33 (interquartile range [IQR], 18-40)} were compared with 28 controls; 60% were critically ill prior to surgery with mechanical ventilation, vasopressors, or continuous renal replacement therapy. Median interval between procedures was 16.1 (IQR, 12.5-22.7) hours for cases and 12.2 (IQR, 11.1-16.6) hours for controls, p  = 0.27. Median BMI at LT/SG was 47.0 (IQR, 41.7-51.3) kg/m 2 versus 38.1 (IQR, 35.7-39.8) kg/m 2 for controls, p < 0.001. At 1 year, median excess body weight loss was 74.0% (IQR, 46.2%-78.7%) in cases and 15.8% (IQR, -5.4% to 62.6%) in controls, p  = 0.13; total weight loss was 38.1% (IQR, 23.9-42.9) in cases versus 7.7% (IQR, -2.4% to 27.6%) for controls, p  = 0.03. Graft survival at 1 year was 92.9% for cases and 89.3% for controls with similar early postoperative outcomes. This proof-of-concept study revealed that a brief-interval SG during LT is feasible in patients with high MELD and resulted in sustained weight loss at 1 year with similar graft survival. Further studies are needed to determine an optimal strategy.

Elevated hemoglobin A1c level and bariatric surgery complications.

INTRODUCTION: In cardiac and orthopedic surgery, elevated glycosylated hemoglobin (HbA1c) is a modifiable risk factor for postoperative complications. However, in bariatric surgery, there is insufficient evidence to assess the effectiveness of preoperative HbA1c assessment and its association with postoperative complications. The objective of this study was to assess the impact of HbA1c on early postoperative outcomes in bariatric surgery patients. METHODS: Patients who underwent laparoscopic sleeve gastrectomy and laparoscopic Roux-En-Y Gastric Bypass between 2017 and 2018 were selected for a retrospective review from the metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP) database. The study population of 118,742 patients was analyzed for our primary outcome which was defined as a composite of any postoperative complications occurring within 30 days. Two groups were defined by HbA1c cutoff: comparison point A (≤ 8% vs > 8%) and comparison point B (≤ 10% vs > 10%). Procedure-related complications were also examined on subgroup analysis. Propensity score matching (PSM) was used with one-to-one matching. The complication rates before and after PSM were calculated and assessed by Fisher's exact test and conditional logistic regression, respectively. RESULTS: After PSM, demographic and clinical characteristics were all balanced and elevated HbA1C was not associated with worse outcomes. After adjusting for underlying comorbidities, there was no statistically significant difference seen in the composite outcome for comparison point A HbA1C ≤ 8 and HbA1C > 8 (p = 0.22). For comparison point B, patients with HbA1C ≤ 10 had more composite complications compared to patients with HbA1C > 10 (p < 0.001). Also, on subgroup analysis after PSM for procedure-specific complications, patients above the cutoff threshold of 8 did not have worsened composite outcomes (p = 0.58 and 0.89 for sleeve and bypass, respectively). Again, at cutoff threshold of 10, patients in HbA1C ≤ 10 had more composite complications (p = 0.001 and 0.007 for sleeve and bypass, respectively). CONCLUSION: In this study of bariatric patients, elevated HbA1c > 8% or 10% was not associated with increased postoperative complications. HbA1c lower than 10% was associated with some types of adverse outcomes in this bariatric dataset. More studies are needed to investigate these findings further. A high HbA1c alone may not disqualify a patient from proceeding with bariatric surgery.

Bariatric Surgery in End-Stage Heart Failure: Feasibility in Successful Attainment of a Target Body Mass Index.

INTRODUCTION: Orthotopic heart transplantation (OHT) is contraindicated in morbidly obese patients with end-stage heart failure (HF), for whom cardiac allograft is the only means for long-term survival. Bariatric surgery may allow them to achieve target body mass index (BMI) for OHT METHODS: From 4/2014 to 12/2018, 26 morbidly obese HF patients who did not meet BMI eligibility criteria for OHT underwent laparoscopic bariatric surgery. Outcomes of interest were median difference in BMI, number of patients achieving target BMI for OHT, and 30-day mortality. RESULTS: Median age was 49 (IQR 14) years, and 13 (50%) were women. HF was mainly systolic (15 patients, 58%). The median LVEF was 27% (IQR 37%). At the time of bariatric surgery, 12 (46%) patients had mechanical circulatory support: 2 (8%) concomitant left ventricular assist device (LVAD) placements, 8 (31%) LVAD already-in-place, and 2 (8%) intra-aortic balloon pumps. There was no 30-day mortality, but one mortality on postoperative day 48. Over a median follow-up of 6 months (range 0-36 months, IQR 17), there was a significant reduction in BMI (p<0.0001). The median postoperative BMI was 36.7 (IQR 8.7), compared to preoperative median BMI of 42.7 (IQR 9.4). Target BMI of < 35 was achieved in 11 (42%) patients. Three patients (12%) have undergone OHT. CONCLUSION: Bariatric surgery in end-stage HF is feasible and results in a high number of patients achieving target BMI, increasing their probability of undergoing OHT. The presence of a LVAD should not preclude these patients from undergoing a bariatric intervention.

Post-bariatric surgery lab tests: are they excessive and redundant?

INTRODUCTION: Following bariatric surgery, ongoing postoperative testing is required to measure nutritional deficiencies; the purpose of this study was to quantify the prevalence of these nutritional deficiencies based on two-year follow-up tests at recommended time points. METHODS AND PROCEDURES: A retrospective data analysis was conducted of all laboratory tests for bariatric patients who underwent surgery between May 2016 and January 2018 with available lab data (n = 397). Results for nine different nutritional labs were categorized into six recommended postoperative time periods based on time elapsed since the procedure date. Binary variables were created for each laboratory result to calculate descriptive statistics of abnormalities for each lab test over time and used in the individual GEE logistic regression models. Grouped logistic regression examined the total nutritional deficiencies of the nine combined nutrients considering total available labs. RESULTS: Multiple lab tests indicated a very low frequency of abnormalities (e.g., Vitamin A, Vitamin B12, Copper, and Folate). Many of the nine included nutritional labs had an average deficiency of less than 10% across all time points. The grouped logistic model found preoperative nutritional deficiency to be predictive of postoperative nutritional deficiency (OR 3.70, p < 0.001). CONCLUSIONS: We found the vast majority of routine lab test results to be normal at multiple time points. Current practice can add up to significant lab expenses over time. The frequency of postoperative testing in this population may be redundant and of very little value. Unnecessary follow-up laboratory testing costs the patients and the health care system in both time and resources. Patients with preoperative deficiencies appear to be at higher risk for nutritional deficiencies when compared to bariatric surgery patients that did not have preoperative nutritional deficiencies. Future research should focus on defining cost effective postoperative lab testing guidelines for at risk bariatric patients.

Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae.

BACKGROUND: Primary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair. METHODS: Utilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closure + absorbable or non-absorbable mesh and fundoplication with hiatal closure alone. RESULTS: A total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29 years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the 'Mesh' cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the 'No Mesh' cohort (p = 0.362). A reoperation was necessary in 6 patients (6.7%) in the 'Mesh' cohort as compared to 3 patients (3.5%) in the 'No Mesh' cohort (p = 0.543). CONCLUSIONS: Onlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.

SAGE(S) advice: application of a standardized train the trainer model for faculty involved in a Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) hands-on course.

INTRODUCTION: Currently, no prerequisite teaching qualification is required to serve as faculty for SAGES hands-on courses (SAGES-HOC). The Lapco-Train-the-Trainers (Lapco-TT) is a course for surgical trainers, in which delegates learn a standardized teaching technique for skills acquisition. The aims of this study were to 1) determine if this curriculum could be delivered in a day course to SAGES-HOC faculty and 2) assess the impact of such training on learners' educational experience taught by this faculty at a subsequent SAGES-HOC. METHODS AND PROCEDURES: Six experts attended a one-day Lapco-TT course. SAGES-HOC participants were split into two groups: Group A taught by Lapco-TT trained, and Group B by "untrained" course faculty. Opinion surveys were completed by both the SAGES-HOC learners and the Lapco-TT trained course faculty. Furthermore, the latter underwent self-, learner-, and observer-based evaluation using a previously validated teaching assessment tool (cSTTAR). Mean scores were reported and analyzed [Mann-Whitney U, t test (p < 0.05)]. RESULTS: All 6 Lapco-TT delegates found the course useful (5), and felt that it would influence the way they taught in the OR (4.83), that their course objectives were met (4.83), and that they would recommend the course to their colleagues (4.83). Of the SAGES-HOC participants, compared to Group B (n = 22), Group A learners(n = 10) better understood what they were supposed to learn (5 vs. 4.15 [p = 0.046]) and do (5 vs. 4 [p = 0.046]), felt that the session was well organized (5 vs. 4 [p = 0.046]), that time was used effectively (5 vs. 3.9 [p = 0.046]), and that performance feedback was sufficient (5 vs. 3.9 [p = 0.028]) and effective (5 vs. 3.95 [p = 0.028]). Group A faculty were rated significantly higher by their learners on the cSTTARs than Group B (p < 0.0005). Group A faculty rated themselves significantly lower than both expert observers (p < 0.0005) and compared to the Group B faculty's self-assessment (p < 0.002). CONCLUSIONS: The Lapco-TT course can be delivered effectively over one day and impacts the educational experience of learners at a SAGES-HOC. This could help establish a standardized method of teaching at SAGES-HOCs and thereby increase their value for learners.

Endoscopic suture fixation of self-expanding metallic stents with and without submucosal injection.

BACKGROUND: Self-expanding metallic stents (SEMS) are useful for treating leaks after bariatric procedures but stent migration (12 to 40 %) remains a problem. Suture fixation has been used to minimize migration but has attendant risks of transmural penetration. We hypothesized that submucosal injection would decrease the risk of full thickness suture penetration while still providing greater pullout forces than endoscopic clipping. METHODS: Porcine explant models and 155 mm SEMS were used with a force meter to measure the pullout forces required to dislodge the stent. Stents were first deployed without fixation and this pullout force acted as a control. The explants were then randomized to receive fixation with clips, endoscopic suturing with submucosal elevation, or endoscopic suturing without submucosal elevation. The pullout force was again measured and the ratio of the experimental to control pullout forces was used as a measure of the efficacy of the fixation. RESULTS: Endoscopic suture fixation after submucosal injection resulted in statistically significant increased pullout force compared to clip fixation (n = 5; mean force ratio 462 %; 95 % confidence interval [CI] 281-643 %; p < 0.01). Endoscopic suturing fixation without submucosal injection also resulted in statistically significant increased pullout force (n = 5; mean force ratio 765 %; 95 % CI 258-632 %; p < 0.01). Fixation with clips did not result in significantly increased pullout force compared to no fixation (n = 5; mean force ratio 108 %; 95 % CI 56-159 %; p < 0.01). Submucosal injection also eliminated full thickness suture penetration (0/10 submucosal injection; 7/10 no injection). CONCLUSIONS: Endoscopic suture fixation of SEMS resulted in a statistically significant increase in pullout force necessary to displace the stents. Submucosal injection prior to suture fixation preserves the increased pullout force while minimizing the risk of transmural penetration with the potential for less risk of injury to mediastinal structures.

Clinical management of patients presenting with non-adjustable gastric band (NAGB) complications.

BACKGROUND: A number of bariatric surgical procedures have been developed to manage morbid obesity and related co-morbidities. The non-adjustable gastric band (NAGB) was one such procedure that created restriction to food intake by gastric segmentation. Benefits of the procedure included a low risk of perioperative complications and substantial early weight loss. Unfortunately, the long term results of NAGB include a high incidence of complications and failure to maintain weight loss. The purpose of this study was to examine the presentation, workup, and treatment of patients presenting with complications following NAGB placement. METHODS: A retrospective review of the diagnosis and management of 11 patients who presented with complications related to NAGB placement. RESULTS: All patients presented with some degree of proximal gastric outlet obstruction. The majority of patients (8/11) presented with vomiting as the main complaint. Other complaints included intolerance to solids, liquids, and reflux. Only 2/11 patients presented with weight loss since undergoing NAGB placement, while the remainder had weight regain to their pre-NAGB level and above. Depending on clinical presentation, desire for additional weight loss and co-morbid conditions, patients underwent a variety of treatments. This included NAGB removal (endoscopic, laparo-endoscopic, and laparoscopic) as well as conversion to another bariatric procedure (sleeve gastrectomy, Roux-en-Y gastric bypass). CONCLUSION: Patients with NAGB complications present with symptoms related to a proximal gastric outlet obstruction, related to constriction imposed by the band. This may result in severe food and liquid intolerance and subsequent weight loss, but more likely results in maladaptive eating and subsequent weight gain. Optimal therapy involves removal of the NAGB. Laparoscopic conversion to another bariatric procedure, optimally a Roux-en-Y gastric bypass, is warranted to treat morbid obesity and associated co-morbidities.

Elevated Hb A1C level and revisional bariatric surgery complications.

BACKGROUND: Elevated Hb A1C is a modifiable risk factor for postoperative complications. However, in bariatric surgery, as published by our group and others, elevated preoperative Hb A1C may not be associated with increased postoperative complications. Previous literature has focused on primary bariatric surgery and has excluded the higher-risk revisional surgery cohort. OBJECTIVE: To assess the impact of Hb A1C on early postoperative outcomes in patients requiring revisional bariatric surgery. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. METHODS: We undertook a retrospective review of patients undergoing revisional bariatric surgery between 2017 and 2018 from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Two groups were studied, defined by Hb A1C cutoff, ≤8% versus >8% and ≤10% versus >10%. Early postoperative complications were compared at each threshold, with the primary outcome defined as a composite of all complications. Propensity score matching (PSM) was used with one-to-one matching for covariates, and the complication rates before and after PSM were calculated and assessed by Fisher's exact test and conditional logistic regression, respectively. RESULTS: A total of 16,234 patients had undergone revisional bariatric surgery. After PSM, elevated Hb A1C was not associated with worse outcomes. No significant difference was seen in the composite outcomes for Hb A1C ≤8% versus Hb A1C >8% (P = .22) or for patients with Hb A1C ≤10% versus Hb A1C >10% (P < .46). There were no differences in individual outcomes such as surgical-site infections, cardiopulmonary complications, or readmissions/reinterventions. CONCLUSION: In this study of revisional bariatric patients, elevated Hb A1C >8% or >10% was not associated with increased postoperative complications. Prospective studies are needed to investigate this further.