Bariatric surgery and COVID-19 outcomes: a systematic review and meta-analysis

BackgroundObesity and its associated complications have a negative impact on human health. Metabolic and bariatric surgery (MBS) ameliorates a series of clinical manifestations associated with obesity. However, the overall efficacy of MBS on COVID-19 outcomes remains unclear.ObjectivesThe objective of this article is to analyze the relationship between MBS and COVID-19 outcomes.SettingA meta-analysis.MethodsThe PubMed, Embase, Web of Science, and Cochrane Library databases were searched to retrieve the related articles from inception to December 2022. All original articles reporting MBS-confirmed SARS-CoV-2 infection were included. Outcomes including hospital admission, mortality, intensive care unit (ICU) admission, mechanical ventilation utilization, hemodialysis during admission, and hospital stay were selected. Meta-analysis with fixed or random-effect models was used and reported in terms of odds ratios (ORs) or weighted mean differences (WMDs) along with their 95% confidence intervals (CIs). Heterogeneity was assessed with the I² test. Study quality was assessed using the Newcastle-Ottawa Scale.ResultsA total of 10 clinical trials involving the investigation of 150,848 patients undergoing MBS interventions were included. Patients who underwent MBS had a lower risk of hospital admission (OR: .47, 95% CI: .34–.66, I² = 0%), mortality (OR: .43, 95% CI: .28–.65, I² = 63.6%), ICU admission (OR: .41, 95% CI: .21–.77, I² = 0%), and mechanical ventilation (OR: .51, 95% CI: .35–.75, I² = 56.2%) than those who did not undergo surgery, but MBS did not affect hemodialysis risk or COVID-19 infection rate. In addition, the length of hospital stay for patients with COVID-19 after MBS was significantly reduced (WMD: −1.81, 95% CI: −3.11–.52, I² = 82.7%).ConclusionsOur findings indicate that MBS is shown to improve COVID-19 outcomes, including hospital admission, mortality, ICU admission, mechanical ventilation, and hospital stay. Patients with obesity who have undergone MBS infected with COVID-19 will have better clinical outcomes than those without MBS.     

Prior bariatric surgery in COVID-19–positive patients may be protective

BackgroundPatients infected with novel COVID-19 virus have a spectrum of illnesses ranging from asymptomatic to death. Data have shown that age, sex, and obesity are strongly correlated with poor outcomes in COVID-19–positive patients. Bariatric surgery is the only treatment that provides significant, sustained weight loss in the severely obese.ObjectivesExamine if prior bariatric surgery correlates with increased risk of hospitalization and outcome severity after COVID-19 infection.SettingUniversity hospitalMethodsA cross-sectional retrospective analysis of a COVID-19 database from a single, New York City–based, academic institution was conducted. A cohort of COVID-19–positive patients with a history of bariatric surgery (n = 124) were matched in a 1:4 ratio to a control cohort of COVID-19–positive patients who were eligible for bariatric surgery (BMI ≥40 kg/m² or BMI >35 kg/m² with a co-morbidity at the time of COVID-19 diagnosis) (n = 496). A comparison of outcomes, including mechanical ventilation requirements and deceased at discharge, was done between cohorts using χ² test or Fisher’s exact test. Additionally, overall length of stay and duration of time in intensive care unit (ICU) were compared using Wilcoxon rank sum test. Conditional logistic regression analyses were done to determine both unadjusted (UOR) and adjusted odds ratios (AOR).ResultsA total of 620 COVID-19–positive patients were included in this analysis. The categorization of bariatric surgeries included 36% Roux-en-Y gastric bypass (RYGB, n = 45), 36% laparoscopic adjustable gastric banding (LAGB, n = 44), and 28% laparoscopic sleeve gastrectomy (LSG, n = 35). The body mass index (BMI) for the bariatric group was 36.1 kg/m² (SD = 8.3), which was significantly lower than the control group, 41.4 kg/m² (SD = 6.5, P < .0001). There was also less burden of diabetes in the bariatric group (32%) compared with the control group (48%) (P = .0019). Patients with a history of bariatric surgery were less likely to be admitted through the emergency room (UOR = .39, P = .0001), less likely to require a ventilator during the admission (UOR=.42, P = .028), had a shorter length of stay in both the ICU (P = .033) and overall (UOR = .44, P = .0002), and were less likely to be deceased at discharge compared with the control group (OR = .42, P = .028).ConclusionA history of bariatric surgery significantly decreases the risk of emergency room admission, mechanical ventilation, prolonged ICU stay, and death in patients with COVID-19. Even when adjusted for BMI and the co-morbidities associated with obesity, patients with a history of bariatric surgery still have a significant decrease in the risk of emergency room admission.     

Outcomes of the overweight and obese major trauma patient in the rural setting

PurposeOverweight and obese patients are more prevalent in rural and remote areas and are of major public health concern in Australia. We aimed to evaluate the mortality and morbidity of overweight and obese trauma patients in the rural Australian context.MethodThis was a retrospective cohort study on 207 major trauma patients (injury severity score [ISS] > 12) treated at the Mackay Base Hospital between 2018 and 2021. Data was extracted from the Mackay Base Hospital trauma database and hospital records. Outcomes were compared between body mass index (BMI) groups.ResultsThere were 164 males (79%) and 43 females (21%). The average BMI was 27.09 (standard deviation 5.46). 7 patients (3%) were in the underweight category (BMI < 18.5 kg/m²), 70 (34%) were of normal weight (BMI 18.5–24.9 kg/m²), 79 (38%) were overweight (BMI 25–29.9 kg/m²), and 51 (25%) were obese (BMI > 30 kg/m²). The majority of trauma was blunt (n = 203, 98%). Compared to patients with normal BMI, obese patients were significantly more likely to require intubation, intensive care unit (ICU) admission, and have a longer ICU stay. There were no significant differences in requirement for surgery, duration of surgery, hospital length of stay, ventilator time, or mortality (P > 0.05). However, subgroup analysis of the obese patient group showed an increased rate of complications (sepsis, acute kidney injury, fluid overload and pneumonia), longer ventilation times, hospital and ICU length of stay with increasing BMI in these patients.ConclusionThe majority of trauma presentations in our regional community are in overweight or obese patients. Overweight and obese patients are more likely to require intubation and have a longer intensive care unit admission than normal weight counterparts. Amongst obese patients, those with BMI > 40 (obesity class 3) are at significantly increased risk of complications.     

Impact of metabolic surgery on 10-year cardiovascular disease risk in Chinese individuals with type 2 diabetes

BackgroundIn recent years, many reports have highlighted that metabolic surgery may ameliorate the cardiovascular risk in morbidly obese patients with or without type 2 diabetes (T2D). However, few studies have evaluated the long-term cardiovascular disease (CVD) risk after metabolic surgery in T2D patients with a low body mass index (BMI).ObjectivesTo use the Prediction for ASCVD Risk in China (China-PAR) equations and United Kingdom Prospective Diabetes Study (UKPDS) risk engine to assess the 10-year CVD risk in low-BMI T2D patients after metabolic surgery.SettingUniversity hospital, China.MethodsWe retrospectively reviewed our prospectively collected data of T2D patients who underwent metabolic surgery at our hospital between 2010 and 2018. We included patients who met the criteria for calculating a 10-year cardiovascular risk score by the China-PAR equations and UKPDS risk engine. Demographic characteristics, anthropometric variables, and glycolipid metabolic parameters were assessed preoperatively and during a 4-year follow-up period. Patients with a BMI < 30 kg/m² were compared with those with a BMI > 30 kg/m².ResultsWe evaluated 117 patients, of whom 62 (53%) had a BMI < 30 kg/m² and 55 (47%) had a BMI > 30 kg/m². Patients with a BMI < 30 kg/m² were significantly older and had a longer duration of diabetes. The rate of complete T2D remission in the group of patients with BMIs < 30 kg/m² was significantly lower than that in the group with BMIs > 30 kg/m² (35.2% versus 56.1%, respectively; P = .042). The overall 10-year and lifetime atherosclerotic cardiovascular disease risks were reduced from 4.2% to 2.3% and 25.3% to 13.9%, respectively (both P < .05), at 1 year postoperatively using the China-PAR equation. The overall 10-year coronary heart disease (CHD) and fatal CHD risks were reduced by 48.1% and 53.1%, respectively, at 1 year after surgery using the UKPDS risk engine. The advantages of metabolic surgery in reducing CVD risks are similar in both BMI groups, whether using the China-PAR equation or the UKPDS risk engine.ConclusionThe 10-year CVD risk in T2D patients with BMIs < 30 kg/m² and BMIs > 30 kg/m² were significantly reduced after metabolic surgery, although the rate of complete T2D remission T2Din patients with BMIs < 30 kg/m² was lower than that in patients with BMIs > 30 kg/m². The China-PAR equation is a reliable and useful clinical tool for CVD risk evaluation in Chinese patients after metabolic surgery.     

The comparative effects of metabolic surgery,SGLT2i,or GLP-1RA in patients with obesity and type 2 diabetes: a retrospective cohort study

BackgroundNew antidiabetic agents (sodium-glucose cotransporter-2 inhibitor [SGLT2i] and glucagon-like peptide-1 receptor agonist [GLP-1RA]) and metabolic surgery have protective effects on metabolic syndromes.ObjectivesTo compare the changes of metabolic parameters and costs among patients with obesity and type 2 diabetes undergoing metabolic surgery and initiating new antidiabetic agents over 12 months.SettingHong Kong Hospital Authority database from 2006–2017.MethodsThis is a population-wide retrospective cohort study consisting of 2616 patients (1810 SGLT2i, 528 GLP-1RA, 278 metabolic surgery). Inverse probability treatment weighting of propensity score was applied to balance baseline covariates of patients with obesity and type 2 diabetes who underwent metabolic surgery, or initiated SGLT2i or GLP-1RA. Metabolic parameters and direct medical costs were measured and compared from baseline to 12 months in metabolic surgery, SGLT2i, and GLP-1RA groups.ResultsPatients in all 3 groups had improved metabolic parameters over a 12-month period. Patients with metabolic surgery achieved significantly better outcomes in BMI (?5.39, ?.56, ?.40 kg/m², P < .001), % total weight loss (15.16%, 1.34%, 1.63%, P < .001), systolic (?2.21, ?.59, 1.28 mm Hg, P < .001) and diastolic (?1.16, .50, ?.13 mm Hg, P < .001) blood pressure, HbA1c (?1.80%, ?.77%, ?.80%, P < .001), triglycerides (?.64, ?.11, ?.09 mmol/L, P < .001), and estimated glomerular filtration rate (3.08, ?1.37, ?.41 mL/min/1.73m², P < .001) after 12 months compared with patients with SGLT2i and GLP1-RA. Although the metabolic surgery group incurred the greatest direct medical costs (US$33,551, US$10,945, US$10,627, P < .001), largely due to the surgery itself and related hospitalization, the total monthly direct medical expenditure of metabolic surgery group became lower than that of SGLT2i and GLP-1RA groups at 7 months.ConclusionBeneficial weight loss and metabolic outcomes at 12 months were observed in all 3 groups, among which the metabolic surgery group showed the most remarkable effects but incurred the greatest medical costs. However, studies with a longer follow-up period are warranted to show long-term outcomes.     

Obesity surgery in patients with end-stage organ failure: Is it worth it?

BackgroundLittle is known about the long-term outcomes of patients with end-stage organ failure (ESOF) undergoing obesity surgery.ObjectiveTo investigate the perioperative and mid-term outcomes of patients with ESOF undergoing obesity surgery.SettingUniversity hospital, Germany.MethodsA total of 1 094 patients undergoing obesity surgery from 2006 to 2019 were screened. Inclusion criteria were ejection fraction <30%, continuous oxygen/noninvasive ventilation therapy, liver cirrhosis, or kidney failure stage 4/5. ESOF patients were compared with matched standard (MS) patients without advanced organ failure and matched for age, gender, body mass index (BMI), operation type, diabetes, arterial hypertension, and sleep apnea.ResultsTwenty-seven ESOF patients (56% female, age 50.3 ± 8.6, BMI 53.8 ± 8.7 kg/m²) were identified. Eighty-five percent had a sleeve gastrectomy. Mid-term total weight loss was 26.6% ± 9.0% in the ESOF patients versus 17.8% ± 11.1% in MS patients (P = .181). Long-term improvement of type 2 diabetes was comparable (ESOF: HbA1C 8.79 ± 2.06% to 6.25±1.17%, P = .047; MS: HbA1C 7.94 ± 2.02% to 7.2 ± 1.28%; P = .343). Depression scores (Patient Health Questionnaire 9) among ESOF patients improved from 13.0 ± 6.3 to 6.1 ± 5.8 (P = .004) but without significant change in MS patients (9.4 ± 7.3 to 4.3 ± 5.7; P = .082). Lung function improved in all patients although only 15% were off oxygen therapy. Treatment goals were achieved in >50% of the other groups. Major complications occurred in 11% (ESOF) versus 4% (MS) of patients (P = .299) with one death in the ESOF group (4%).ConclusionBoth groups had similar outcomes regarding weight loss and co-morbidity improvement. Depression only improved significantly in the ESOF group. Patients with ESOF should not be precluded from obesity surgery. Further investigation is needed to define optimized selection criteria.     

Long-term outcomes comparing metabolic surgery to no surgery in patients with type 2 diabetes and body mass index 30–35

BackgroundWe previously conducted a randomized study comparing metabolic surgery with medical weight management in patients with type 2 diabetes (T2D) and body mass index (BMI) 30 to 35 kg/m². At 3-year follow-up, surgery was very effective in T2D remission; furthermore, in the surgical group, those with a higher baseline soluble receptor for advanced glycation end products had a lower postoperative BMI.ObjectivesTo provide long-term follow-up of this initial patient cohort.SettingUniversity Hospital.MethodsRetrospective chart review was performed of the initial patient cohort. Patients lost to follow-up were systematically contacted to return to clinic for a follow-up visit. Data were compared using 2-sample t test, Fisher’s exact test, or analysis of variance when applicable.ResultsOriginally, 57 patients with T2D and BMI 30 to 35 kg/m² were randomized to metabolic surgery (n = 29) or medical weight management (n = 28). Ten patients in the medical weight management group crossed over to surgery. Five-year follow-up data were available in 43 of 57 (75%) patients. Baseline mean BMI and glycated hemoglobin were 32.6 kg/m² and 7.8%, respectively. Median follow-up was 79 and 88 months in the surgical group and nonsurgical group, respectively. Compared with the nonsurgical group, the surgical patients had significantly lower rate of T2D (62% versus 100%; P = .008), lower insulin use (10% versus 50%; P = .0072), lower glycated hemoglobin (6.93% versus 8.26%; P = .012), lower BMI (25.8 versus 28.6 kg/m²; P = .007), and higher percent weight loss (21.4% versus 10.3%; P = .025). Baseline soluble receptor for advanced glycation end products was not associated with long-term outcomes.ConclusionsMetabolic surgery in T2D patients with BMI 30 to 35 kg/m² remains effective long term. Baseline soluble receptor for advanced glycation end products are most likely predictive of early outcomes only.     

The association of body mass index with same-day hospital admission,postoperative complications,and 30-day readmission following day-case eligible joint arthroscopy: A national registry analysis

Study objectiveWe examined the association of body mass index (BMI) with hospital admission, same-day complications, and 30-day hospital readmission following day-case eligible joint arthroscopy.DesignRetrospective cohort study.SettingMulti-institutional.PatientsAdult patients undergoing arthroscopy of the knee, hip or shoulder in the outpatient setting.InterventionNone.MeasurementsUsing the American College of Surgeons National Surgical Quality Improvement Program dataset from 2012 to 2016, we examined seven BMI ranges: normal BMI (≥20 kg/m² and <25 kg/m²), underweight (<20 kg/m²), overweight (≥25 kg/m² and <30 kg/m²), Class 1 and 2 obese (≥30 kg/m² and <40 kg/m², reference variable), and severe obesity, which we divided into the following BMI ranges: ≥40 kg/m² and <50 kg/m², ≥50 kg/m² and <60 kg/m², and ≥60 kg/m². The primary outcome was hospital admission. Secondary outcomes included same-day postoperative complications and 30-day hospital readmission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p-value of <0.05 as statistically significant.Main resultsThere were a total of 99,410 patients included in the final analysis, in which there was a 2.6% rate of hospital admission. When compared to class 3 obesity, only those with BMI ≥50 kg/m² (OR 1.55, 95% CI 1.18–2.01, p = 0.005) had increased odds of hospital admission. There were no differences in 30-day hospital readmission or same-day postoperative complications.ConclusionWe found that only patients with BMI ≥50 kg/m² had increased odds for same-day hospital admission even when patient's comorbid conditions are optimized, suggesting that a BMI ≥50 kg/m² may be used as a sole factor for patient selection in patients undergoing joint arthroscopy. For patients with BMI <50 kg/m², we recommend that BMI alone should not be solely used to exclude patients from having joint arthroscopies performed in an outpatient setting, especially since this patient group makes up a significant proportion of joint arthroscopy.     

Bariatric and metabolic surgery in patients with morbid obesity and multiple sclerosis - a nationwide,matched cohort study

BackgroundDespite an association between obesity and multiple sclerosis (MS), very little is known regarding the safety and efficacy outcomes for patients with MS and severe obesity undergoing metabolic surgery.ObjectivesThe aim of the present study was to evaluate early complications and efficacy outcomes of metabolic surgery in patients with severe obesity and MS.SettingNationwide, Sweden.MethodsIn this, matched cohort study, 196 patients with an MS diagnosis in the Swedish MS register who were undergoing metabolic surgery (gastric bypass or sleeve gastrectomy) with a registration in the Scandinavian Obesity Surgery Registry (SOReg) were matched 1:10 with a control group without MS diagnosis from the SOReg. A 2-stage matching procedure was used (exact match by surgical method, followed by propensity Score matching, including age, sex, preoperative BMI, surgical center, surgical access, year of surgery, hypertension, diabetes, sleep apnea, and dyslipidemia).ResultsWeight loss at 2 years after surgery was similar for patients with MS and controls (total weight loss 31.6 ± 9.1 versus 31.8 ± 9.2, P = .735). No significant differences were seen in either the overall postoperative complication rate (7.9% versus 7.2%, P = .778), or serious postoperative complications (3.7% versus 2.8%, P = .430). All aspects of health-related quality of life (HRQoL) improved in both groups but less so for the physical aspects of HRQoL in patients with MS.ConclusionMetabolic surgery is a safe and efficient treatment for severe obesity in patients with MS, and it leads to subsequent improvements in HRQoL. Further studies addressing the effects of metabolic surgery on MS-related symptoms are needed.     

Class 3 obesity is not associated with same-day admission in obese patients undergoing parathyroidectomy

ImportanceRising rates of obesity and outpatient performance of parathyroidectomies are making it increasingly crucial to investigate the association of obesity with post-operative complications.ObjectiveTo determine whether Class 3 obesity is associated with increased same-day admission compared to lower obesity classes following outpatient parathyroidectomy.DesignRetrospective cohort study.SettingOutpatient surgery.Patients12,973 patients ≥18 years old who underwent outpatient parathyroidectomy between 2014 and 2016, per the American College of Surgeons National Surgical Quality Improvement Program registry.InterventionsPrimary exposure variable: body mass index (BMI), with patients assigned to one of six cohorts.MeasurementsPrimary outcome measure: same-day admission. Secondary outcome measure: 30-day readmission. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI).Main resultsThere was a final sample size of 12,973 adult patients who underwent parathyroidectomy from 2014 to 2016. The admission rate for BMI ≥30 and < 40 kg/m² (reference cohort) was 42.6%. The admission rates for Class 3 obesity categories were 46.2%, 56.2%, and 52.6% for those in the BMI range of ≥40 kg/m² and < 50 kg/m², ≥50 kg/m² and < 60 kg/m², and ≥ 60 kg/m², respectively. On multivariable logistic regression, there were no difference in the odds of 30-day hospital admission or readmission rate with any of the BMI cohorts when compared to the reference group.ConclusionsThere is no significant difference in rates of same-day admission or 30-day readmission between any Class 3 (BMI ≥40 kg/m²) obesity cohort and the Class 1 and 2 (BMI ≥30 and < 40 kg/m²) reference cohort following outpatient parathyroidectomy. This corroborates the notion that BMI classes cannot be used in a vacuum to determine eligibility for outpatient parathyroidectomy – a concept that can guide safe and cost-effective institutional practices.     

Clinical significance of diabetes control before metabolic surgery

BackgroundEven though observational studies have suggested that poor preoperative diabetes control increases risk after major abdominal surgery, it is unclear whether this effect is seen in metabolic surgery patients.ObjectivesTo determine whether poor preoperative diabetes control is associated with worse outcomes in patients with obesity and diabetes undergoing metabolic surgery.SettingMetabolic and Bariatric Surgery Quality Improvement Project (MBSAQIP) database.MethodsUsing the MBSAQIP 2017 and 2018 database and preoperative glycated hemoglobin (HbA1C) as a diabetes control surrogate, we examined the association between diabetes control and major outcomes of primary laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) in patients with diabetes and obesity. Multivariate logistic regression modeling examined five 30-day postoperative outcomes: composite serious complications (composite of 10 adverse events), composite infection (composite of 7 infectious complications), length of stay >5 days, reoperation, and readmission. Models were adjusted for multiple covariates.ResultsIn total, 26,674 patients with HbA1C data available within 30 days before metabolic surgery were included in the primary analysis and 35,884 patients with HbA1C data within 90 days before surgery were included in the sensitivity analysis. The mean body mass index (BMI) and preoperative HbA1C were 45.6 ± 8.2 kg/m² and 8.2 ± 2.7%, respectively. The incidence of 30-day postoperative infections and serious complications were 1.62% and 1.35%, respectively. Neither primary analysis nor sensitivity analysis demonstrated any association between higher HbA1C and worsening of 5 primary outcomes of interest. The odds ratio of an overall effect for SG was 1.01 (95% CI .98–1.03; P = .58) and for RYGB was .99 (95% CI .96–1.02; P = .41).ConclusionSuboptimal preoperative diabetes control is not associated with increased adverse events and should not delay metabolic surgery, as metabolic surgery is generally a safe procedure and intrinsically improves diabetes control.     

Prognostic predictors in patients with sepsis after gastrointestinal tumor surgery: A retrospective study

BACKGROUNDThere have been different reports on mortality of sepsis; however, few focus on the prognosis of patients with sepsis after surgery.AIMTo study the clinical features and prognostic predictors in patients with sepsis after gastrointestinal tumor surgery in intensive care unit (ICU).METHODSWe retrospectively screened patients who underwent gastrointestinal tumor surgery at Peking University Cancer Hospital from January 2015 to December 2019. Among them, 181 patients who were diagnosed with sepsis in ICU were included in our study. Survival was analysed by the Kaplan-Meier method. Univariate and multivariate adjusted analyses were performed to identify predictors of prognosis.RESULTSThe 90-d all-cause mortality rate was 11.1% in our study. Univariate analysis showed that body mass index (BMI), shock within 48 h after ICU admission, leukocyte count, lymphocyte to neutrophil ratio, international normalized ratio, creatinine, procalcitonin, lactic acid, oxygenation index, and sequential organ failure assessment (SOFA) score within 24 h after ICU admission might be all significantly associated with the prognosis of sepsis after gastrointestinal tumor surgery. In multiple analysis, we found that BMI ≤ 20 kg/m², lactic acid after ICU admission, and SOFA score within 24 h after ICU admission might be independent risk predictors of the prognosis of sepsis after gastrointestinal tumor surgery. Compared with SOFA score, SOFA score combined with BMI and lactic acid might have higher predictive ability (area under the receiver operating characteristic curve, 0.859; 95% confidence interval, 0.789-0.929).CONCLUSIONLactic acid and SOFA score within 24 h after ICU admission are independent risk predictors of the prognosis of sepsis after gastrointestinal tumor surgery. SOFA score combined with BMI and lactic acid might have good predictive value.     

A Comparison of Open Surgery,Robotic-Assisted Surgery and Conventional Laparoscopic Surgery in the Treatment of Morbidly Obese Endometrial Cancer Patients

Methods:Morbidly obese (body mass index [BMI] > 40 kg/m²) patients with endometrial cancer who underwent OS, robotic-assisted laparoscopic surgery (RS), or conventional laparoscopic surgery (LS) were eligible. We sought to discern any outcome differences with regard to operative time, perioperative complications, and hospital stay.Results:Sixteen patients were treated with LS (BMI = 47.9 kg/m²), 13 were managed via RS (BMI = 51.2 kg/m²), and 24 underwent OS (BMI = 53.7 kg/m²). The OS (1.35 hours) patients had a significantly shorter operative duration than the LS (1.82 hours) and RS (2.78 hours) patients (P < .001); blood loss was greater in the OS (250 mL) group in comparison with the RS (100 mL) and LS (175 mL) patients (P = .002). Moreover, the OS (4 days) subjects had a significantly longer hospital stay than the LS (2 days) and RS (2 days) patients (P = .002).Conclusion:In the present study, we ascertained that minimally invasive surgery was associated with longer operative times but lower rates of blood loss and shorter hospital stay duration compared with treatment comprising an open procedure.     

Outcomes of bariatric surgery in extreme obesity: results from the United Kingdom National Bariatric Surgery Registry for patients with a body mass index >70 kg/m2

BackgroundBariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity.ObjectivesThis study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/m².SettingNational Health Service and private hospitals in the United Kingdom.MethodsThis cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/m² undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric band (AGB) between January 2009 and June 2014.ResultsThere were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/m² for AGB; 75 ± 5 kg/m² for SG; 74 ± 5 kg/m² for RYGB). The median postoperative follow-up was 13 months for AGB (10–22 mo), 18 for SG (6–28 mo), and 15 for RYGB (6–24 mo). Patients undergoing RYGB and SG exhibited the greatest postoperative total body weight loss (35 ± 13% and 31 ± 15%, respectively; P = .14), which led to postoperative BMIs of 48 ± 10 kg/m² and 51 ± 11 kg/m², respectively (P = .14). All procedures conferred a reduction in the incidence of co-morbidities, including type 2 diabetes, and led to improved functional statuses. The overall complication rate was 7%, with 3 deaths (1%) within 30 days of surgery.ConclusionThis study found that primary BMS in patients with a BMI >70kg/m² has an acceptable safety profile and is associated with good medium-term clinical outcomes. RYGB and SG are associated with better weight loss and great improvements in co-morbidities than AGB. Given the noninferiority of SG outcomes and SG’s potential for further conversion to other BMS procedures if required, SG may be the best choice for primary BMS in patients with extreme obesity.     

The impact of chronic obstructive pulmonary disease and obesity on length of stay and cost of spine surgery

Background:

Chronic obstructive pulmonary disease (COPD) and obesity may be more common among spine surgery patients than in the general population and may affect hospital cost.

Materials and Methods:

We retrospectively studied the prevalence of COPD and obesity among 605 randomly selected spine surgery inpatients operated between 2005 and 2008, including lumbar microdiskectomy, anterior cervical decompression and fusion and lumbar decompression and fusion patients. The length of hospital stay and hospital charges for patients with and without COPD and obesity (body mass index [BMI]≥30 kg/m²) were compared.

Results:

Among 605 spine surgery patients, 9.6% had a history of COPD. There were no statistical difference in the prevalence of COPD between the three spine surgery groups. Obesity was common, with 47.4% of the patients having a BMI≥30 kg/m². There were no significant differences in obesity rates or BMI values between the three types of spine surgery patients. Obesity rates between patients with and without COPD were 62.1% vs. 45.9%, and were statistically different (P<0.05). Similarly, significant difference (P<0.01) in BMI values between COPD and non-COPD groups, 32.66±7.19 vs. 29.57±6.048 (mean ± std. deviation), was noted. There was significant difference (P<0.01) in cost between nonobese female patients without COPD and those with obesity and COPD in the anterior cervical decompression and fusion (ACDF) group. No association with increased hospital length of stay or cost was found in the other two types of spine surgery or in male ACDF patients.

Conclusion:

COPD and obesity seem to additively increase the length of hospital stay and hospital charges in ACDF female patients, an important finding that requires further investigation.     

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.     

The impact of obesity on polytraumatized patients with operatively treated fractures

IntroductionThe objective of this study was to evaluate the effect of obesity on outcomes following operative treatment of fractures in obese polytrauma patients.MethodsThis was a prospective cohort study at a level I trauma centre from January 2014 until December 2017. The eligibility criteria were adult (age >= 18 years) polytrauma patients who presented with at least one orthopaedic fracture that required operative fixation. Polytrauma was defined as having an Injury Severity Score (ISS) >= 16. Out of 891 patients, a total of 337 were included with 85 being obese. The primary outcome variable was the total hospital length of stay in days. The secondary outcome variables were the number of patients who had an intensive care unit (ICU) admission, the ICU length of stay in days, the number of patients who had mechanical ventilation, the duration of mechanical ventilation in days, perioperative complications, and mortality.ResultsObesity was associated with increased total hospital stay (36 vs. 27 days; P<0.001), increased ICU stay (13 vs. 8 days; P = 0.04), increased ICU admissions (83.5% vs. 68.6%; P = 0.008) and increased incidence of mechanical ventilation (64.7% vs. 43.7%; P = 0.001). These findings remained statistically significant following adjusted regression models for age, gender, ISS, and injuries sustained. However, the mechanical ventilation duration was not significantly different between both groups on adjusted and unadjusted analyses. However, an increase per unit BMI significantly increases the duration of mechanical ventilation (P = 0.02). In terms of complications, obesity was only associated with an increase in acute renal failure (ARF) on unadjusted analyses (P = 0.004). Whereas, adjusted logistic regression demonstrated that an increase per BMI unit led to a significant increase in the odds ratio for wound infection (P = 0.03) and ARF (P = 0.024).ConclusionsThis study displayed that obesity was detrimental to polytrauma patients with operatively treated fractures leading to prolonged hospital and ICU length of stay. This highlights the importance of optimizing trauma care for obese polytraumatized patients to reduce morbidity. With 41.1% of our population being obese, obesity presents a unique challenge in the care of polytrauma patients which mandates further research in improving health care for this population group.     

The metabolic and liver-related outcomes of bariatric surgery in adult patients with insulin-treated type 2 diabetes and nonalcoholic fatty liver disease at high risk of liver fibrosis

BackgroundNonalcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease, with a prevalence estimated to between 20% and 30% of the general population and approximately 70% of stage 2 obese people with type 2 diabetes (T2D) with normal liver enzymes.ObjectivesTo investigate the metabolic and liver-related outcomes of bariatric surgery among patients with insulin-treated T2D and NAFLD who are at high risk of liver fibrosis.SettingMore than 600 locations within the United Kingdom.MethodsThe study comprises a retrospective cohort comparison of patients with NAFLD and a fibrosis 4 (Fib-4) score > 1.45 who received a bariatric intervention versus comparable patients who received no bariatric intervention. Metabolic outcomes (glycated hemoglobin [HbA1C] level, weight, body mass index [BMI], and Fib-4 score) and composite liver-related outcomes (cirrhosis, portal hypertension, liver failure, and hepatoma) were compared between groups over a period of 5 years. The outcomes were adjusted for baseline and time-varying covariates.ResultsThe study sample included 4108 patients, 45 of whom underwent bariatric surgery. The mean age at baseline was 62.4 ± 12.4 years; 43.8% of patients were female; the mean weight was 89.5 ± 20.8 kg; the mean BMI was 31.7 ± 7.6 kg/m²; and the mean HbA1C level was 68.4 ± 16.7 mmol/mol. In addition, the median Fib-4 score was 2.3 (interquartile range, 1.7–4.2). During the 5 years during which follow-up outcomes were recorded, the weight and BMI reductions were significantly lowered compared with baseline in the bariatric surgery group. Similarly, the HbA1C levels were lower in the bariatric surgery group, with statistically significant differences observed in the first and second postintervention years (bariatric surgery versus non–bariatric surgery patient levels at 1 year, 63.1 mmol/mol versus 68.1 mmol/mol, respectively [P = .042], and at 2 years, 62.7 mmol/mol versus 68.1 mmol/mol, respectively [P = .028]). No significant difference was observed between groups in the proportion of patients with liver fibrosis or the likelihood of developing composite liver disease during the follow-up period (bariatric surgery group, 8.9%; non–bariatric surgery group, 4.7%; X² = 1.75; P = .18).ConclusionBariatric surgery amongst patients with insulin-treated T2D with NAFLD who were at high risk of liver fibrosis was associated with significant improvements in metabolic outcomes. No significant adverse effects were observed with regards to liver-related outcomes.     

The Edmonton Obesity Staging System: assessing a potential tool to improve the management of obesity surgery in the Brazilian public health services

BackgroundLimited access to publicly funded, insurance-covered, and self-paid obesity surgery is a reality worldwide. Waiting lists for procedures are usually based on chronologic criteria and body mass index (BMI)-defined obesity categorization. Obesity classification systems assess overall health and have been proposed as an alternative.ObjectiveTo investigate the correlation between BMI-based classification and the Edmonton Obesity Staging System (EOSS) to support current evidence that the assessment of the clinical severity of obesity could be a helpful tool to maximize access to surgery.SettingUniversity hospital, Brazil.MethodsRetrospective analysis of all 2011 to 2014 adult patients who underwent obesity surgery under the public health system. Data on sex, age, presurgical BMI, and co-morbidities were extracted from hospital records. Spearman correlation coefficients were used to assess the strength and direction of the relationship between BMI classification and EOSS.ResultsOf 565 patients, 79% were female, mean age 44.1 ± 10.9 years and mean BMI 46.9 ± 6.2 kg/m². The most common EOSS stage was 2 (86.5%), followed by stages 3 (8.5%) and 1 (4.9%). There was no correlation between the severity of obesity measured by BMI and EOSS (ρ = −.030, P = .475). Older patients had higher Edmonton scores (ρ = .308, P < .001). No difference was observed regarding sex.ConclusionsNo correlation was found between EOSS and BMI and between these and sex. Age correlated with both obesity indicators. EOSS was reproducible in Brazilian surgical patients and may be an important tool from a health services perspective contributing to the more efficient use of limited resources for obesity surgery.     

The impact of obesity on severely injured children and adolescents

Purpose/Background

In conjunction with the obesity epidemic in adults, we are starting to see an increase of obesity in children and adolescents. Obesity has been identified as risk factor for poor outcomes in adult trauma patients, but has not been investigated adequately in younger patients. The purpose of this study was to investigate the impact of obesity on the outcomes of a severely injured population of children and adolescents.

Methods

Retrospective review of traumatized children (age 6-12) and adolescents (age 13-19) admitted to the intensive care unit (ICU) at an urban, level I trauma center from 1998 to 2003. The trauma registry and ICU database were used for data acquisition. Height and weight were recorded for each patient upon admission to the ICU and used to calculate body mass index (BMI). Patients were categorized as either lean (BMI <95th percentile for age) or obese (BMI ≥95th percentile for age). The two groups were compared regarding admission demographics, vital signs, mechanism of injury, patterns of injury, Injury Severity Score, and operations required. Outcomes evaluated were need for and length of mechanical ventilation, complications, length of hospital and ICU stay, and mortality.

Results

There were 316 pediatric and adolescent trauma patients (262 [83%] lean, mean BMI = 23 kg/m² and 54 [17%] obese, mean BMI = 33 kg/m²) admitted to the ICU. The lean and obese groups were similar regarding age, sex, mechanism of injury, admission vitals, injury severity, and operations required. Injury patterns were similar, except obese patients had less severe head injuries. Although there was no difference in mortality among obese (15%) and non-obese (9%) patients (P = .39), obese children did have more complications (41% vs 22%, P = .04). In addition, obese patients required longer ICU stays (8 ± 9 vs 6 ± 6 days, P = .05) after severe trauma.

Conclusions

Despite similar admission characteristics and less severe head injuries, obese children and adolescents have more complications and require longer ICU stays than their lean counterparts.