Sleep Apnea: Is Routine Preoperative Screening Necessary?

Background

Because perioperative complications of unrecognized obstructive sleep apnea (OSA) can be severe, many bariatric surgery programs routinely screen all patients. However, many obese non-bariatric surgery patients do not get screened. We wanted to evaluate the need for routine preoperative OSA screening.

Methods

Morbidly obese patients with a body mass index (BMI)?>?40 kg/m² undergoing bariatric surgery—all screened for OSA—were compared to morbidly obese orthopedic lower extremity total joint replacements (TJR) patients—not screened for OSA. Cardio-pulmonary complications were recorded.

Results

Eight hundred eighty-two morbidly obese patients undergoing either bariatric (n?=?467) or orthopedic TJR surgery (n?=?415) were compared. As a result of screening, 119 bariatric surgery patients (25.5 %) were newly diagnosed with OSA, bringing the incidence to 42.8 % (200/467). Orthopedic surgery group had 72 of 415 (17.3 %) patients with pre-existing OSA. The unscreened orthopedic patients had a 6.7 % (23/343) cardiopulmonary complications rate compared to 2.6 % (7/267) for screened bariatric surgery patients. This difference was not statistically significant when adjusted for age and comorbidity (p?=?0.3383).

Conclusion

Sleep apnea screening prior to bariatric surgery identifies an additional 25 % of patients as having OSA. In this study, unscreened morbidly obese patients did not have an increased incidence of cardiopulmonary complications after surgery compared to screened patients. Prospective randomized studies should be conducted to definitively assess utility and cost effectiveness of routine OSA screening of all morbidly obese patients undergoing surgery. Preoperative OSA screening may be safely omitted when randomizing patients for such a trial.     

Pulmonary Function Testing and Complications of Laparoscopic Bariatric Surgery

Background

Obesity is associated with respiratory symptoms and impaired pulmonary function, which could increase the risk of complications after bariatric surgery. The purpose of this study is to assess the relationship between pulmonary function parameters before, and the risk of complications after, laparoscopic bariatric surgery.

Methods

This prospective study included patients (age 18–60, BMI >35 kg/m²), who were eligible for bariatric surgery. Spirometry was performed in all patients. Complications up to 30 days after bariatric surgery were recorded.

Results

Four hundred eighty-five patients were included (304 laparoscopic sleeve gastrectomy, 181 laparoscopic gastric bypass). There were 53 complications (8 pulmonary, 27 surgical, 14 infectious, 4 other) in 50 patients (10 %). There were 35 re-admissions (7.2 %), and 17 re-laparoscopies (3.5 %). Subjects with and without complications did not differ significantly with respect to demographics, weight, BMI, abdominal circumference or fat percentage. Subjects with complications had a significantly lower mean FEV₁ (mean 86.9 % predicted) and FVC (95.6 % predicted) compared to patients without complications (95.9 % predicted, p?=?0.005, and 100.1 % predicted, p?=?0.045, respectively). After adjustment for age, gender, BMI, and smoking, abnormal spirometry value remained the single predictive covariable of postoperative complications: FEV₁/FVC <70 % adjusted OR 3.1 (95%CI 1.4–6.8, p?=?0.006) and ΔFEV₁ ≥12 % adjusted OR 2.9 (95 %CI 1.3–6.6, p?=?0.010).

Conclusions

The risk of pulmonary complications after laparoscopic bariatric surgery is low. However, subjects with abnormal spirometry test results have a threefold risk of complications after laparoscopic bariatric surgery. Preoperative pulmonary function testing might be useful to predict the risk of complications of laparoscopic bariatric surgery.     

Revisional Bariatric Surgery for Unsuccessful Weight Loss and Complications

Background

There are growing numbers of patients who require revisional bariatric surgery due to the undesirable results of their primary procedures. The aim of this study was to review our experience with bariatric patients undergoing revisional surgery.

Methods

We conducted a retrospective analysis to review the indications for revisional bariatric procedures and assess their postoperative outcomes.

Results

From 04/04 to 01/11, 2,918 patients underwent bariatric surgery at our institution. A total of 154 patients (5.3 %) of these cases were coded as revisional procedures. The mean age at revision was 49.1?±?11.3 and the mean BMI was 44.0?±?13.7 kg/m². Revisional surgery was performed laparoscopically in 121 patients (78.6 %). Laparoscopic revisions had less blood loss, shorter length of hospital stay, and fewer complications compared to open revisions. Two groups (A and B) were defined by the indication for revision: patients with unsuccessful weight loss (group A, n?=?106) and patients with complications of their primary procedures (group B, n?=?48). In group A, 74.5 % of the patients were revised to a bypass procedure and 25.5 % to a restrictive procedure. Mean excess weight loss was 53.7?±?29.3 % after revision of primary restrictive procedures and 37.6?±?35.1 % after revision of bypass procedures at >1-year follow-up (p?<?0.05). In group B, the complications prompting revision were effectively treated by revisional surgery.

Conclusions

Revisional bariatric surgery effectively treated the undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic bariatric procedures without a prohibitive complication rate. Carefully selected patients undergoing revision for weight regain have satisfactory additional weight loss.     

Prevalence and Predictors of Atrial Fibrillation Among Patients Undergoing Bariatric Surgery

Background

While AF is a disease of the elderly, it can occur earlier in the presence of risk factors such as obesity. Bariatric surgery patients are significantly younger and more obese than previously described populations with AF. Therefore, it remains to be determined whether current estimates of the prevalence and predictors for AF remain true in the bariatric surgery population.

Methods

We performed a cross-sectional analysis of 1,341 consecutive patients who underwent bariatric surgery from January 2008 to October 2012. Baseline characteristics were compared between patients with and without AF. For additional comparison, 176 patients with AF and body mass index (BMI) >40 kg/m² were identified from the Vanderbilt AF Registry. A multivariable logistic regression was performed to identify predictors of AF within the bariatric surgery cohort.

Results

The prevalence of AF in the bariatric surgery cohort was 1.9 % (25/1,341). Patients with AF were older (median 56 years (interquartile range [52–64) vs.46 [38–56] years, p?<?0.001), were more often male (48 vs. 23 %, p?=?0.004), had more comorbidities, but had no difference in BMI (50 kg/m² [44–58] vs. 48 [43–54], p?=?0.4). In multivariable analysis, the odds of AF increased 2.2-fold by age per decade (95 % CI, 1.4–3.5; p?<?0.001) and 2.4-fold by male gender (1.1–5.4, p?=?0.03) when adjusted for BMI. BMI was not independently associated with AF (OR 1.15 [95 % CI, 0.98–1.41], p?=?0.09).

Conclusions

The prevalence of AF is 1.9 % among patients undergoing bariatric surgery. Risk of AF was found to increase with age and male gender, but not with higher BMI.     

Incidence of Venous Thromboembolism After Bariatric Surgery: A Population-Based Cohort Study

Background

The incidence of venous thromboembolism (VTE) after bariatric surgery is uncertain.

Methods

Using the resources of the Rochester Epidemiology Project and the Mayo Bariatric Surgery Registry, we identified all residents of Olmsted County, Minnesota, with incident VTE after undergoing bariatric surgery from 1987 through 2005. Using the dates of bariatric surgery and VTE events, we determined the cumulative incidence of VTE after bariatric surgery by using the Kaplan–Meier estimator. Cox proportional hazards modeling was used to assess patient age, sex, weight, and body mass index as potential predictors of VTE after bariatric surgery.

Results

We identified 396 residents who underwent 402 bariatric operations. The most common operation was an open Roux-en-Y gastric bypass (n?=?228). Eight patients had VTE that developed within 6 months (7 within 1 month) after surgery; five events occurred after hospital discharge but within 1 month after bariatric surgery. The cumulative incidence of VTE at 7, 30, 90, and 180 days was 0.3, 1.9, 2.1, and 2.1 %, respectively (180-day 95 % confidence interval (CI), 0.7–3.6 %). Patient age was a predictor of postoperative VTE (hazard ratio, 1.89 per 10-year increase in age; 95 % CI, 1.01–3.55; P?=?0.05).

Conclusions

In our population-based study, bariatric surgery had a high risk of VTE, especially for older patients. Because most VTE events occurred after hospital discharge, a randomized controlled trial of extended outpatient thromboprophylaxis is warranted in patients undergoing open Roux-en-Y gastric bypass for medically complicated obesity.     

Comparative Review of the Safety and Efficacy of Ferric Carboxymaltose Versus Standard Medical Care for the Treatment of Iron Deficiency Anemia in Bariatric and Gastric Surgery Patients

Background

Iron deficiency anemia (IDA) is a common finding in patients after bariatric surgery. The cause is multifactorial including reduced oral iron intake and malabsorption. While many patients can be managed with oral supplements, parenteral iron may be needed to restore and maintain iron stores.

Methods

Subjects who had previous bariatric surgery and had participated in phase 3 industry-sponsored clinical trials designed to assess the safety and/or efficacy of intravenous (IV) ferric carboxymaltose (FCM) were retrospectively selected from the databases of each of these studies. Demographic data, efficacy measures [hemoglobin, ferritin, and transferrin saturation (TSAT)], and adverse events were compared between FCM and other agents utilized as comparators in the trials.

Results

Two hundred eighty-one subjects from the intention to treat (ITT) population were included (mean age 49 years, BMI 33 kg/m², including 253 females). FCM had similar or improved efficacy (p?<?0.05) in terms of increasing hemoglobin, ferritin, and TSAT values when compared to other iron products used as standard of care for IDA. The incidence of adverse events in the FCM patients (n?=?123) versus patients receiving any IV iron (n?=?126) was 61 and 56.3 %, respectively. The adverse events were similar in both groups with the exception of a transient decrease in serum phosphate which was observed more frequently in the FCM group.

Conclusions

These data in post-bariatric surgery IDA patients suggest that FCM is a safe and effective alternative to existing iron products permitting higher and thus less frequent individual doses.     

Predictors of Post-bariatric Surgery Appointment Attendance: the Role of Relationship Style

Background

Attendance at bariatric surgery follow-up appointments has been associated with bariatric surgery outcomes. In this prospective study, we sought to examine psychosocial predictors of attendance at post-operative follow-up appointments.

Methods

Consecutive bariatric surgery patients (n?=?132) were assessed pre-surgery for demographic variables, depressive symptoms, and relationship style. Patients were followed for 12 months post-surgery and, based on their attendance at follow-up appointments, were classified as post-surgery appointment attenders (attenders—attended at least one appointment after post-operative month 6) or post-surgery appointment non-attenders (non-attenders—did not attend at least one appointment after post-operative month 6). Psychosocial and demographic variables were compared between the attender and non-attender groups. Multivariate logistic regression was used to identify significant predictors of attendance at post-bariatric surgery follow-up appointments.

Results

At 12 months post-surgery, 68.2 % of patients were classified as attenders. The non-attender group was significantly older (p?=?0.04) and had significantly higher avoidant relationship style scores (p?=?0.02). There was a trend towards patients in the non-attender group living a greater distance from the bariatric center (p?=?0.05). Avoidant relationship style was identified as the only significant predictor of post-operative appointment non-attendance in the logistic regression analysis.

Conclusions

These findings suggest that avoidant relationship style is an important predictor of post-bariatric surgery appointment non-attendance. Recognition of patients' relationship style by bariatric surgery psychosocial team members may guide the delivery of interventions aimed at engaging this patient group post-surgery.     

Lack of Adherence to Follow-Up Visits After Bariatric Surgery: Reasons and Outcome

Background

A substantial number of patients undergoing bariatric surgery are lost to follow-up for unknown reasons, which may cause an overestimation of the benefits of operation. The aim of this study was to identify the reasons of failure to attend controls after bariatric surgery and the relationship with poor weight loss.

Methods

A retrospective analysis of a prospective database including all patients undergoing bariatric surgery from January 2004 to February 2012 was performed. Nonadherence was defined as missing any scheduled control visit for more than 6 months. Contact was attempted (mail, telephone, and e-mail), and responders were requested to complete a questionnaire.

Results

Forty-six (17.5 %) out of 263 patients were considered nonadherent. Thirty-three (71.7 %) of these patients completed the questionnaire. The main reasons for nonadherence were work- (36.4 %) and family-related (18.2 %) problems or having moved outside the city or to the country (15.2 %). The percentage of nonadherent patients aged ≤45 years was greater as compared with those aged >45 years [28 (60.1 %) vs 18 (42.2 %), respectively, P?=?0.034]. Likewise, of the 30 patients with unsuccessful weight loss (<50 % EWL), seven (30.4 %) were in the nonadherent group while 23 (10.6 %) in the adherent group (P?=?0.046). Finally, 96.9 % of patients were completely satisfied with surgery and would recommend the procedure to other morbid obese patients.

Conclusion

The nonadherence rate to follow-up visits after bariatric surgery was 17.5 %, mainly associated with work-related problems. Nonadherence was greater in patients aged ≤45 years and in those with poor weight loss.     

Long-term Changes in Leptin, Chemerin and Ghrelin Levels Following Different Bariatric Surgery Procedures: Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Background

Different studies have evaluated changes in adipo/cytokine levels after bariatric surgery and have given conflicting results. The adipo/cytokines, leptin and chemerin, and the orexigenic hormone, ghrelin, have been shown to play a role in the regulation of metabolism and appetite. The aims of our study were to test the levels of these molecules after bariatric surgery and to compare the results between Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.

Methods

We analysed circulating levels of chemerin, ghrelin and leptin in 30 morbidly obese women (body mass index of >40 kg/m²). Subjects were studied at three time points: baseline (before the surgery started), and after 6 and 12 months.

Results

After surgery, chemerin (baseline, 95.03?±?23.79; after 12 months, 76.80?±?21.51; p?=?0.034) and leptin levels (baseline, 248.17?±?89.16; after 12 months, 63.85?±?33.48; p?<?0.001) were significantly lower than their baseline levels, whereas ghrelin was higher (baseline, 0.87?±?0.38; after 12 months, 1.08?±?0.31; p?=?0.010). Fasting glucose, insulin and homeostasis model assessment of insulin resistance levels were markedly lower postoperatively. High-density lipoprotein levels moderately increased and triglyceride levels sharply decreased. There were no differences between the types of bariatric surgery in terms of weight reduction, general metabolic state or adipo/cytokine levels after surgery.

Conclusions

Our study demonstrates a marked decrease in fasting leptin and chemerin levels, and an increase in ghrelin levels, after bariatric surgery-induced weight loss, independently of the type of surgery performed. Further studies are needed on the interrelation between the changes in the circulating levels of these molecules and the efficacy of the bariatric surgery procedures to induce the beneficial metabolic changes and to sustain body weight loss.     

Rhabdomyolysis in Bariatric Surgery: a Systematic Review

Background

Rhabdomyolysis (RML) is a rare complication of bariatric surgery. A systematic review was performed to identify risk factors and patient outcomes in morbidly obese patients undergoing bariatric surgery who develop RML.

Methods

A comprehensive search was performed between January 1990 and March 2012 using relevant MeSH terms. Studies were chosen based on predefined inclusion criteria. RML was defined as a creatine kinase of more than 1,000 IU/L. The parameters assessed included patient characteristics of the RML population, type of bariatric surgery performed, operating time, complications, presentation and diagnosis of RML.

Results

Twenty-two studies were analysed which included 11 case reports, two case series, six prospective and three retrospective comparative studies. Overall 145 patients with RML were reported following bariatric surgery. Acute renal failure was found in 20 patients (14 %) and was significantly more likely to occur in patients with postoperative muscle pain (p?<?0.05). The mortality rate after renal failure was 25 % (n?=?5). In the comparative studies, 87 RML patients were compared with 325 non-RML patients. The RML patients were more likely to be male, had a greater mean body mass index (BMI) (52 vs 48 kg/m², p?<?0.01) and underwent a longer operation (255 vs 207 min, p?<?0.01) compared to non-RML patients.

Conclusions

Risk factors of developing RML following bariatric surgery include male gender, elevated BMI and prolonged operating time. Patients with a biochemical diagnosis of RML and postoperative myalgia after bariatric surgery are at increased risk of developing acute renal failure and mortality. These patients must be identified and treated promptly.     

Diagnosis and Management of Oesophageal Cancer in Bariatric Surgical Patients

Background

Oesophageal cancer following bariatric surgery adds significant complexity to an already challenging disease. There is limited data on the diagnosis, presentation and management in these complex cases.

Methods

A retrospective cohort study on prospectively collected data over 10 years was conducted. The oesophago-gastric cancer database was searched for patients with prior bariatric surgery. Data were retrieved on bariatric and cancer management.

Results

We identified nine patients with oesophageal or gastro-oesophageal junction adenocarcinoma after bariatric surgery. Mean age was 58.3?±?6.9 years, and duration from bariatric surgery was 13.2?±?9.4 years. Weight loss at diagnosis was 30.6?±?23.3 kg (excess weight loss 58.1 %?±?29.6). Modes of presentation were Barrett’s surveillance (n?=?3), reflux symptoms (n?=?4) and incidental (n?=?2). Management was surgical resection (n?=?4), endoscopic mucosal resection (n?=?2) and palliative (n?=?3). Surgical resections were challenging due to adhesions, obesity, luminal dilatation and scarring on the stomach. There were two substantial leaks following gastroplasty.

Conclusions

Oesophageal cancer following bariatric surgery is a challenging problem, and surgical resection carries high risk. A high index of suspicion is required and symptoms investigated precipitously. Technical challenges of operating on obese patients and the specific effects of previous bariatric procedures need to be understood, particularly the limitations on reconstructive options.

     

Change in Levels of C-Reactive Protein (CRP) and Serum Cortisol in Morbidly Obese Patients After Laparoscopic Sleeve Gastrectomy

Background

C-Reactive protein (CRP) has been associated with the macro- and microvascular effects of hypertension and diabetes mellitus. Referring to serum cortisol, it has been proposed to contribute to the pathogenesis of metabolic syndrome, and it has been demonstrated that weight loss normalizes cortisol levels and improves insulin resistance. The aims of this study were to analyze CRP and cortisol levels pre- and postoperatively in morbidly obese patients undergoing a laparoscopic sleeve gastrectomy and to correlate them with weight loss and parameters associated with cardiovascular risk.

Methods

A prospective study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric procedure between October 2007 and May 2011 was performed.

Results

A total of 40 patients were included in the study. CRP levels decreased significantly 12 months after surgery (median reduction of 8.9 mg/l; p?=?0.001). Serum cortisol levels decreased significantly 6 months after surgery (median reduction of 34.9 μg/dl; p?=?0.001). CRP values reached the normal range (<5 mg/l) 1 year after surgery. Referring to cortisol, a significant association was observed with the cardiovascular risk predictor (triglyceride/high-density lipoprotein cholesterol ratio) from the 6th month after surgery onward (Pearson correlation coefficient, 0.559; p?=?0.008).

Conclusion

CRP levels are increased preoperatively and in the postoperative course up to 1 year after surgery. Serum cortisol levels remain elevated until the 6th month after surgery. From this moment onward, serum cortisol is associated with the cardiovascular risk predictor reflecting the cardiovascular risk decreasement during the weight loss.     

Bariatric Surgery in Patients with Cirrhosis and Portal Hypertension

Introduction

Studies on bariatric patients with cirrhosis and portal hypertension are limited. The aim of this study was to review our experience in cirrhotic patients with portal hypertension who had bariatric surgery.

Method

All cirrhotic patients with portal hypertension who underwent laparoscopic bariatric surgery, from 2007 to 2017, were retrospectively reviewed.

Results

Thirteen patients were included; eight (62%) were female. The median age was 54 years (interquartile range, IQR 49–60) and median BMI was 48 kg/m² (IQR 43–55). Portal hypertension was diagnosed based on endoscopy (n?=?5), imaging studies (n?=?3), intraoperative increased collateral circulation (n?=?2), and endoscopy and imaging studies (n?=?3). The bariatric procedures included sleeve gastrectomy (n?=?10, 77%) and Roux-en-Y gastric bypass (n?=?3, 23%). The median length of hospital stay was 3 days (IQR 2–4). Three 30-day complications occurred including wound infection (n?=?1), intra-abdominal hematoma (n?=?1), and subcutaneous hematoma (n?=?1). No intraoperative or 30-day mortalities. There were 11 patients (85%) at 1-year follow-up and 9 patients (69%) at 2-year follow-up. At 2 years, the median percentage of excess weight loss (EWL) and total weight loss (TWL) were 49 and 25%, respectively. There was significant improvement in diabetes (100%), dyslipidemia (100%), and hypertension (50%) at 2 years after surgery.

Conclusion

Bariatric surgery in selected cirrhotic patients with portal hypertension is relatively safe and effective.

     

Predictors of Weight Loss are Different in Men and Women After Sleeve Gastrectomy

Background

Weight loss following bariatric surgery varies according to patient factors before the intervention. However, whether predictors of weight loss differ between men and women is, to our knowledge, unknown. We therefore aimed to investigate baseline predictors for overall weight loss and identify potential sex-specific baseline predictors in bariatric surgery patients.

Methods

In this prospective cohort study, 160 patients (117 women and 43 men) who underwent sleeve gastrectomy were followed up for 2 years. Weight loss was defined as percent excess body mass index loss (%EBMIL). To investigate whether %EBMIL differed between men and women, we included all two-way interactions with sex by incorporating the product term sex and predictors using multiple linear regression analysis.

Results

The overall mean ± standard deviation of %EBMIL after 2 years was 78.3?±?23.5. Predictors for lower %EBMIL in a regression model with no interactions were female sex (P?=?0.003), higher body mass index before surgery (P?=?0.001), and nonsmoking (P?=?0.029). When examining sex-specific predictors for %EBMIL, higher age (P?=?0.027) and not having diabetes (P?=?0.007) predicted lower %EBMIL in men. In women, unemployment (P?=?0.006) and anxiety and/or depression (P?=?0.009) predicted lower %EBMIL.

Conclusions

This study suggests that weight loss and predictors for weight loss 2 years after sleeve gastrectomy are sex-specific. These findings may be useful for the surgical strategy used to treat these patients.     

Effect of bariatric surgery on oncologic outcomes: a systematic review and meta-analysis

Background

Obesity is a major public health issue and is associated with increased risk of several cancers, currently a leading cause of mortality. Obese patients undergoing bariatric surgery may allow for evaluation of the effect of intentional excess weight loss on subsequent risk of cancer. We aimed to evaluate cancer risk, incidence, and mortality after bariatric surgery.

Methods

A comprehensive literature search was conducted using PubMed/MEDLINE and Embase with literature published from the inception of both databases to January 2012. Inclusion criteria incorporated all human studies examining oncologic outcomes after bariatric surgery. Two authors independently reviewed selected studies and relevant articles from their bibliographies for data extraction, quality appraisal, and meta-analysis.

Results

Six observational studies (n = 51,740) comparing relative risk (RR) of cancer in obese patients undergoing bariatric surgery versus obese control subjects were analyzed. Overall, the RR of cancer in obese patients after undergoing bariatric surgery was 0.55 [95 % confidence interval (CI) 0.41–0.73, p < 0.0001, I ² = 83 %]. The effect of bariatric surgery on cancer risk was modified by gender (p = 0.021). The pooled RR in women was 0.68 (95 % CI 0.60–0.77, p < 0.0001, I ² < 0.1 %) and in men was 0.99 (95 % CI 0.74–1.32, p = 0.937, I ² < 0.1 %).

Conclusions

Bariatric surgery reduces cancer risk and mortality in formerly obese patients. When stratifying the meta-analysis by gender, the effect of bariatric surgery on oncologic outcomes is protective in women but not in men.     

Improvement of Exercise Capacity and Peripheral Metaboreflex After Bariatric Surgery

Background

Bariatric surgery is the only predictable method to obtain weight loss in severe obesity. Poor physical performance of obese individuals may be mediated by the peripheral metaboreflex, which controls blood flow redistribution to exercising muscles. Weight reduction improves exercise capacity through several possible mechanisms that are insufficiently understood. We hypothesized that the metaboreflex is one among the causes of improvement in exercise capacity after weight loss. This study thus aimed to examine the effect of bariatric surgery on exercise performance and metaboreflex.

Methods

Severely obese patients were assessed before and 3 months after bariatric surgery. Metaboreflex was evaluated by the technique of selective induction by post-exercise circulatory occlusion (PECO+) after isometric handgrip exercise at 30 % of maximum voluntary contraction. The exercise capacity was assessed by 6-min walking test.

Results

Seventeen patients completed the protocol. Body mass index decreased from 46.4?±?2 to 36.6?±?2 kg/m² (P?<?0.001). The distance walked in 6 min increased from 489?±?14 to 536?±?14 m (P?<?0.001). The peripheral metaboreflex activity, expressed by the area under the curve of vascular resistance, was lower after than before bariatric surgery (42?±?5 to 20?±?4 units, P?=?0.003). Heart rate, blood pressure, and vascular resistance were also significantly decreased. The correlation between change in distance walked in 6 min and change in peripheral metaboreflex activity was not significant.

Conclusions

Weight loss after bariatric surgery increases exercise capacity and reduces peripheral metaboreflex, heart rate, and blood pressure. Further investigation on the role of metaboreflex regarding mechanisms of exercise capacity of individuals with obesity is warranted.     

Outcomes of Bariatric Surgery in Patients with Inflammatory Bowel Disease

Background

Obesity has become prevalent in patients with inflammatory bowel disease (IBD). Bariatric surgery can be considered to be contraindicated in IBD patients. We aimed to evaluate feasibility, safety, and efficacy of bariatric surgery in IBD patients.

Methods

We retrospectively identified all morbidly obese patients with a known diagnosis of IBD, who underwent bariatric surgery between January 2005 and December 2012. Postoperative outcomes and status of IBD in patients on maintenance therapy for their disease were assessed.

Results

We identified 20 IBD patients including 13 ulcerative colitis (UC) and 7 Crohn’s disease (CD) patients with a mean age of 54.0?±?10.5 years, BMI of 50.1?±?9.0 kg/m², and duration of IBD of 11.3?±?5.2 years. Eleven patients were on medication for IBD at baseline. Bariatric procedures included sleeve gastrectomy (N?=?9), gastric bypass (N?=?7), gastric banding (N?=?3), and one conversion of band to gastric bypass. There were no intraoperative complications, but two conversions to laparotomy due to adhesions. Mean BMI change and excess weight loss at 1 year was 14.3?±?5.7 kg/m² and 58.9?±?21.1 %, respectively. Seven early postoperative complications occurred including dehydration (N?=?5), pulmonary embolism (N?=?1), and wound infection (N?=?1). During a mean follow-up of 34.6?±?21.7 months, five patients developed complications including pancreatitis (N?=?2), ventral hernia (N?=?2), and marginal ulcer (N?=?1). Nine out of ten eligible patients experienced improvement in their IBD status.

Conclusions

Bariatric surgery is feasible and safe in morbidly obese patients suffering from IBD. In addition to being an effective weight loss procedure, bariatric surgery may help mitigate symptoms in this patient population.

     

The Effect of Bariatric Surgery on Intestinal Absorption and Transit Time

Background

Bariatric surgical procedures are classified by their presumed mechanisms of action: restrictive, malabsorptive or a combination of both. However, this dogma is questionable and remains unproven. We investigated post-operative changes in nutrient absorption and transit time following bariatric surgery.

Methods

Participants were recruited into four groups: obese controls (body mass index (BMI) >30 kg/m², n?=?7), adjustable gastric banding (n?=?6), Roux-en-Y gastric bypass (RYGB, n?=?7) and biliopancreatic diversion with duodenal switch (DS, n?=?5). Participants underwent sulphasalazine/sulphapyridine tests (oro-caecal transit time); fasting plasma citrulline (functional enterocyte mass); 3 days faecal collection for faecal elastase 1 (FE-1); calprotectin (FCp); faecal fatty acids (pancreatic exocrine function, gut inflammation and fat excretion, respectively); and 5 h d-xylose, l-rhamnose and lactulose test (intestinal absorption and permeability).

Results

Age and gender were not different but BMI differed between groups (p?=?0.001). No difference in oro-caecal transit time (p?=?0.935) or functional enterocyte mass (p?=?0.819) was detected. FCp was elevated post-RYGB vs obese (p?=?0.016) and FE-1 was reduced post-RYGB vs obese (p?=?0.002). Faecal fat concentrations were increased post-DS vs obese (p?=?0.038) and RYGB (p?=?0.024) and were also higher post-RYGB vs obese (p?=?0.033). Urinary excretion of d-xylose and l-rhamnose was not different between the groups; however, lactulose/rhamnose ratio was elevated post-DS vs other groups (all p?<?0.02), suggesting increased intestinal permeability.

Conclusions

Following RYGB, there are surprisingly few abnormalities or indications of severe malabsorption of fats or sugars. Small bowel adaptation after bariatric surgery may be key to understanding the mechanisms responsible for the beneficial metabolic effects of these operations.     

Is Social Deprivation Associated with Weight Loss Outcomes Following Bariatric Surgery? A 10-Year Single Institutional Experience

Background

Social deprivation is associated with a greater morbidity and shorter life expectancy. This study evaluates differences in weight loss following bariatric surgery and deprivation, based on UK deprivation measures in a London bariatric centre.

Methods

All patients undergoing bariatric surgery between 2002 and 2012 were retrospectively identified. Demographic details, type of surgery and percentage excess weight loss data were collected. UK Index of Multiple Deprivation (IMD, 2010) and IMD domain of the Health Deprivation and Disability (HDD) scores were used to assess deprivation (where 1 is the most deprived in rank order and 32,482 is the least deprived). Two-way between-subjects analysis of variance (ANOVA) was performed to examine the effect of IMD score, deprivation, procedure type and gender on percentage excess weight loss.

Results

Data were included from 983 patients (178 male, 805 female) involving 3,663 patient episodes. Treatments comprised laparoscopic gastric bands (n?=?533), gastric bypass (n?=?362) and gastric balloons (n?=?88). The average percentage excess weight loss across all procedures was 38 % over a follow-up period (3 months–9 years). There was no correlation between weight loss and IMD/HDD rank scores. Gastric bypass was significantly more effective at achieving weight loss than the other two procedures at 3-, 6- and 9-month and 1-year follow-up.

Conclusions

Social deprivation does not influence weight loss after bariatric surgery, suggesting that all socioeconomic groups may equally benefit from surgical intervention. Social deprivation should not therefore negatively influence the decision for surgical intervention in these patients.