Medical management of patients after bariatric surgery: Principles and guidelines

Obesity is a major and growing health care concern. Large epidemiologic studies that evaluated the relationship between obesity and mortality, observed that a higher body-mass index(BMI) is associated with increased rate of death from several causes, among them cardiovascular disease; which is particularly true for those with morbid obesity. Being overweight was also associated with decreased survival in several studies. Unfortunately, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. All obese patients(BMI ≥ 30 kg/m2) should receive counseling on diet, lifestyle, exercise and goals for weight management. Individuals with BMI ≥ 40 kg/m2 and those with BMI 35 kg/m2 with obesity-related comorbidities; who failed diet, exercise, and drug therapy, should be considered for bariatric surgery. In current review article, we will shed light on important medical principles that each surgeon/gastroenterologist needs to know about bariatric surgical procedure, with special concern to the early post operative period. Additionally, we will explain the common complications that usually follow bariatric surgery and elucidate medical guidelines in their management. For the first 24 h after the bariatric surgery, the postoperative priorities include pain management, leakage, nausea and vomiting, intravenous fluid management, pulmonary hygiene, and ambulation. Patients maintain a low calorie liquid diet for the first few postoperative days that is gradually changed to soft solid food diet within two or three weeks following the bariatric surgery. Later, patients should be monitored for postoperative complications. Hypertension, diabetes, dumping syndrome, gastrointestinal and psychosomatic disorders are among the most important medical conditions discussed in this review.     

How much narcotics are really needed after bariatric surgery: results of a prospective study

BackgroundTo mitigate the opioid crisis, physicians are reevaluating opioid prescribing patterns.ObjectivesTo evaluate outcomes of maximal opioid reduction on top of an existing Enhanced Recovery after Surgery (ERAS) pathway in our The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited bariatric surgery program.SettingAcademic tertiary care hospital, United States.MethodsPatients undergoing primary bariatric operation were studied from July 2017 to April 2019, (standard ERAS cohort), and compared to patients from April 2019 to February 2021 (standard ERAS with Sparing Opioid Use Postoperatively protocol) (SOUP cohort). The primary endpoint was reduction of perioperative opioid use.ResultsOf 367 patients, 212 (57.8%) and 155 (42.2%) were in the ERAS and SOUP cohorts, respectively. Roux-en-Y gastric bypass was 48.6% (n = 103) versus 54.2% (n = 84) and sleeve gastrectomy was 51.4% (n = 109) versus 45.8% (n = 71) for ERAS versus SOUP, respectively (P = .29).The SOUP cohort of patients required a low median inpatient morphine equivalent dose of 4 mg [0–6.2]. The ERAS cohort was discharged on a higher morphine equivalent dose than the SOUP cohort at 186.7 mg ± 92.9 versus 37.6 ± 32.3 (P < .05), and median consumption of the standard 5 mg oxycodone tablet was 1.5 tablets [0–4]. The SOUP cohort patients rated their pain satisfaction score on a scale of 1 to 10 at 9.1 points (standard deviation ± 1.8). The SOUP cohort had a shorter length of stay (P < .05), with comparable readmission rates.ConclusionsAn opioid-sparing protocol can be implemented after bariatric surgery with high overall satisfaction with pain control.     

Screening endoscopy before bariatric surgery: a series of 448 patients

BackgroundThe role of upper esophagogastroduodenoscopy (EGD) in morbidly obese patients before bariatric surgery is controversial. The purpose of this study was to determine the diagnostic yield of routine EGD before bariatric surgery.MethodsA consecutive series of 448 morbidly obese patients, who were otherwise cleared for bariatric surgery, underwent routine EGD. The endoscopic findings were classified by the clinical significance. The findings were tabulated and analyzed.ResultsA total of 447 patients (389 women and 58 men) underwent EGD successfully. Of the 447 patients, 85% had a body mass index of 40–59.9 kg/m², and 93% had significant co-morbidities. Abnormal findings that did not change the surgical approach or postpone surgery were found in 60 patients (13%), including hiatal hernia and benign polyps. Abnormal findings that changed the medical management before surgery were found in 81 patients (18%), including inflammation and/or ulcers. This group included 9 of 61 patients with gastritis who were treated for Helicobacter pylori found within the biopsy specimen. Findings that changed the surgical approach were found in 1 patient, and findings of severe ulcerations that postponed surgery were found in another patient. Of the 447 patients, 389 actually underwent bariatric surgery, including Roux-en-Y gastric bypass in 57% and adjustable gastric banding in 43%. During follow-up, 37 gastric bypass patients (13%) developed ulceration. Both gastritis and duodenitis, but not the presence of H. pylori, was statistically related to ulcer formation (Fisher's exact test).ConclusionIn this consecutive series of 451 successful screening EGDs, positive findings led to a change in medical treatment in a significant number of patients (18%), but a change in the timing of surgery or the surgical technique in relatively few (<1%). In addition, a significant correlation between gastritis and postoperative anastamotic ulceration suggests a causative link, with implications arguing for stronger medical therapy. A randomized trial should be performed to validate the usefulness of preoperative EGD in bariatric patients.     

Effects of bariatric surgery in older patients

OBJECTIVE: Evaluate the safety and efficacy of bariatric surgery in older patients. BACKGROUND: Because of an increased morbidity in older patients who may not be as active as younger individuals, there remain concerns that they may not tolerate the operation well or lose adequate amounts of weight. METHODS: The database of patients who had undergone bariatric surgery since 1980 and National Death Index were queried for patients <60 and >/= 60 years of age. GBP was the procedure of choice after 1985. Data evaluated at 1 and 5 years included weight lost, % weight lost (%WL), % excess weight loss (%EWL), % ideal body weight (%IBW), mortality, complications, and obesity comorbidity. RESULTS: Eighty patients underwent bariatric surgery: age 63 +/- 3 years, 78% women, 68 white, 132 +/- 22 kg, BMI 49 +/- 7 kg/m, 217 +/- 32%IBW. Preoperative comorbidity, was greater (P < 0.001) in patients >/= 60 years. There were no operative deaths but 11 late deaths. Complications: 4 major wound infections, 2 anastomotic leaks, 10 symptomatic marginal ulcers, 5 stomal stenoses, 3 bowel obstructions, 26 incisional hernias (nonlaparoscopic), and 1 pulmonary embolism. At 1 year after surgery (94% follow-up), patients lost 38 +/- 11 kg, 57%EWL, 30%WL, BMI 34.5 +/- 7 kg/m, %IBW 153 +/- 31. Comorbidities decreased (P < 0.001); however, %WL and %EWL and improvement in hypertension and orthopedic problems, although significant, were greater in younger patients. At 5 years after surgery (58% follow-up), they had lost 31 +/- 18 kg, 50%EWL, 26%WL, BMI 35 +/- 8 kg/m, and %IBW 156 +/- 36. CONCLUSIONS: Bariatric surgery was effective for older patients with a low morbidity and mortality. Older patients had more pre- and post-operative comorbidities and lost less weight than younger patients. However the weight loss and improvement in comorbidities in older patients were clinically significant.     

Outcome of bariatric surgery in older patients

Background

People are living longer than they were expected to 2 decades ago. Increased life expectancy and reduced mortality encompasses a simultaneous increase in the number of older adults with obesity that entails an increase of co-morbidities, such as diabetes, hypertension, cancer, and many other diseases. The aim of our study was to compare the outcomes of bariatric surgery in patients age ≥65 in comparison with younger patients.

Patulous eustachian tube in bariatric surgery patients

Objective

Patulous eustachian tube (PET) is associated with several factors, including weight loss. Rapid and significant weight loss in bariatric surgery patients may be risk factors for developing PET. The aim of this study is to provide information about the prevalence of PET after bariatric surgery and its association to weight loss.

Study Design

Case series with planned data collection.

Setting

Tertiary center.

Subjects and Methods

We recruited 163 patients who had undergone bariatric surgery at the Clinical Hospital of the University of Chile between 2006 and 2009. One hundred forty-one patients were finally analyzed by clinical interview and physical examination. Two groups were formed, with and without PET. The degree, time, and velocity of weight loss were compared between groups. Demographic information and clinical presentation are also presented.

Results

The mean age was 38.9 years, and 76.6 percent of the patients were female. We found PET in 21.28 percent of the patients. Autophony was present in 96.6 percent of patients diagnosed with PET. Patients without PET experienced weight loss at an average of 39.54 kg during 16.59 months, while patients with PET experienced weight loss at an average of 48.63 kg in 12.11 months. The weight loss velocity in the PET group had a mean of 5.34 ± 3.4 kg/month versus 2.98 ± 1.3 kg/month in patients without PET. Time (P = 0.0037), magnitude (P = 0.0002), and velocity (P = 0.0005) of weight loss was higher in patients with PET.

Conclusion

Our case series shows a significant prevalence of PET in bariatric surgery patients, which has a correlation with weight loss velocity and magnitude.     

Cause of death in patients awaiting bariatric surgery

Background

Obesity is associated with increased mortality. Bariatric surgery is becoming an important treatment modality for obesity, with an associated reduction in mortality. There are few data available on the incidence and cause of death in referred patients while they are waiting for bariatric surgery.

Methods

We retrospectively examined all cases of death in patients who were referred for bariatric surgery assessment but who had not yet undergone bariatric surgery at a tertiary care centre in Halifax, Nova Scotia. The wait list comprised patients referred for surgery between March 2008 and May 2013. All cases of death were reviewed to determine age, sex, time of referral, time spent on the wait list, cause of death, comorbidities and body mass index (BMI).

Results

Of the 1399 patients referred, 22 (1.57%) died before receiving surgery. The mean age of these patients was 62.7 (range of 32–70) years. The average time from referral to death was 21.6 months, and the average BMI was 51.5. The most frequent cause of death was cancer, followed by cardiac and infectious causes.

Conclusion

This study provides useful information about mortality and causes of death among patients awaiting bariatric surgery at our centre. Our results will help guide the development of a judicious system for triage in light of long wait times.     

Systematic review: Outcomes of bariatric surgery in patients with inflammatory bowel disease and de-novo IBD development after bariatric surgery

A large proportion of patients diagnosed with inflammatory bowel disease are obese. Outcomes of bariatric surgery in patients with IBD and on IBD disease course itself is not clear. Furthermore, there is some evidence that bariatric surgery can precipitate the development of de-novo IBD. Thus, the aim of this systematic review was to summarise the evidence from the literature surrounding these questions. A comprehensive literature review was conducted based on the preferred reporting items for systematic reviews and meta-analysis guidelines (PRISMA). PUBMED, and MEDLINE databases was searched using a combination of keywords and MeSH terms including “gastric bypass”, “sleeve gastrectomy”, “Roux-en-Y”, “Duodenal switch”, “RYGB”, “bariatric surgery” and “inflammatory bowel disease”, “Crohn’s disease” ,“Ulcerative colitis”. Studies published up to March 2020 were included in this analysis. 22 studies met the inclusion criteria. Studies revealed that bariatric surgery is safe and effective for patients with IBD and resulted in significant weight loss at both the 6-month and 12-month time points. Furthermore, multiple studies reported de-novo IBD development following bariatric surgery in a selection of patients.     

Vitamin D deficiency in preoperative bariatric surgery patients

BACKGROUND: Obese patients are at risk of hypovitaminosis D. This is particularly concerning for those considering bariatric surgery because of the risk of postoperative nutritional deficiency. We hypothesized that it is necessary to screen for vitamin D deficiency preoperatively and conducted a study to identify the patterns of vitamin D deficiency among prospective bariatric surgery patients. METHODS: A retrospective analysis of available preoperative laboratory values was conducted for all consecutive patients (n = 312) scheduled to undergo bariatric surgery from January 2004 to October 2006. RESULTS: Of the 312 patients, 179 (57.4%) were deficient in vitamin D preoperatively (25-hydroxyvitamin D < or =20 ng/mL). The average body mass index was 52.3 kg/m2 and the average age was 42.4 years. Of the 139 black patients evaluated, 109 (78.4%) were vitamin D deficient; of the 156 white patients evaluated, 57 (36.5%) were vitamin D deficient; and of the 14 Hispanic patients evaluated, 11 (78.6%) were vitamin D deficient. We also evaluated serum red blood cell folate, vitamin B(12), and free retinol vitamin A levels preoperatively. Of the 312 patients, 39 (12.5%) were vitamin A deficient and 11 (3.5%) were vitamin B(12) deficient. No patient had a red blood cell folate deficiency. Patients with hypovitaminosis D were also checked for secondary hyperparathyroidism; 42 patients (23.5%) fit the criteria (parathyroid hormone levels >75 pg/mL). Many patients with low vitamin D levels were being considered for the duodenal switch procedure. CONCLUSION: The results of our study have shown that prospective bariatric surgery patients, particularly candidates for highly malabsorptive procedures, should be screened for hypovitaminosis D preoperatively. Our findings also showed that blacks are particularly at risk of vitamin D deficiency.     

Reporting of weight loss outcomes in bariatric surgery following introduction of 2015 ASMBS guidelines

BackgroundHeterogeneity in reporting weight loss (WL) outcomes within the bariatric surgery literature limits synthesis and meta-analysis. In 2015, the American Society for Metabolic and Bariatric Surgery (ASMBS) published reporting guidelines to achieve consistency in the literature.ObjectivesWe aimed to assess the effect of the ASMBS guidelines in the bariatric surgery literature.MethodsNine PubMed-indexed bariatric surgery journals were screened for articles published in the first 6 months of 2015 and 2021. Of 1807 articles, 105 and 158 articles in 2015 and 2021, respectively, reported primarily on WL outcomes following surgery.ResultsOverall ASMBS compliance increased from 5% to 20%, P < .05. Initial weight and body mass index (BMI) was reported in all studies, but specification of this as the immediate preoperative weight reduced from 15% to 6%, P < .05. The percent total WL (%TWL) increased from 17% to 61%, P < .05. Change in the BMI (DBMI) remained 41%. The percent excess BMI or WL (%EBMIL or %EWL) did not significantly change from 76% to 69%, P = .203. In 2021, 2 of the 9 journals gave guidance on reporting WL in their instructions to authors. Thirty percent (42/142) of articles did not comply with the journals’ WL reporting guidance. The number of unique WL outcomes used increased from 45 to 54.ConclusionsSignificant heterogeneity in reporting WL outcomes remains, hindering robust meta-analysis of articles. Use of referral weight instead of preoperative weight can inflate WL in those with mandated preoperative WL, clarifying initial weight is needed. Use of nonstandard measures of WL remains high.     

Obesity hypoventilation syndrome in bariatric surgery patients: an underestimated disease

BackgroundObesity is a known risk factor for obesity hypoventilation syndrome (OHS). However, study on the prevalence and clinical characteristics of OHS among bariatric surgery patients is scarce.ObjectivesTo investigate the prevalence of OHS in bariatric surgery patients and to identify its related predictors.SettingThe study was conducted at a bariatric surgery center in a tertiary university hospital.MethodsA cross sectional analysis was performed in the patients undergoing bariatric surgery between March 2017 and January 2020. Anthropometric, laboratory, pulmonary function, blood gas analysis, and polysomnographic data was collected and analyzed.ResultsOf 522 patients, the overall prevalence of OHS was 15.1%, with men (22.8 %) having a greater frequency than women (9.4%) (P < .001). The prevalence increases with obesity severity, from 4.1% in those with body mass index (BMI) <35 kg/m² to 39.1% in those with BMI ≥50 kg/m². Of 404 patients with obstructive sleep apnea (OSA), OHS was present in 17.3%, with 9.8% in mild OSA, 10.0% in moderate OSA, and 27.3%in severe OSA. Only 11.4% of patients diagnosed with OHS had no OSA. On logistic regression, BMI (odds ratio [OR]: 1.10; 95% confidence interval [CI], 1.01–1.21; P = .033), neck circumference (OR: 1.15; 95% CI, 1.03–1.28; P = .014), serum bicarbonate (OR: 1.39; 95% CI, 1.20–1.61; P = .000), C-reactive protein (CRP) (OR: 1.04; 95% CI, 1.00–1.07; P = .034) were independently associated with OHS.ConclusionIn bariatric surgery patients, OHS presented a high prevalence, especially in men. Higher levels of BMI, neck circumference, serum bicarbonate, and CRP indicated higher risk of OHS.     

Dietary protein intake and bariatric surgery patients: a review

Bariatric surgery, a highly successful treatment for obesity, requires adherence to special dietary recommendations to insure the achievement of weight loss goals and weight maintenance. Postoperative consumption of protein is linked to satiety induction, nutritional status, and weight loss. Hence, we conducted an extensive literature review to identify studies focused on the following: protein and nutritional status; recommendations for dietary protein intake; the effects of protein-rich diets; and associations between dietary protein intake and satiety, weight loss, and body composition. We found that there have been few studies on protein intake recommendations for bariatric patients. Dietary protein ingestion among this population tends to be inadequate, potentially leading to a loss of lean body mass, reduced metabolic rates, and physiological damage. Conversely, a protein-rich diet can lead to increased satiety, enhanced weight loss, and improved body composition. The quality and composition of protein sources are also very important, particularly with respect to the quantity of leucine, which helps to maintain muscle mass, and thus is particularly important for this patient group. Randomized studies among bariatric surgery patient populations are necessary to establish the exact quantity of protein that should be prescribed to maintain their nutritional status.     

Defining the role of bariatric surgery in polycystic ovarian syndrome patients

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women.To meet PCOS criteria,women must have a combination of hyperandrogenism,anovulation and ultrasound findings.Almost 10% of all reproductive age women worldwide show signs of PCOS.Although women often seek care for gynecological or body image concerns,many PCOS women are at risk for metabolic syndrome (MS).Many of the metabolic consequences are overlooked and un-dertreated by physicians because these patients tend to be young,reproductive age women.MS and obesity coexist commonly with PCOS.These young women are predisposed to glucose abnormalities and ulti-mately diabetes mellitus,dyslipidemia and eventually cardiovascular disease.Bariatric surgery can be an ef-fective means of weight loss in PCOS women.Surgical techniques have become safer and less invasive over time and have been found to be effective in achieving significant weight loss.Surgical options have also in-creased,giving patients more choices.Bariatric surgery may prevent or reverse metabolic syndrome.Bariatric surgery may also have reproductive benefits in PCOS patients.Although bariatric surgery has historically been performed in older,reproductive aged women,it has recently gained favor in adolescents as well.This is of particular importance due to the prevalence of both PCOS and MS in adolescents.Treatment of PCOS and MS certainly requires a combination of medical therapy,psychological support and lifestyle modifications.These treatments are difficult and often frustrating for pa-tients and physicians.Bariatric surgery can be effective in achieving significant weight loss,restoration of the hypothalamic pituitary axis,reduction of cardiovascular risk and even in improving pregnancy outcomes.Ulti-mately,bariatric surgery should be considered part of the treatment in PCOS women,especially in those with MS.