Safety of bariatric surgery in patients older than 65 years

BackgroundThe increase in life expectancy along with the obesity epidemic has led to an increase in the number of older patients undergoing bariatric surgery. There is conflicting evidence regarding the safety of performing bariatric procedures on older patients.ObjectiveThe purpose of this study was to compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for older patients (>65 yr).SettingNationwide analysis of accredited centers.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2017 database was used to identify nonrevisional laparoscopic RYGB and SG procedures. Comparisons were made based on patient age. Clinical outcomes included postoperative events and mortality.ResultsThere was a total 13,422 and 5395 matched pairs for SG and RYGB in comparing patients aged 18 years to those aged 65 and >65 years, respectively, and 5395 matched RYGB and SG procedures performed in patients >65 years. The complication rate was higher in older patients undergoing RYGB compared with SG (risk difference = 2.39%, 95% confidence interval: 1.57%–3.21%, P < .0001). When comparing older to younger patients, the older group had a higher complication rate for SG but not for RYGB (SG: risk difference = 1.01%, 95% confidence interval: .59%–1.43%, P < .0001, RYGB: risk difference = .59%, 95% confidence interval: ?.29% to 1.47%, P = .2003).ConclusionsOverall complication rates of bariatric surgery are low in patients >65 years. SG appears to have a favorable safety profile in this patient population compared with RYGB. The overall complication rate for RYGB is not significantly different between the older and younger groups.     

Metabolic effects of bariatric surgery on patients with type 2 diabetes: a population-based study

BackgroundBariatric surgery among patients with obesity and type 2 diabetes (T2D) can induce complete remission. However, it remains unclear whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has better T2D remission within a population-based daily practice.ObjectivesTo compare patients undergoing RYGB and SG on the extent of T2D remission at the 1-year follow-up.SettingNationwide, population-based study including all 18 hospitals in the Netherlands providing metabolic and bariatric surgery.MethodsPatients undergoing RYGB and SG between October 2015 and October 2018 with 1 year of complete follow-up data were selected from the mandatory nationwide Dutch Audit for Treatment of Obesity (DATO). The primary outcome is T2D remission within 1 year. Secondary outcomes include ≥20% total weight loss (TWL), obesity-related co-morbidity reduction, and postoperative complications with a Clavien-Dindo (CD) grade ≥III within 30 days. We compared T2D remission between RYGB and SG groups using propensity score matching to adjust for confounding by indication.ResultsA total of 5015 patients were identified from the DATO, and 4132 (82.4%) had completed a 1-year follow-up visit. There were 3350 (66.8%) patients with a valid T2D status who were included in the analysis (RYGB = 2623; SG = 727). RYGB patients had a lower body mass index than SG patients, but were more often female, with higher gastroesophageal reflux disease and dyslipidemia rates. After adjusting for these confounders, RYGB patients had increased odds of achieving T2D remission (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14–2.1; P < .01). Groups were balanced after matching 695 patients in each group. After matching, RYGB patients still had better odds of T2D remission (OR, 1.91; 95% CI, 1.27–2.88; P < .01). Also, significantly more RYGB patients had ≥20%TWL (OR, 2.71; 95% CI, 1.96–3.75; P < .01) and RYGB patients had higher dyslipidemia remission rates (OR, 1.96; 95% CI, 1.39–2.76; P < .01). There were no significant differences in CD ≥III complications.ConclusionUsing population-based data from the Netherlands, this study shows that RYGB leads to better T2D remission rates at the 1-year follow-up and better metabolic outcomes for patients with obesity and T2D undergoing bariatric surgery in daily practice.     

Gastrointestinal symptoms before and after laparoscopic Roux-en-Y gastric bypass: a longitudinal assessment

BackgroundRoux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity, but many patients have increased gastrointestinal symptoms.ObjectivesTo evaluate gastrointestinal symptoms and food intolerance before and after RYGB over time in a large cohort of morbidly obese patients.SettingA high-volume bariatric center of excellence.MethodsA prospective cohort study was performed in patients who underwent RYGB between September 2014 and July 2015, with 2-year follow-up. Consecutive patients screened for bariatric surgery answered the Gastrointestinal Symptom Rating Scale (GSRS) and a food intolerance questionnaire before RYGB and 2 years after surgery. The prevalence of gastrointestinal symptoms before and after surgery and the association between patient characteristics and postoperative gastrointestinal symptoms were assessed.ResultsFollow-up was 86.2% (n = 168) for patients undergoing primary RYGB and 93.3% (n = 28) for revisional RYGB. The total mean GSRS score increased from 1.69 to 2.31 after surgery (P < .001), as did 13 of 16 of the individual scores. Preoperative GSRS score is associated with postoperative symptom severity (B = .343, P < .001). Food intolerance was present in 16.1% of patients before primary RYGB, increasing to 69.6% after surgery (P < .001). Patients who underwent revisional RYGB had a symptom severity and prevalence of food intolerance comparable with that among patients with primary RYGB, even though they had more symptoms before revisional surgery.ConclusionsTwo years after surgery, patients who underwent primary RYGB have increased gastrointestinal symptoms and food intolerance compared with the preoperative state. It is important that clinicians are aware of this and inform patients before surgery.     

Impact of insurance plan design on bariatric surgery utilization

BackgroundBariatric surgery is underused in the United States.ObjectivesThis study examined whether utilization of bariatric surgery is associated with payor and insurance plan type, after removing potential sociodemographic confounders.SettingThe study used Pennsylvania Health Care Cost Containment Council’s data in 5 counties of Pennsylvania from 2014 to 2016.MethodsBariatric surgery patients and eligible patients who did not undergo surgery were identified and 1:1 matched by age, sex, race, and zip code (n = 5114). A logistic regression was performed to investigate the association of payor type and insurance plan within payor type with odds of undergoing bariatric surgery.ResultsThe odds of undergoing bariatric surgery were not statistically different based on payor type. Medicare preferred provider organization plan was associated with greater odds of undergoing surgery (odds ratio [OR] = 2.49, 95% confidence interval [CI] 1.23–5.04, P = .01) compared with Medicare health maintenance organization (HMO). Medicaid fee for service plan was associated with smaller odds of undergoing surgery (OR = .04, 95% CI .005–.27, P = .001) compared with Medicaid HMO. Individuals with Blue Cross preferred provider organization (OR = 2.43, 95% CI 1.83–3.24, P < .001), Blue Cross fee for service (OR = 1.79, 95% CI 1.32–2.43, P < .001), and Blue Cross HMO (OR = 1.85, 95% CI 1.39–2.46, P < .001) had greater odds of undergoing surgery compared with those with other commercial HMO plans.ConclusionsSpecific aspects of insurance plan design, rather than more general payor type, is more strongly associated with the utilization of bariatric surgery. Further investigations could identify which components of insurance plan design have the greatest influence on the utilization of bariatric surgery.     

Perioperative and 1-year outcomes of bariatric surgery in septuagenarians: implications for patient selection

BackgroundAlthough bariatric surgery is an effective treatment for obesity, utilization of bariatric procedures in older adults remains low. Previous work reported higher morbidity in older patients undergoing bariatric surgery. However, the generalizability of these data to contemporary septuagenarians is unclear.ObjectivesWe sought to evaluate differences in 30-day outcomes, 1-year weight loss, and co-morbidity remission after bariatric surgery among 3 age groups as follows: <45 years, 45–69 years, and ≥70 years.SettingStatewide quality improvement collaborative.MethodsUsing a large quality improvement collaborative, we identified patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2006 and 2018. We used multivariable logistic regression models to evaluate the association between age cohorts and 30-day outcomes, 1-year weight loss, and co-morbidity remission.ResultsWe identified 641 septuagenarians who underwent SG (68.5%) or RYGB (31.5%). Compared with 45–69 year olds, septuagenarians had higher rates of hemorrhage (5.1% versus 3.1%; P = .045) after RYGB and higher rates of leak/perforation (.9% versus .3%; P = .044) after SG. Compared with younger patients, septuagenarians lost less of their excess weight, losing 64.8% after RYGB and 53.8% after SG. Remission rates for diabetes and obstructive sleep were similar for patients aged ≥70 years and 45–69 years.ConclusionsBariatric surgery in septuagenarians results in substantial weight loss and co-morbidity remission with an acceptable safety profile. Surgeons with self-imposed age limits should consider broadening their selection criteria to include patients ≥70 years old.     

Surgeon factors are strongly correlated with who receives a sleeve gastrectomy versus a Roux-en-Y gastric bypass

BackgroundSleeve gastrectomy (SG) has replaced Roux-en-Y gastric bypass (RYGB) as the most common bariatric operation. While SG constitutes ～70% of all bariatric volume, we hypothesize that the distribution of SG versus RYGB varies widely at the level of the surgeon and that surgeon rather than patient factors are the primary driver of the procedure performed.ObjectivesTo determine the distribution of bariatric procedures performed at the surgeon level.SettingPopulation-level analysis using the Statewide Planning and Research Cooperative System (SPARCS) for New York State (2004–2014).MethodsIdentified surgeons performing SG and RYGB using billing codes. Logistic regression performed to determine the impact of surgeon, patient, and hospital factors on receiving a RYGB.ResultsOf the 142 surgeons who perform >5 bariatric operations per year, 32 (22.5%) performed a SG in ≥95% of their bariatric cases in the year 2014. In logistic regression, diabetes (odds ratio [OR] 1.45; P < .001) and gastroesophageal reflux disease (OR 1.36; P < .001) were associated with receiving a RYGB. However, the most correlated factor was whether the surgeon had a RYGB case volume >66^th percentile in the preceding year (OR 33.8; P < .001). In pseudo-R² analysis, 83% of the power of the regression could be explained by surgeon factors alone.ConclusionsWhile the percentage of SG in this cohort closely matches the national average, there is wide variation at the surgeon level with a significant proportion predominantly performing a single procedure. Surgeon factors are more strongly correlated with procedure selection compared to patient or hospital factors.     

Contribution of glycemic variability to hypoglycemia,and a new marker for diabetes remission after Roux-en-Y gastric bypass surgery

BackgroundDiabetes remission after bariatric surgery was reported to be characterized by increased risk of hypoglycemia.ObjectivesThis study aimed to examine the contribution of glycemic variability (GV) to the risk of hypoglycemia, and the suitability of time in range (TIR), an emerging glycemic marker, to define diabetes remission after Roux-en-Y gastric bypass (RYGB).SettingA single referral center in China.MethodsThis retrospective study included 175 individuals with type 2 diabetes and obesity who underwent RYGB. Subjects were classified as remission/nonremission according to the current standard. Each participant underwent continuous glucose monitoring both before and 1 year after RYGB. GV was measured by glucose coefficient of variation (CV), and hypoglycemia was assessed by time below range (TBR).ResultsComplete remission was achieved in 88 of the 175 participants following RYGB. In the remission group, significant correlations between postoperative CV and TBRs (r = .353–.442, both P ≤ .001) were found. Excess hypoglycemia (TBR_{<54 ,} ≥1%, TBR_<70, ≥4%) increased with ascending CV quintiles (both P for trend <.05) and was significantly more frequent in subjects with glucose CV >32.2% (both P <.05). Compared with glycated hemoglobin A1C, TIR showed stronger correlation with glucose CV and risk of hypoglycemia.ConclusionIncreased glycemic variability was linked to excess risk of hypoglycemia after RYGB. Furthermore, TIR may serve as a new metric, in addition to HbA1C, for defining diabetes remission.     

Early cardiac complications after bariatric surgery: does the type of procedure matter?

BackgroundMajor adverse cardiac events (MACE) can be a cause of postoperative mortality. This is specifically important in bariatric surgery due to obesity-related cardiovascular risk factors.ObjectiveTo assess postoperative cardiac adverse events after bariatric surgery and its independent predictors.SettingA retrospective analysis of 2011–2015 Healthcare Cost and Utilization Project-National Inpatient Sample.MethodsData on patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were retrieved. MACE was identified as a composite variable including myocardial infarction, acute ischemic heart disease without myocardial infarction, and acute heart failure. Dysrhythmia (excluding premature beats) was identified as a separate outcome. Multivariate regression analysis for MACE was performed using demographic factors, co-morbidities, and type of surgery.ResultsThe analysis included 108,432 patients (SG: 54.6%, RYGB: 45.4%). MACE was found in 116 patients (.1%), and dysrhythmia occurred in 3670 patients (3.4%). Median length of stay in patients with MACE was 4.5 versus 2 days in others (P < .001). There were 43 deaths overall, and 31 were in patients with MACE or dysrhythmia (P < .001). Age ≥ 50 years, male sex, congestive heart failure, chronic pulmonary disease, ischemic heart disease, history of pulmonary emboli, and fluid or electrolyte disorders were independent predictors of MACE based on multivariate analysis. Type of surgery (SG versus RYGB) was not an independent predictor for MACE (odds ratio 1.41, 95% confidence interval: .77–2.55).ConclusionsWhile cardiac complications are rare after bariatric surgery, their occurrence is associated with increased length of stay, hospital charges, and mortality. Older age, male sex, cardiopulmonary co-morbidities, and fluid or electrolyte disorders are predictive of MACE. RYGB does not increase the risk of MACE compared with SG.     

Cost-effectiveness of enhanced recovery pathway in bariatric surgery: It is not all about length of stay

BackgroundThe goal of enhanced recovery pathways (ERP) is to optimize perioperative recovery and decrease variability of care between patients.ObjectivesIn this study, we aimed to assess the clinical and cost saving before and after implementation of an ERP program in bariatric surgery at our institution.SettingAcademic Center, United States.MethodsA pilot bariatric surgery ERP was implemented in June 2016. Demographic characteristics, outcomes, and technical direct costs of patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy were compared between the control group (January 2015–June 2016) and ERP group (July 2016–December 2017).ResultsTwo hundred fifty-two patients (118 [45%] in the control group and 144 [55%] in the ERP group) were included. Patient demographic characteristics were similar in both groups (P > .05). There were 2 (1.3%) reoperations within the ERP group but no mortalities. The median length of stay (LOS) was shorter in the ERP group by 1 day (P < .001) with comparable readmission rates. However, ERP implementation was associated with a 3.8% increase in costs for patients undergoing RYGB (P = .02). Finally, ERP protocol did not lead to an increase in either reoperation or readmission rates.ConclusionERP implementation decreases LOS without increasing adverse postoperative outcomes or readmissions. However, cost of care may increase for patients undergoing RYGB related to anesthesia and surgical services, which offset the gains noted by a decrease in LOS. Program implementing ERP need to focus on containing the costs of anesthesia care to realize financial benefits of ERP.     

Ten-year outcomes after Roux-en-Y gastric bypass and sleeve gastrectomy: an observational nonrandomized cohort study

BackgroundSleeve gastrectomy (SG) has replaced Roux-en-Y gastric bypass (RYGB) as the most commonly performed bariatric surgery procedure. Data on the long-term (up to 10 yr) outcomes after SG is scarce. No previous study has compared the long-term outcomes between RYGB and SG.ObjectiveTo compare 10-year weight lost and 10-year remission rates of type 2 diabetes, hypertension, and dyslipidemia between RYGB and SG.SettingUniversity hospital, Spain.MethodsNonrandomized cohort study including all patients that underwent RYGB or SG at our institution between January 2005 and March 2008. Participants were followed yearly after bariatric surgery. Data obtained at the 10-year evaluation after RYGB or SG (between January 2015 and March 2018) was analyzed. Main study outcomes were 10-year percentage of total weight lost and percentage of excess weight lost. Secondary outcomes included 10-year remission rates of type 2 diabetes, hypertension, and dyslipidemia. Between-groups differences in 10-year percentage of total weight lost and percentage of excess weight lost were evaluated using analysis of covariance. Association between type of surgery and remission rates of obesity-related co-morbidities were evaluated using logistic regression analyses.ResultsFive hundred four patients were included in the study, 390 underwent RYGB and 134 SG. Follow-up rate was 84.5%. Mean 10-year percentage of total weight lost and percentage of excess weight lost were 25.3 ± 11.2% and 56.0 ± 25.6% in the RYGB group, and 27.5 ± 13.5% and 53.2 ± 25.1% in the SG group (P = .853 and P = .746, respectively). In logistic regression analyses RYGB was superior to SG in achieving 10-year hypertension and dyslipidemia remission.ConclusionsThis study suggested comparable effectiveness between SG and RYGB on weight loss.     

Circulating magnesium status is associated with type 2 diabetes remission after Roux-en-Y gastric bypass surgery: a long-term cohort study

BackgroundLow serum magnesium levels predict cardiovascular and all-cause mortality in patients with typ 2 diabetes.SettingOutpatient clinic of obesity and central hospital.ObjectivesTo assess long-term alterations in circulating magnesium status after Roux-en-Y gastric bypass (RYGB) surgery and associations with remission of type 2 diabetes (T2D).MethodsRetrospective analysis of 5-year outcomes of plasma magnesium (p-Mg) and glucometabolic statuses in patients who underwent primary RYGB and who completed the annual follow-up program. Data were investigated from 84 patients without diabetes and 62 with T2D before RYGB, who showed either prolonged remission (n = 30), temporary remission (n = 16), or no remission (n = 16) after surgery.ResultsBody mass indexes before RYGB were similar in patients with and without T2D, irrespective of remission. The patients not achieving remission showed longer diabetes durations; higher circulating glucose levels; more intensive antidiabetic drug treatment, including insulin; and significantly lower p-Mg concentrations (.73 [±.08] mmol/L compared with .80–.82 [±.07] mmol/L, respectively; P < .01) than the groups showing remission or without diabetes before surgery. After RYGB, the p-Mg increased similarly, by 10–12% in the groups with T2D before surgery, irrespective of remission; however, the nonremission group did not reach the p-Mg levels registered in the other groups after follow-up. The nonremission group reached .82 (.09) mmol/L, compared with .87 (.06) and .88 (.08) mmol/L (P < .05), respectively, in patients with remission or without a history of diabetes.ConclusionThe p-Mg concentrations increased after RYGB, with similar increments irrespective of T2D remission; however, the nonremission group started from an inferior level and did not reach the p-Mg concentrations seen in the groups achieving remission or without a history of diabetes before surgery.     

Influence of post–Roux-en-Y gastric bypass weight recidivism on insulin resistance: a 3-year follow-up

BackgroundAlthough some early metabolic benefits provided by bariatric surgery are known to occur regardless of weight loss, the impact of mid- to long-term weight recidivism after Roux-en-Y gastric bypass (RYGB) on metabolic outcomes is not profoundly understood.ObjectiveTo investigate the effect of weight recidivism on insulin resistance among nondiabetic individuals with morbid obesity after RYGB during a 3-year follow-up.SettingPublic tertiary university hospital.MethodsThis is a cohort study based on a prospectively collected database of a public tertiary university hospital, which enrolled individuals with morbid obesity who underwent RYGB and were followed-up for 3 years. Weight loss was classified into the following 3 categories: (1) no weight regain; (2) expected regain (regain ≤20% of the maximum weight loss); and (3) obesity recidivism (regain >20% of the maximum weight loss). Homeostasis model assessment (HOMA) values were compared over time.ResultsOf 100 patients, 20% presented obesity recidivism and 52% an expected regain after 3 years of surgery; 28% showed no regain. The recidivism group presented a significant increase in HOMA 3 years after surgery (P = .02). The recidivism group presented a significantly higher HOMA 3 years after surgery than the observed in the other groups (P < .001), as well as a significantly higher percentage of HOMA variation throughout the follow-up (P = .02).ConclusionWeight recidivism after RYGB was significantly associated with a worsening of insulin resistance among nondiabetic individuals with morbid obesity. Thus, weight loss seems to play a significant role in the maintenance of the early metabolic improvement achieved after RYGB.     

Hospital utilization 4 years after bariatric surgery: sleeve gastrectomy versus Roux-en-Y gastric bypass

BackgroundWhile sleeve gastrectomy (SG) has lower perioperative risk compared with Roux-en-Y gastric bypass (RYGB), long-term data about their differential impact on overall health are unclear. Hospital use after bariatric surgery is an important parameter for improving peri- and postoperative care.ObjectiveThis present study was aimed to compare SG and RYGB in terms of their effect on long-term hospital-based healthcare utilization.SettingMulticenter, statewide database.MethodsA retrospective cohort study of adult patients who underwent SG and RYGB between 2009 and 2011, with follow-up until 2015 and 2-year presurgery information. Propensity score–matched SG and RYGB groups were created using preoperative demographic characteristics, co-morbidities, and presurgery hospital use, measured by cumulative length of stay (LOS) and frequency of emergency department visits. Postsurgery yearly LOS, incidence of hospital visits, and the reason for the visit were compared. Primary outcomes included postoperative hospital visits during years 1 to 4 after bariatric surgery and cumulative LOS. Secondary outcomes included specific reasons for hospital use.ResultsThere were 3540 SG and 13,587 RYGB patients, whose mean (95% confidence interval [CI]) LOS was 1.3 (1.3–1.4), .9 (.8–1), 1 (.9–1.1), and 1.2 (1–1.3) days at years 1 through 4, respectively. Postoperative yearly LOS was similar between the 2 propensity-matched groups. The risk of hospitalizations (odd ratio .73, 95% CI .64–.84, P < .0001) and emergency department visits (odds ratio .84, 95% CI .75–.95, P = .005) was significantly lower for SG, during the first postoperative year. The reverse was seen at the fourth postoperative year, with higher risk of emergency department use after SG (odds ratio 1.16, 95% CI 1.01–1.33, P = .035).ConclusionPostoperative 4-year hospital utilization remains low for both SG and RYGB. The previously established lower early perioperative risk of SG was not appreciated for longer-term hospital use compared with RYGB.     

Comparison of early type 2 diabetes improvement after gastric bypass and sleeve gastrectomy: medication cessation at discharge predicts 1-year outcomes

BackgroundAlthough weight loss–dependent type 2 diabetes (T2D) improvement after sleeve gastrectomy (SG) is well documented, whether SG has a weight-independent impact on T2D is less studied.ObjectivesTo evaluate early, weight-independent T2D improvement after SG and Roux-en-Y gastric bypass (RYGB) and its relationship to longer-term T2D outcomes.SettingUniversity Hospital, United States.MethodsWe completed a retrospective cohort study of patients with T2D who underwent SG (n = 187) or RYGB (n = 246) from 2010 to 2015. Pre- and postoperative parameters, including demographic characteristics, T2D characteristics, and T2D medication requirements, blood glucose, glycosylated hemoglobin, weight, and body mass index, were reviewed.ResultsT2D improved within days after both SG and RYGB, with more patients off T2D medications after SG than RYGB (39% versus 25%, respectively; P < .01) at the time of discharge (2.5 ± .8 versus 2.7 ± 1 d; P = .04). Over the initial postoperative 12 months, T2D medication cessation rates remained relatively stable after SG but continued to improve after RYGB (at 12 mo: 52% versus 68%, respectively; P < .05). T2D medication cessation at discharge predicts 12-month T2D medication cessation (92% [RYGB] and 78% [SG] positive predictive value). In a mixed-effects regression model adjusting for weight loss and severity of diabetes, discharge T2D medication cessation remained a significant predictor of T2D outcomes after both RYGB (odds ratio, 51; 95% confidence interval, 16.1–161; P < .0001) and SG (6.4; 95% confidence interval, 2.8–14.7; P < .0001).ConclusionsBoth SG and RYGB lead to high rates of T2D medication cessation within days of surgery, suggesting both operations activate weight loss–independent anti-T2D pathways. T2D medication cessation at discharge is predictive of 12-month T2D outcomes, particularly in noninsulin requiring patients. By 1 year after the surgery, RYGB leads to more weight loss and higher rates of T2D medication cessation than SG.     

Remission of type 2 diabetes after Roux-en-Y gastric bypass is associated with greater weight loss

BackgroundPhysiologic studies in rodents and preliminary human studies have suggested that Roux-en-Y gastric bypass (RYGB) improves type 2 diabetes mellitus (T2DM) by way of metabolic changes, long before the bariatric or weight loss effects occur, leading to the concept of “metabolic surgery.” To test this hypothesis, we studied patients with insulin-dependent T2DM who underwent RYGB to determine whether T2DM remission in this treatment-resistant subgroup occurred independent of weight loss.MethodsOf all the patients undergoing RYGB from 2000 to 2006 (n = 1546) with ≥12 months of follow-up, 318 had T2DM (21%), and 75 (24%) of these were insulin dependent. Of the 75 patients, 4 were found to have T1DM (5.3%) and were excluded, leaving a study population of 71 patients. The patients who achieved remission, defined as a cessation of diabetic medications with a hemoglobin A1c level of <7%, were compared with those who did not achieve remission. Statistical significance was set at P < .05, using the Student t test, chi-square test, and logistic regression analysis, as appropriate.ResultsAfter RYGB, all 71 patients with insulin-dependent T2DM had achieved a reduction in the dose and/or number of medications at 29.6 ± 17.0 months. Of these 71 patients, 35 (49%) demonstrated a remission of T2DM. The preoperative body mass index, age, number of medications, and hemoglobin A1c level did not differentiate between those who attained remission and those who still required diabetic medication. From the multivariate analysis, the significant factors associated with remission were the preoperative insulin dose and the percentage of excess weight loss. The percentage of excess weight loss was greater in the remission patients as early as 3 months postoperatively (P = .04) and also at 6, 12, 18, and 24 months.ConclusionRYGB uniformly improved the medication requirements of patients with insulin-dependent T2DM. Although physiologic mechanisms likely contributed, early rapid weight loss was associated with the remission of T2DM.     

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.     

Opioid consumption in patients undergoing Roux-en-Y bariatric surgery compared with population controls with and without obesity

BackgroundPatients with obesity are prescribed more opioids than the general population.ObjectivesTo compare opioid consumption in patients with obesity who underwent Roux-en-Y bariatric surgery (RYGB) with population controls with and without obesity, not undergoing bariatric surgery, and to identify characteristics associated with opioid use.SettingThis study included all patients with a principal diagnosis of obesity, aged 18–72 years, with a RYGB surgical code in the Swedish Patient Register between 2007 and 2013.MethodsRYGB patients (n = 23,898) were age- and sex-matched with 1 control patient with obesity (n = 23,898) and 2 population controls without obesity (n = 46,064). Participants were classified as nonconsumers and consumers based on their opioid dispensations during the 12 months before baseline. Opioid consumption was assessed for 24 months.ResultsNonconsumers. Within 24 months, a significantly higher proportion of RYGB patients (16.6%) started using opioids compared with the controls with obesity (14.3%, P < .0001) and population controls (5.4%, P < .0001). RYGB patients and controls with obesity had higher median daily intake of opioid morphine equivalent (MEQ) (2.8 mg/d) than population controls (2.5 mg/d, P < .0001). Consumers. Within 24 months, the proportion of RYGB patients and controls with obesity that was using opioids were similar (53.1% and 53.4%), but higher compared to population controls (38.0%, P < .0001). The median daily opioid MEQ was higher among RYGB patients than in population controls (10.5 versus 7.8 mg/d, P < .0001). RYGB patients, overall, had higher incidence of bowel surgery and cholecystectomy compared with controls with obesity and population controls, leading to prolonged opioid use in this group. Opioid consumption in general was associated with chronic pain and psychiatric disorder, which were more common in patients with obesity than in the population controls.ConclusionRYGB surgery increased the risk of prolonged opioid use in patients with obesity who were nonconsumers before surgery but had no effect on overall opioid use among prior consumers. RYGB-associated complications requiring surgery influenced opioid use for both nonconsumers and consumers. Regular reassessments of pain mechanisms and specific treatment owing to type of pain could prevent unnecessary opioid use in this patient group.     

Banded versus nonbanded Roux-en-Y gastric bypass: a systematic review and meta-analysis of randomized controlled trials

BackgroundBariatric surgery is remarkably effective in achieving weight loss and improving obesity-related co-morbidities; however, efforts still continue to improve its long-term outcomes. Particularly, banded Roux-en-Y gastric bypass (RYGB) has been scrutinized in comparison to standard (nonbanded) RYGB in terms of benefits and postoperative complications.ObjectivesThis study aims to compare the safety and efficacy of banded versus nonbanded RYGB.SettingMeta-analysis of randomized controlled trials (RCTs).MethodsA meta-analysis of high-quality studies that compared banded and nonbanded RYGB was conducted through February 2019 by systematically searching multiple electronic databases. Published RCTs comparing these 2 procedures were included to pool the data on excess weight loss, food tolerability, and postoperative complications.ResultsThree RCTs were eligible to be included in this meta-analysis, comprising a total of 494 patients (247 in each group). Two of the RCTs provided 2-year postoperative data, and 1 study reported 5-year outcome. Age ranged from 21 to 50 years, and body mass index ranged from 42 to 65 kg/m². Percentage of excess weight loss was significantly greater with banded RYGB than with nonbanded RYGB (mean difference 5.63%; 95% CI 3.26–8.00; P < .05). Postoperative food intolerance, emesis, and dysphagia were more common after banded RYGB (odds ratio 3.76; 95% CI 2.27–6.24; P < .001). Nevertheless, major postoperative complications did not significantly differ between the 2 groups.ConclusionFindings of this meta-analysis of RCTs indicate that in a medium-term follow-up, excess weight loss with banded RYGB would be 5% greater than that with the nonbanded RYGB (about 1 point difference in body mass index) at the expense of more food intolerance and postoperative vomiting; however, the frequency of postoperative complications would not be significantly different.     

Racial disparity in causes for readmission following bariatric surgery

BackgroundReadmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.ObjectiveOur study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.SettingAcademic hospital.MethodsWe performed a retrospective analysis of the 2015–2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.ResultsMore than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%–4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism–related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).ConclusionReadmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.     

The influence of preoperative carbohydrate loading on postoperative outcomes in bariatric surgery patients: a randomized,controlled trial

BackgroundPreoperative carbohydrate loading is a component of Enhanced Recovery After Surgery (ERAS) protocols, but there is limited literature in bariatric surgery patients.ObjectivesThe objective of this study was to characterize the impact of preoperative carbohydrate loading on postoperative bariatric surgery outcomes.SettingUniversity Hospital.MethodsPatients undergoing a primary minimally invasive Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2018 and 2020 were randomized to standard management or intervention. Standard management patients were nothing by mouth (NPO) after midnight prior to surgery. Intervention patients consumed 2 carbohydrate drinks: 1 the night before and another 3 hours prior to surgery. Primary outcomes analyzed included postoperative nausea and vomiting (PONV), length of stay, and overall complications.ResultsIn total, 134 patients were analyzed: 64 intervention (47.8%) and 70 (52.2%) standard. In the end, 7% and 15% of patients were lost to follow-up at 6-weeks and 3-months, respectively. There was no statistically significant difference in length of stay (2.0 ± 1.2 vs 2.1 ± .9 d; P = .65) or postoperative outcomes between the 2 groups. There were no episodes of aspiration among the intervention group. Among RYGB patients, intervention patients had a shorter duration of nausea compared with standard patients. There was no significant difference in glycemic control among patients with and without diabetes.ConclusionsPreoperative carbohydrate drinks can be administered to bariatric surgery patients without significant risks. Carbohydrate loading preoperatively can decrease the duration of PONV in RYGB patients. Carbohydrate drinks can be safely included in bariatric ERAS protocols for patients with and without diabetes, although the benefits remain unknown.