Venous thromboembolism prophylaxis with low molecular weight heparin versus unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures

BackgroundThe objective of this study was to compare inpatient mortality rates for patients with operatively treated closed femoral shaft fractures (AO/OTA 32 A-C) who received venous thromboembolism (VTE) prophylaxis with either low molecular weight heparin (LMWH) or unfractionated heparin.MethodsThis was a retrospective cohort study of a national database of patients presenting to Level I through IV trauma centers in the United States. All patients ≥18 years of age who sustained an operatively treated closed femoral shaft fracture were included. The primary outcome of inpatient mortality was compared between two groups: those who received LMWH or unfractionated heparin for VTE prophylaxis. Secondary outcomes were complications including VTE and bleeding events. Groups were compared using a multivariate regression model.ResultsThere were 2058 patients included in the study. Patients who received VTE prophylaxis with LMWH had lower odds of inpatient mortality compared to patients who received VTE prophylaxis with unfractionated heparin (OR 0.19; 95% CI 0.05 to 0.68, p = 0.011).ConclusionsVTE prophylaxis with LMWH is associated with lower inpatient mortality compared to VTE prophylaxis with unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures. To our knowledge this is the first study to report these associations for a specific subset of orthopedic trauma patients.     

A retrospective analysis of the effectiveness of low molecular weight heparin for venous thromboembolism prophylaxis in trauma patients

Background

In trauma patients, Enoxaparin (a low molecular weight heparin, LMWH) prophylaxis for venous thromboembolism (VTE) risk reduction is unproven.

Methods

Cohort analysis conducted consisting of all trauma patients age >13 admitted to Level-I trauma center and hospitalized >48 hours. VTE risk determined by the Risk Assessment Profile. High risk patients received LMWH unless contraindicated, while low and moderate risk patients received LMWH at attending surgeon's discretion. Odds ratio for VTE by logistic regression. VTE incidence, relative risk (RR), and number needed to treat (NNT) to prevent deep vein thrombosis (DVT) or pulmonary embolism determined by risk category.

Results

Cohort consisted of 2,281 patients (1,211 low, 979 moderate, 91 high risks). VTE occured in 254 patients (11.1%). High-risk patients had significantly higher VTE incidence, odds ratio = 31.8 (P < .001). VTE was significantly reduced in high-risk patients receiving LMWH versus those who did not (.26 vs .53, P = .02). Among moderate and high risk, prophylactic LMWH reduced the incidence of pulmonary embolism (RR = .19, NNT = 40.4, P = .01), and trended toward reduced DVT incidence (RR = .81, NNT = 27.3, P = .15). LMWH lowered DVT incidence (RR = .52, NNT = 4.1, P = .03) in high risk patients.

Conclusion

Prophylactic LMWH is associated with reduction of VTE in trauma patients.     

Prevalence and risk factors for symptoms suggestive of hypoglycemia and early dumping syndrome after sleeve gastrectomy

BackgroundPostprandial hypoglycemia and early dumping syndrome are common complications after bariatric surgery. Although sleeve gastrectomy (SG) has become a primary option for many bariatric surgeons, limited information was available for the prevalence and risk factors of the complications.ObjectiveTo assess the prevalence and possible risk factors for postprandial hypoglycemia and early dumping syndrome based on self-reported symptoms of SG patients.SettingThe study was conducted at a bariatric surgery center in a university hospital.MethodsIn this study, all patients who underwent an SG (n = 222) between December 2011 and May 2018 in our center were invited to participate in a questionnaire survey. The Edinburgh Hypoglycemia Scoring System and the Dumping Symptom Rating Scale were used to evaluate symptoms, and clinical data of the patients were collected. The median follow-up time was 1.1 years.ResultsThe questionnaire was completed and returned by 54.95% (122/222) of the patients and 62.30% (76/122) of the responders were women. The prevalence rates of mild and moderate symptoms suggestive of hypoglycemia were 65.57% (80/122) and .82%, respectively. An associated risk factor was younger age (adjusted for sex, body mass index, and waist circumference at baseline: odds ratio 3.69; 95% confidence interval [1.22–11.21]), but this association disappeared after further adjustment of low-density protein cholesterol (LDL-C) (odds ratio 6.42; 95% confidence interval [.38–108],;P > .05). The prevalence rate of mild symptoms suggestive of early dumping was 40.98% (50/122), associated risk factor was lower LDL-C.ConclusionMild-to-moderate symptoms suggestive of hypoglycemia and early dumping syndrome were common in patients after SG, with the prevalence rates of 66.39% (81/122) and 40.98% (50/122), respectively. Patients with both symptoms suggestive of early dumping syndrome and hypoglycemia accounted for 33.61% (41/122) of all patients. Younger age indicated higher risk of hypoglycemia after SG and lower LDL-C may play an important role in this relationship. Lower LDL-C was associated with higher risk of early dumping syndrome after SG.     

Effect of long-term proton pump inhibitor therapy on hemoglobin and serum iron levels after sleeve gastrectomy

BackgroundIron deficiency anemia and iron deficiency are commonly seen after bariatric surgery. Gastroesophageal reflux disease is commonly associated with sleeve resections and warrants postoperative acid reducing therapy.ObjectiveTo analyze the impact of long-term proton pump inhibitors on iron deficiency or iron deficiency anemia in laparoscopic sleeve gastrectomy (LSG) patients.SettingUniversity hospital, USA.MethodsA single-institution case control study included 2 groups of bariatric patients who underwent LSG. Patient characteristics such as age, sex, American Society of Anesthesiologists risk, body mass index, nutritional status, and co-morbidities were comparable. Postoperative follow-up was scheduled at 1-week, and 1-, 3-, 6-, and 12-month durations. All received standard postoperative iron, multivitamin therapy, and nutritional screening and evaluation. All patients were placed on postoperative proton pump inhibitors (PPI) therapy for at least 3 months. At third postoperative visit, anemia indicators were assessed by serum iron concentration, total iron binding capacity, transferrin saturation, red blood cell count, hemoglobin concentration, mean corpuscular volume, and mean corpuscular hemoglobin concentration. Postoperative hemoglobin and serum iron levels were compared between those patients still taking PPIs to those not taking PPIs at 12 months.ResultsA total of 287 patients underwent LSG from January 2016 to December 2017, 203 were included and 84 patients were excluded. Patients taking long-term PPIs (>12 mo, n = 85) were compared with those not taking PPIs (n = 118) and outcomes were respectively as follows: mean pre- and postoperative hemoglobin levels (in g/DL) were 13.2 and 10.7, and 13.3 and 13.7; mean postoperative serum iron levels (in μg/DL) were 41.7 and 88.7. Results were computed using paired t test and odds ratio that showed iron deficiency anemia in 12.9% (11/85) in PPI group compared with 4.23% (5/118) in the non-PPI group (odds ratio of 3.3, 95% confidence interval [1.21–10], and P = .03). Iron deficiency was seen in 22.3% (19/85) in the PPI group and 11% (13/118) in the non-PPI group (odds ratio of 2.3, 95% confidence interval [1.07–5.02] and P = .031).ConclusionsOur study indicates that PPIs can increase the severity of iron deficiency and iron deficiency anemia in patients who underwent LSG. Aggressive surveillance is needed in those taking long-term PPIs after LSG. It is encouraged to further analyze these findings in a larger randomized study model design.     

Validation of biochemical scores for liver steatosis before and 1 year after sleeve gastrectomy

BackgroundBariatric surgery is a potential treatment for liver steatosis in morbidly obese patients, showing an improvement in approximately 90% of cases of fatty liver after surgery. Liver biopsy is the gold standard method to monitor liver steatosis. Imaging tests, such as magnetic resonance (MR) spectroscopy, have shown a good accuracy in the diagnosis of liver steatosis. Several biochemical markers have been proposed as diagnostic alternatives to evaluate fatty liver.ObjectivesThe aim of this study was to analyze the potential of different biochemical markers for evaluating liver steatosis in morbidly obese patients before and after undergoing sleeve gastrectomy.SettingGarcilaso Clinic, Madrid, Spain.MethodsA prospective observational study of patients undergoing sleeve gastrectomy was performed. Diverse biochemical markers were assessed and correlated with MR spectroscopy as the diagnostic method for liver steatosis.ResultsOne hundred consecutive patients were included. Twelve months after surgery, mean body mass index was 28.3 ± 3.7 kg/m² and mean excess weight loss 82.5% ± 17.8%. Preoperatively, 67% of the patients had liver steatosis and 12 months after surgery the steatosis rate was reduced to 23%, as measured by MR spectroscopy. A significant direct correlation could only be observed between the percentage of lipid content, determined by MR spectroscopy and the liver fat score, at baseline and in the preoperative score. A cut-off point for liver fat score to determine the presence of liver steatosis was established at 1.22, for baseline and postoperative determinations.ConclusionThe liver fat score is the most accurate biochemical score to correlate with the percentage of lipid content of the liver, determined by MR spectroscopy.     

Laparoscopic loop duodenaljejunal bypass with sleeve gastrectomy in type 2 diabetic patients

BackgroundLaparoscopic loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG) is a new metabolic procedure. Our initial data on type 2 diabetes (T2D) remission after LDJB-SG were promising.ObjectivesThe aim of this study was to look at our intermediate outcomes after LDJB-SG.SettingAn academic medical center.MethodsA prospective analysis of T2D patients who underwent LDJB-SG between October 2011 and October 2014 was performed. Data collected included baseline demographic, body mass index, fasting blood glucose, glycosylated hemoglobin, C-peptide, resolution of co-morbidities, and postoperative complications.ResultsA total of 163 patients with minimum of follow-up >1 year were enrolled in this study (57 men and 106 women). The mean age and body mass index were 47.7 (±10.7) years and a 30.2 (±5.1) kg/m², respectively. There were 119 patients on oral hypoglycemic agents only, 29 patients were on oral hypoglycemic agents and insulin, 3 patients were on insulin only, and the other 12 patients were not on diabetic medication. Mean operation time and length of hospital stay were 144.7 (± 45.1) minutes and 2.4 (± 1.0) days, respectively. Seven patients (3.6%) needed reoperation due to bleeding (n = 1), anastomotic leak (n = 2), sleeve strictures (n = 2), and incisional hernia (n = 2). At 2 years of follow-up, there were 56 patients. None of the patients were on insulin and only 20% of patients were on oral hypoglycemic agents. Mean body mass index significantly dropped to 22.9 (±5.6) kg/m² at 2 years. The mean preoperative fasting blood glucose, glycosylated hemoglobin, and C-peptide levels were 174.7 mg/dL (± 61.0), 8.8% (±1.8), and 2.6 (±1.7) ng/mL, respectively. The mean fasting blood glucose, glycosylated hemoglobin, and C-peptide at 2 years were 112.5 (±60.7) mg/dL, 6.4% (±2.0), and 1.5 (±0.6) ng/mL, respectively. No patient needed revisional surgery because of dumping syndrome, marginal ulcer, or gastroesophageal reflux disease at the last follow up period.ConclusionAt 2 years, LDJB-SG is a relatively safe and effective metabolic surgery with significant weight loss and resolution of co-morbidities.     

Laparoscopic sleeve gastrectomy follow-up: use of connected devices in the postoperative period

BackgroundDuring the last decade, laparoscopic sleeve gastrectomy (LSG) has become the most performed bariatric procedure worldwide.ObjectivesTo evaluate the feasibility of the use of connected devices in monitoring patients operated on by LSG and discharged 24 hours after surgery under the enhanced recovery after surgery protocol.SettingPrivate hospital, France.MethodsThis is a prospective pilot study designed to assess the risk and benefit of using connected devices in the postoperative follow-up of patients operated on by LSG. Patients operated on with LSG were discharged 24 hours after surgery, and vital signs such as blood pressure, heart rate, peripheral capillary oxygen saturation, and temperature were monitored via connected devices with data sent to an internet platform to make them immediately viewable by the surgeon.ResultsThe study population consisted of 82 women and 18 men. The mean body mass index was 43.4 kg/m², and the mean age was 39.6 years. Two patients were reoperated on for bleeding and, consequently, were excluded from the study. At postoperative day 8, 1 patient presented with tachycardia, fever, and mild abdominal discomfort. After the alert was received from the internet platform, the patient was immediately contacted, admitted to the ward, and promptly reoperated on. At 1 year after the surgery, the mean percentage of excess weight loss and total weight loss were 68.1 ± 18.1% and 36 ± 9.8 kg, respectively. For the patients not available for follow-up at the 1-year control, weight loss data were extrapolated from the internet platform. Globally, 92% of patients felt safe when they returned home, and 92% of patients would recommend this way of managing the postoperative period.ConclusionsIn conclusion, this study shows that the early postoperative follow-up to an intervention such as LSG can be done at the patient's home under the monitoring of connected devices without a risk of increase in the rate of complications and rehospitalization. The role of the connected devices in the long-term postoperative follow-up seems promising.     

Bariatric surgery is safe and effective in Medicare patients regardless of age: an analysis of primary gastric bypass and sleeve gastrectomy outcomes

BackgroundNumerous studies have shown that bariatric surgery in older patients is safe and effective. However, both the Agency for Healthcare Research and Quality (AHRQ) and a Medicare Evidence Advisory Committee (MEDCAC) have cited gaps in the evidence for outcomes in Medicare patients undergoing bariatric surgery. These gaps are predominantly in the safety and outcomes evidence in Medicare patients younger than 65 years old (Centers for Medicare and Medicaid Services [CMS] < 65).ObjectivesThe aim of our study was to review both the safety and efficacy of gastric bypass (RYGB) and sleeve gastrectomy (SG) in Medicare patients compared with other payers.SettingA single academic medical center.MethodsA prospectively maintained database of 3300 patients who underwent bariatric surgery between January 2007 and December 2017 was utilized. The outcomes of Medicare patients undergoing RYGB and SG were analyzed and compared to those of similar patients covered by Medicaid or Commercial insurers.ResultsThere were too few patients with commercial insurance older than 65 to compare to those with Medicare (CMS ≥ 65). Mortality at 90 days for CMS ≥ 65 was 1.3% and the overall complication rate was 20.1% (minor 15.6%; major 7.1%). Total weight loss (TWL) at 6 months and 1, 2, and 3 years was 25.3%, 30.0%, 29.9%, and 29.4% respectively. For any time after surgery, 23% of CMS ≥ 65 had complete remission of diabetes and 45% had partial remission.Demographic analysis of CMS < 65 found Medicare patients were significantly older with more diabetes, hypertension and hyperlipidemia than those with commercial payers. Mortality at 90 days for CMS < 65 was 0.6% and the overall complication rate was 18.3% (minor 14.3%; major 4.7%). Mortality was not significantly different between payers. After adjustment for baseline differences and comparing to the Medicare group, the commercial group was less likely to have minor complications (P = .019), any complications (P = .007), and extended length of stay (P < .001). The TWL for the entire cohort age <65 at 6 months and 1, 2, and 3 years was 28.1%, 34.1%, 34.1%, and 31.8% respectively. After adjusting for differences, there was no significant difference in TWL between payers. For any time after surgery, complete remission of diabetes was 45% in CMS < 65 patients and partial remission was 59%. The comparison of remission between groups was then adjusted for DiaRem score and surgery type. CMS < 65 patients had significantly less partial remission of diabetes than commercial patients (P = .034) but no difference in complete remission.ConclusionsRYGB and SG are both safe and effective in Medicare patients of all ages. CMS ≥ 65 have acceptable mortality and complication rates with TWL and diabetes remission similar to younger patients. CMS < 65 patients are older than those with commercial insurance with more comorbid disease. While they have longer hospital stays after bariatric surgery, their weight loss and complete remission of diabetes are no different than patients with Medicaid or commercial insurance. This study helps fill an important evidence gap in bariatric surgical patients raised by both Agency for Healthcare Research and Quality, and a Medicare Evidence Advisory Committee.     

Perioperative outcomes of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in super-obese and super-super-obese patients: a national database analysis

BackgroundEvidence remains contradictory for perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients undergoing bariatric surgery.ObjectiveTo identify national 30-day morbidity and mortality of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients.SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.MethodsAll LSG and LRYGB patients from 2015 through 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were grouped based on body mass index (BMI) as follows: morbidly obese (MO; BMI 35.0–49.9 kg/m²), SO (BMI 50.0–59.9 kg/m²), and SSO (BMI ≥60.0 kg/m²). Complications and mortality within 30 days were compared between BMI groups using Pearson X² or Fischer’s exact tests. Multivariate logistic regression was used to adjust for demographic characteristics and co-morbidities, and adjusted odds ratio (AOR) was reported for each outcome.ResultsOf 356,621 patients, 71.6% had LSG and 28.4% LRYGB. A total of 272,195 patients were in the MO group, 65,565 in the SO group, and 18,861 in the SSO group. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for SO (AOR = 1.20, 95% confidence interval [CI] 1.13–1.28 for LSG; AOR = 1.08, 95% CI 1.01–1.15 for LRYGB) and SSO (AOR = 1.44, 95% CI 1.31–1.58 for LSG; AOR = 1.31, 95% CI 1.19–1.45 for LRYGB) compared with the MO group. Mortality was also significantly higher for SO (AOR = 1.65, 95% CI 1.10–2.48 for LSG; AOR = 1.85, 95% CI 1.23–2.80 for LRYGB) and SSO (AOR = 3.30, 95% CI 1.98–5.48 for LSG; AOR = 3.32, 95% CI 1.93–5.73 for LRYGB) compared with the MO group.ConclusionsSO and SSO patients are at increased risk of 30-day morbidity and mortality compared with MO patients. Despite this elevated perioperative risk, the overall risk of these procedures remains low and acceptable especially as bariatric surgery is the durable treatment option for obesity.     

Weight loss after sleeve gastrectomy in developmentally delayed adolescents and young adults

BackgroundAdolescent obesity is a significant factor in caring for patients with developmental delay (DD). Sleeve gastrectomy provides durable weight loss for teens with obesity but requires behavioral change that may not occur in patients with DD.ObjectivesTo determine whether patients with DD had similar weight loss and adverse outcomes to patients without a diagnosis of DD after sleeve gastrectomy.SettingAcademic children's hospital, United States.MethodsPatients with DD undergoing sleeve gastrectomy were matched to adolescents without DD. Chart review was performed to determine etiology and severity of DD, weight, and body mass index (BMI) change in each group at 3, 6, 9, and 12 months postoperatively. One-year emergency department visits, readmissions, and reoperations were reviewed.ResultsTen patients with DD and 44 patients without DD underwent sleeve gastrectomy between 2008 and 2017. Six patients with DD (60%) had mild cognitive impairment, 3 patients (30%) had moderate cognitive impairment, and 1 patient (10%) had severe cognitive impairment. Patients were 81.5% female, had a mean age of 17.3 years, and had a preoperative BMI of 48.6 kg/m². Preoperative BMI was similar in the 2 groups, and percent BMI reduction at 1 year was ?29% (95% confidence interval: ?35 to ?23) and ?26% (95% confidence interval: ?29 to ?23) in groups with and without DD respectively (group by time interaction, P = .27).ConclusionAdolescents with DD experience similar 1-year weight loss and adverse events following sleeve gastrectomy to adolescents without DD. Understanding the long-term outcomes for this population is crucial to ensure appropriate implementation of surgical weight loss programs.     

The effect of bougie size and distance from the pylorus on dehydration after laparoscopic sleeve gastrectomy: an analysis of the ACS-MBSAQIP database

BackgroundDehydration is the most common cause of readmission after laparoscopic sleeve gastrectomy (SG). Bougie size and distance from the pylorus, both of which have been associated with rates of dehydration postoperatively, varies by surgeon and across institutions.ObjectivesTo determine if there is an association between bougie size or distance from the pylorus on the rate of dehydration after laparoscopic SG.SettingAmerican College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database.MethodsAll patients undergoing first-time, elective laparoscopic SG from 2015–2016 were identified. The association of bougie size and distance from the pylorus on the rate of dehydration within the first 30 days postoperatively was investigated.ResultsThe inclusion criteria were met by 170,751 patients. The most commonly used bougie size was 36 Fr and the most common distance from the pylorus at which the gastric sleeve was started was 5 cm. Patients were divided into 4 groups based on bougie size and distance from the pylorus (Group 1: bougie size <36 Fr, pylorus distance <4 cm; Group 2: bougie size ≥36 Fr, pylorus distance <4 cm; Group 3: bougie size ≥36 Fr, pylorus distance ≥4 cm; and Group 4: bougie size <36 Fr, pylorus distance ≥4 cm). Patients in Group 4 were significantly less likely than any other group to experience dehydration-related complications.ConclusionBoth distance from the pylorus and bougie size are significantly associated with dehydration-related complications after SG. Consideration should be made for standardizing these technical aspects of SG to help reduce the rate of postoperative dehydration and hospital readmission.     

Single- or double-anastomosis duodenal switch versus Roux-en-Y gastric bypass as a revisional procedure for sleeve gastrectomy: A systematic review and meta-analysis

BackgroundLaparoscopic sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedure worldwide. There is currently no consensus on which revisional procedure is best after an initial SG.ObjectivesTo compare the efficacy and safety between single-anastomosis duodeno-ileal bypass (SADI) or biliopancreatic diversion with duodenal switch (BPD-DS) versus Roux-en-Y gastric bypass (RYGB) as a revisional procedure for SG.SettingUniversity Hospital, Canada.MethodsMEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PubMed were searched up to August 2018. Studies were eligible for inclusion if they compared SADI or BPD-DS with RYGB as a revisional bariatric procedure for SG. Primary outcome was absolute percentage of total weight loss. Secondary outcomes were length of stay, adverse events, and improvement or resolution of co-morbidities (diabetes, hypertension, or hypercholesterolemia). Pooled mean differences were calculated using random effects meta-analysis.ResultsSix retrospective cohort studies involving 377 patients met the inclusion criteria. The SADI/BPD-DS group achieved a significantly higher percentage of total weight loss compared with RYGB by 10.22% (95% confidence interval, ?17.46 to ?2.97; P = .006). However, there was significant baseline equivalence bias with 4 studies reporting higher initial body mass index (BMI) in the SADI/BPD-DS group. There were no significant differences in length of stay, adverse events, or improvement of co-morbidities between the 2 groups.ConclusionSADI, BPD-DS, and RYGB are safe and efficacious revisional surgeries for SG. Both SADI and RYGB are efficacious in lowering initial BMI but there is more evidence for excellent weight loss outcomes with the conversion to BPD-DS when the starting BMI is high. Further randomized trials are required for definitive conclusions.     

Impact of rapid weight loss on risk reduction of developing arterial hypertension in severely obese patients undergoing bariatric surgery. A single-institution experience using the Framingham Hypertension Risk Score

BackgroundMorbid obesity is strongly associated with hypertension.ObjectiveThe objective of this study is to compare the risk of developing hypertension before and after bariatric surgery.SettingU.S. university hospital.MethodsWe retrospectively reviewed all patients who underwent bariatric surgery from 2010 to 2015 at our institution. Nonhypertensive white individuals without diabetes at baseline were included in our study. The Framingham Hypertension Risk Score was used to predict the near-term incidence of the disease. This calculator predicts 1-, 2-, and 4-year incidence of hypertension.ResultsA total of 475 patients met the criteria for the hypertension risk score calculation. Females composed 72% (n = 342) of our population with a mean age of 42.6 ± 11.6 years. Laparoscopic sleeve gastrectomy was the most prevalent procedure at 81.89% (n = 389). At 12- month follow-up, the 1-year absolute risk reduction (ARR) and the relative risk reduction (RRR) were 6.2% and 69.2% (P < .01), respectively. The 2-year ARR was 11.9%, with an RRR of 67.9% (P < .01). The 4-year risk was also calculated at 12-month follow-up, resulting in an ARR of 20.1%, and RRR of 63.7% (P < .01). Furthermore, stratifying by type of procedure, the results were comparable between sleeve gastrectomy and Roux-en-Y gastric bypass. Regarding blood pressure values at 12-month follow-up, the systolic blood pressure was reduced 11.4 mm Hg (P < .01) and the diastolic blood pressure was reduced 4.4 mm Hg (P = .07). The percentage of estimated body mass index loss at 12-month follow-up was 71.7%.ConclusionsSleeve gastrectomy and Roux-en-Y gastric bypass significantly diminish the risk of developing hypertension in morbidly obese patients. Prospective studies are needed to better comprehend these findings.     

Analysis of vitamin levels and deficiencies in bariatric surgery patients: a single-institutional analysis

BackgroundBariatric surgery patients are at risk for vitamin deficiencies.ObjectivesInvestigate the prevalence of deficiencies of vitamins A, B1, B12, D, and folate in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) patients in a single institution.SettingAn academic medical center.MethodsRetrospective chart reviews of 468 bariatric surgery patients (358 SG and 110 RYGB) were analyzed for vitamin levels, calcium, and parathyroid hormone. Both preoperative and postoperative measurements were obtained.ResultsDeficiency of vitamin D was the most common, seen in 27% preoperatively. Postoperatively, RYGB patients had a higher prevalence of vitamin D deficiency than SG patients (11.5% RYGB versus 5.2% SG within the first postoperative year, and 20.3% RYGB versus 13.4% SG after 1 year). Elevated parathyroid hormone was observed in 45% of RYGB patients after 1 year postoperatively. Vitamin A deficiency was uncommon preoperatively (2.7% SG versus 1.7% RYGB), but increased after surgery (9.4% SG versus 15.9% RYGB within 1 year postoperatively, and 5.2% SG versus 7.7% RYGB after 1 year). Vitamin B1 deficiency was observed in 8.1% SG versus 1.7% RYGB patients preoperatively and increased during the first year postoperatively (SG 10.5% and RYGB 13.7%), but improved after 1 year (7.2% SG versus 5.9% RYGB). Less than 2% of Vitamin B12 deficiencies and no folate deficiencies occurred in both SG and RYGB patients.ConclusionsThe highest prevalence of vitamin B1 and A deficiencies were seen in the first year postoperatively. Vitamin B12 and folate deficiency were uncommon in our patients. Vitamin D deficiency improved after surgery, but elevated parathyroid hormone was common after RYGB.     

Use of noninvasive positive pressure ventilation in patients with severe obesity undergoing esophagogastroduodenoscopy: a randomized controlled trial

BackgroundPatients with severe obesity being considered for bariatric surgery often undergo preoperative esophagogastroduodenoscopy (EGD). Severe obesity is a risk factor for oxygen desaturation events during EGD. The use of noninvasive positive pressure ventilation (NIPPV) to reduce desaturation events during EGD among patients with severe obesity has not been studied.ObjectiveTo evaluate the use of NIPPV among patients with severe obesity undergoing EGD.SettingCommunity hospital endoscopy suite.MethodsA randomized controlled trial evaluated the use of NIPPV in patients with severe obesity undergoing EGD. Patients were randomized into treatment (NIPPV) and control (nasal cannula, NIPPV for rescue) groups. Primary endpoints were oxygen desaturation events ≤94% and oxygen desaturation events <90% requiring intervention. A secondary endpoint was the use of NIPPV as a rescue maneuver.ResultsFifty-six patients with a body mass index of 40 to 60 were randomized (n = 28 treatment and n = 28 control). A statistically significant difference was noted between the groups for desaturation events ≤94% (14.3% of treatment and 57.1% of control groups, P = .002). There was also a statistically significant difference in the risk of a desaturation event <90% requiring intervention (3.5% of treatment and 28.6% of control groups, P = .025). All patients in the control group who developed desaturation events requiring intervention were rescued with NIPPV.ConclusionsThis study demonstrated the successful use of NIPPV as an adjunct to decrease the incidence of desaturation events in patients with severe obesity undergoing EGD.