Racial disparities in perioperative outcomes after bariatric surgery

BackgroundNonHispanic black patients bear a disproportionate burden of the obesity epidemic and its related medical co-morbidities. While bariatric surgery is the most effective treatment for morbid obesity, black patients access bariatric surgery at lower rates than nonHispanic white patients.ObjectivesTo examine racial differences before bariatric surgery and in short-term perioperative outcomes and complications, and the extent to which race is independently associated with perioperative morbidity and mortality.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program national database.MethodsData were extracted from the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use File. Multivariate analysis was used to identify differences in mortality, length of stay, readmission, and reintervention by race in patients undergoing laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy (SG).ResultsA total of 108,198 patients were included in the analysis. There were significant differences in perioperative disease burden. Black patients had a higher body mass index at the time they underwent surgery (laparoscopic Roux-en-Y gastric bypass: 48.0 versus 45.7 kg/m²; SG: 46.8 versus 44.9 kg/m²; P < .001). Black patients had significantly longer length of stay and higher rates of readmission in both the laparoscopic Roux-en-Y gastric bypass and SG groups. In the SG group, black patients had significantly higher 30-day mortality (.2% versus .1%, odds ratio = 3.613, 95% confidence interval 1.990–6.558, P < .001) and higher rates of reoperation or reintervention.ConclusionsWe found significant racial disparities in bariatric surgery outcomes, including higher mortality in black patients undergoing SG. The specific causes of these disparities remain unclear and must be the subject of future research.     

The impact of chronic kidney disease on bariatric perioperative outcome: a MBSAQIP matched analysis

BackgroundMorbid obesity is considered a strong independent risk factor for chronic kidney disease (CKD), and bariatric surgery remains the most effective treatment for obesity-related co-morbidities. Previous large database analyses have suggested that CKD does not independently increase the risk of adverse outcomes after bariatric surgery. The safety of elective bariatric surgery in this patient population remains unclear. To this end, we compared 30-day outcomes in this patient population after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass.ObjectivesTo compare 30-day outcomes in CKD patients after laparoscopic sleeve gastrectomy or gastric bypass.SettingUniversity Hospital, United States.MethodsUsing the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database, we identified patients with CKD who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass in 2015 or 2016. An unmatched cohort analysis, a propensity-matched analysis, and a case-control, matched-cohort analysis was performed of patients with and without CKD.ResultsOf the 302,092 patients included in this study, 2362 (.7%) had CKD, of whom 837 (35.4%) required dialysis. CKD patients were older with significantly higher rates of co-morbid conditions. Hospital length of stay, intensive care unit admission, reoperation, readmission, bleeding, cardiopulmonary, infectious complications, and total morbidity were significantly higher in CKD patients. In propensity-matched and case-control matched analyses of 4006 patients and 2264 patients, respectively, poorer outcomes in CKD patients highlight it an independent risk factor for morbidity.ConclusionsIn contrast to previously reported large database analysis, CKD and dependence on dialysis independently increases the risk of 30-day adverse outcomes after primary bariatric surgery. The benefits conferred by bariatric surgery should be carefully weighed against the increased risk of complications in this challenging population.     

Bariatric surgery outcomes in oxygen-dependent patients: analysis of the MBSAQIP database

BackgroundThe number of bariatric procedures performed on complex, oxygen-dependent patients has increased. These patients often have other medical co-morbidities that can be improved after bariatric surgery; however, questions remain regarding their perioperative risk.ObjectiveTo assess the safety of bariatric surgery among oxygen-dependent patients, and to compare outcomes in this patient group after laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy.SettingUniversity and private hospitals enrolled in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data from 2015 to 2017 was analyzed. A multivariable regression analysis was performed looking at 30-day serious complications for oxygen-dependent patients, with a secondary propensity-matched analysis performed comparing patients undergoing laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass.ResultsIn total, 430,396 patients were analyzed, 3034 (0.7%) of whom were oxygen dependent. The absolute 30-day complication rate among oxygen-dependent patients was more than twice as high (8.24% versus 3.46%, P < .001). The postoperative leak (.69% versus .41%, P = .017), bleed (2.08% versus .91%, P < .001), cardiac event (.16% versus .07%, P = .034), and pneumonia rate (.89% versus .19%, P < .001) were all significantly higher. Mortality was significantly higher among oxygen-dependent patients (.49% versus .09%, P < .001). On multivariable analysis, oxygen dependency was an independent predictor of adverse outcomes (odds ratio 1.30 [1.22–1.50], P < .001). Laparoscopic Roux-en-Y gastric bypass was associated with a statistically significant higher complication rate compared with laparoscopic sleeve gastrectomy (13.23% versus 5.16%, P < .001).ConclusionOxygen-dependent patients undergoing bariatric surgery are at a higher risk of both morbidity and mortality postoperatively.     

Is age a real or perceived discriminator for bariatric surgery? A long-term analysis of bariatric surgery in the elderly

BackgroundBariatric surgery is the most effective treatment of obesity. There are few studies evaluating long-term outcomes in elderly patients.ObjectivesOur study was designed to evaluate the safety and long-term outcomes of bariatric surgery in the elderly compared with a contemporary medically managed cohort.SettingUniversity hospital.MethodsThree hundred thirty-seven patients age ≥60 who underwent a sleeve gastrectomy or Roux-en-Y gastric bypass between January 2007 and April 2017 were identified (ElderSurg) and compared with a matched cohort of medically managed elderly patients with obesity (ElderNonSurg).ResultsThirty-two patients underwent laparoscopic sleeve gastrectomy, 190 underwent laparoscopic Roux-en-Y gastric bypass, and 115 underwent open Roux-en-Y gastric bypass. The cohort was a mean of 64.4-years old, 75.4% female, mean preoperative body mass index was 46.9, and 62.6% had type 2 diabetes. During a median follow-up period of 56.2 months (confidence interval 49.5–62.9), mean percent excess weight loss (EWL) at nadir was 72.1 ± 24.7% and EWL at 36 months or beyond was 60.9 ± 27.6%. On regression analysis, diabetes, body mass index, and laparoscopic sleeve gastrectomy were negatively associated with EWL at all time periods (P < .05). Mean %EWL was greater for Roux-en-Y gastric bypass compared with laparoscopic sleeve gastrectomy (61.7 versus 41.2; P = .039). Diabetes remission rate was 45.8%. There was a statistically significant decrease in the risk of death in ElderSurg (hazard ratio .584, 95% confidence interval .362–.941) compared with ElderNonSurg.ConclusionsOur study supports that bariatric surgery is safe in elderly patients with effective long-term control of obesity, diabetes, and with improved overall survival.     

Bariatric surgery outcomes when assisted by fellows and residents: an MBSAQIP analysis of 477,670 patients

BackgroundPrevious reports of bariatric surgery outcomes when cases are assisted by residents and/or fellows have been inconclusive.ObjectiveTo compare bariatric surgery outcomes for cases with surgical trainees (ST; residents and fellows) versus nonsurgical trainees (nST; all other assistants) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Registry.SettingAcademic teaching.MethodsThe MBSAQIP Registry was reviewed (2015–2017) for Roux-en-Y gastric bypass, sleeve gastrectomy, and revision surgery based on ST and nST status. Univariate, multivariate logistic regression, and propensity matching analyses were performed.ResultsOf 477,670 cases, 26.8% were performed with ST. For ST patients 79.9% were female (versus 80.3% nST) and mean body mass index was 45.2 ± 8 kg/m² (versus 45.0 ± 8.1 kg/m² nST). Overall, 31.7% of patients underwent Roux-en-Y gastric bypass (versus 25.7% nST), 65.9% underwent sleeve gastrectomy (versus 71.6% nST), and 2.4% of patients had revision surgery (versus 2.7% nST). After matching, no difference in 30-day mortality was observed between groups. However, ST patients had higher incidence of deep vein thrombosis (P = .004), pulmonary embolism (P = .005), superficial surgical site infection (P < .0001), postoperative sepsis (P = .005), blood transfusions (P = .0307), nonoperative interventions (P = .004), 30-day readmission rates (P < .0001), and longer operative times (P < .0001), but lower 30-day reoperation rates (P = .0001).ConclusionOverall, there was no difference observed in 30-day mortality between the ST and nST groups. However, despite lower 30-day reoperation rates, ST patients exhibited higher rates of postoperative deep vein thrombosis, pulmonary embolism, superficial surgical site infection, postoperative sepsis, blood transfusions, 30-day readmission rates, and longer operative times than nST patients.     

Examining the Hispanic paradox in bariatric surgery

BackgroundThe obesity rate for the Hispanic population is significantly higher than that of white, non-Hispanic people in the United States, yet Hispanic people undergo disproportionately fewer metabolic and bariatric surgery procedures. This study used the Metabolic Bariatric Surgery Accreditation and Quality Improvement Program data registry to examine potential differences in preoperative co-morbidities and postoperative outcomes in Hispanic adults undergoing sleeve gastrectomy or Roux-en-Y gastric bypass procedures in the United States.ObjectivesTo study the presence of the Hispanic paradox in metabolic and bariatric surgery utilizing the MBSAQIP registry.SettingAcademic Teaching Institution.MethodsParticipant User Files from the Metabolic Bariatric Surgery Accreditation and Quality Improvement Program were reviewed for patients undergoing sleeve gastrectomy or Roux-en-Y gastric bypass (2015–2017). Patients were grouped by race (Hispanic versus all other races) and primary procedure performed. Variables for major and minor postoperative complications were combined. A univariate analysis was performed on unmatched and propensity-matched cohorts.ResultsAfter applying exclusions, 53,353 (13.7%) Hispanic patients and 335,299 non-Hispanic patients remained. A univariate analysis demonstrated Hispanic patients had the lowest preoperative co-morbidity profile compared with all other races and decreased rates of major and minor postoperative complications. Using matched-cohort data, when complications were assessed and grouped as major/minor complications, rates of major and minor complications in Hispanic patients were lower in the Roux-en-Y gastric bypass group, despite Hispanic patients having higher leak rates. Similarly, there were no differences between Hispanic/non-Hispanic sleeve gastrectomy patients in overall major/minor complication rates despite Hispanic patients exhibiting higher venous thromboembolism and lower bleeding compared with non-Hispanic patients.ConclusionHispanic patients undergo disproportionately low rates of metabolic and bariatric surgery procedures and present with lower incidence of preoperative co-morbidities. Additionally, Hispanic patients have the same or decreased incidence of postoperative complications compared with non-Hispanic patients, thereby corroborating the Hispanic paradox.     

First assistant impact on early morbidity and mortality in bariatric surgery

BackgroundThe future of bariatric surgery depends largely on how effectively residents and fellows are trained. The challenge is to assure patient safety during training. Our study compares the impact of first assistants on patient outcomes after Roux-en-Y gastric bypass and sleeve gastrectomy.MethodsA retrospective review of primary, elective Roux-en-Y gastric bypass and sleeve gastrectomy procedures performed in 2015 and 2016 from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant user files was performed. Patient cohorts were categorized by the level of training of the surgical first assistant (FA). Multivariate regression models were developed to determine the impact of the FA level on patient outcomes, adjusting for patient demographic characteristics and co-morbid conditions.ResultsCompared with an attending weight loss surgeon as FA, minimally invasive surgery fellows and general surgery residents were more likely to have an unplanned admission to the intensive care unit (ICU) within 30 days (odds ratio [OR] 1.422, 95% confidence interval [CI] 1.196–1.691; OR 1.206, 95% CI 1.034–1.406, respectively, P < .0001) and were more likely to have a 30-day hospital readmission (OR 1.143, 95% CI 1.056–1.236; OR 1.127, 95% CI 1.055–1.204, respectively, P < .0001). Compared with having a weight loss surgeon as FA, operative duration was significantly longer for all other assistant levels, or no assistant (P < .0001).ConclusionThe training level of the FA does not impact early patient mortality or reoperation rates after Roux-en-Y gastric bypass or sleeve gastrectomy. However, unplanned intensive care unit admissions and readmissions within 30 days were significantly associated with surgical resident or minimally invasive surgery fellow FAs. Further analysis is needed to understand this cause and effect; however, these data provide direction to redesign residency and fellowship training.     

Bariatric surgery decreased the serum level of an endotoxin-associated marker: lipopolysaccharide-binding protein

BackgroundRecent studies have shown serum lipopolysaccharide binding protein (LBP) is associated with obesity and related metabolic disorder. Bariatric surgery can significantly reduce weight, but reports about the change of LBP after bariatric surgery are limited. We investigated LBP concentration and its associations with clinical variables.MethodsWe enrolled 178 obese patients receiving different bariatric surgeries and 38 normal weight individuals. Fasting blood samples were collected at baseline in all and 1 year after surgery in obese individuals. The serum LBP concentration was measured.ResultsThe percentage of excess weight loss of mini-gastric bypass, Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric band were 72.0±20.0%, 65.5±23.0%, 67.2±18.4%, and 16.1±14.3%, respectively. Serum LBP levels were higher in the obese participants than in the normal weight participants (49.9±15.7 versus 25.2±7.5 μg/mL; P<.001) at baseline and significantly decreased to 35.1±22.6 μg/mL after bariatric surgery (P<.001) in the obese group. In the bariatric participants, after multivariate analyses, preoperative LBP and the change of LBP with surgery were independently associated only with high sensitive C-reactive protein (hs-CRP) (P<.001) and the change of hs-CRP (P = .012), respectively, while none of the postoperative variables was independently associated with LBP.ConclusionLBP is associated with body mass index and hs-CRP. Bariatric surgery significantly decreased the serum level of LBP. The relationship between LBP and hs-CRP disappeared after bariatric surgery. (Surg Obes Relat Dis 2014;0:000–000.) © 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.     

Dehydration risk factors and impact after bariatric surgery: an analysis using a national database

BackgroundDehydration is a common complication after bariatric surgery and often quoted as the reason for emergency department (ED) visits and readmission.ObjectiveWe sought to investigate risk factors for dehydration after bariatric surgery and evaluate its impact on ED visits and readmission.SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.MethodsWe used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database to identify patients who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2016 through 2017. The primary outcome was need for outpatient treatment of dehydration within 30 days postsurgery. Secondary outcomes were association between need for outpatient dehydration therapy and 30-day readmission or ED evaluation not resulting in admission.ResultsOf 256,817 patients, 73% underwent laparoscopic sleeve gastrectomy and 27% LRYGB. Of 9592 patients who required dehydration treatment, they were more often younger than age 40, female, black, had a ≥3-day length of stay during their index admission, and experienced a postoperative complication. More patients receiving LRYGB than laparoscopic sleeve gastrectomy required treatment for dehydration. On multivariable analysis, independent-risk factors for postoperative dehydration treatment included LRYGB, length of stay ≥3 days, gastroesophageal reflux disease, hypertension, previous deep vein thrombosis, chronic steroid/immunosuppression, and a postoperative complication. Patients who developed dehydration requiring treatment compared with those that did not had adjusted odds ratio of 3.7 (95% confidence interval: 3.44–3.96; P < .001) and 22 (95% confidence interval: 21.05–23.06; P < .001) of readmission and ED visit.ConclusionDehydration is a strong risk factor for postoperative ED visits and readmission. Closer surveillance and proactive measures for those at higher risk may prevent the development of postoperative dehydration.     

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.     

Evaluating the safety of bariatric surgery for weight loss in class I obesity: A propensity-matched analysis of North American data

BackgroundBariatric surgery is an effective treatment for severe obesity. However, there has been an evolving role for bariatric surgery as a primary treatment in the management of class I obesity.ObjectivesWe aimed to assess the safety of surgery by directly comparing surgical outcomes of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in class I obesity (body mass index [BMI] 30–35 kg/m²) with those with class II obesity (BMI 35–40 kg/m²) and higher (BMI >40 kg/m²) using an analysis of a large-scale matched-patient cohort analysis.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, United States and Canada.MethodsWe performed a retrospective analysis using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, which collects patient information from >790 bariatric surgery centers in North America. Patients included in our analysis underwent surgery in the years 2015 and 2016 and had either LRYGB or LSG for weight loss.ResultsInitial analysis included 274,091 patients. Propensity-matching resulted in 9104 patients for analysis in each of the class I and class II and higher groups. The overall major complication rate between the 2 matched groups was 3.9% for class I and 3.5% for class II and higher (P = .11). We did not find that class I obesity was associated with an increased risk of 30-day complication or death.ConclusionsIn our analysis of propensity-matched patients undergoing LSG and LRYGB for weight loss, class I obesity did not have statistically higher risk of postoperative complication rates compared with class II and higher.     

Incidence of GERD,esophagitis, Barrett’s esophagus,and esophageal adenocarcinoma after bariatric surgery

BackgroundSome bariatric procedures have been associated with increased gastroesophageal reflux disease (GERD) symptoms; however, there are limited data on the long-term changes to the esophagus across bariatric procedures, and how preoperative esophageal disease is impacted by bariatric surgery.ObjectivesTo estimate incidence of GERD, esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma before and after bariatric surgery and to identify potential risk factors for these conditions.SettingRetrospective analysis of New York State Database (SPARCS).MethodsAdult patients undergoing bariatric surgery (Roux-en-Y gastric bypass, adjustable gastric banding, laparoscopic sleeve gastrectomy, and biliopancreatic diversion) from 1995 to 2010. Multivariable Cox proportional hazard models were used to examine the association between preoperative diagnosis, surgery type, and postoperative diagnosis.ResultsA total of 48,967 records were analyzed; 30.3% had a diagnosis of GERD at the time of surgery and .4% had a diagnosis of esophagitis and Barrett’s. Preoperative GERD/esophagitis/Barrett’s was associated with higher risk of GERD, esophagitis, and Barrett’s, but not esophageal adenocarcinoma, postoperatively. Roux-en-Y gastric bypass patients had lowest risk of being diagnosed with GERD postoperatively. Overall, esophageal adenocarcinoma incidence in the sample was .04%; the rate among patients with preoperative GERD and Barrett’s was .1% and .9%, respectively. Incidence of esophageal adenocarcinoma did not differ by bariatric surgery type.ConclusionsPreoperative diagnosis is a risk factor for postoperative esophageal disease after bariatric surgery. Adjustable gastric banding and laparoscopic sleeve gastrectomy are associated with higher risk of postoperative GERD and esophagitis compared with Roux-en-Y gastric bypass. Incidence of esophageal adenocarcinoma did not differ by surgery type.     

Lipoprotein insulin resistance score in nondiabetic patients with obesity after bariatric surgery

BackgroundLipoprotein insulin resistance (LPIR) score is a composite biomarker representative of atherogenic dyslipidemia characteristic of early insulin resistance. It is elevated in obesity and may provide information not captured in glycosylated hemoglobin and homeostatic model assessment for insulin resistance. While bariatric surgery reduces diabetes incidence and resolves metabolic syndrome, the effect of bariatric surgery on LPIR is untested.ObjectivesWe sought to assess the effects of Roux-en-Y gastric bypass and sleeve gastrectomy on LPIR in nondiabetic women with obesity.SettingNonsmoking, nondiabetic, premenopausal Hispanic women, age ≥18 years, undergoing Roux-en-Y gastric bypass or sleeve gastrectomy at Bellevue Hospital were recruited for a prospective observational study.MethodsAnthropometric measures and blood sampling were performed preoperatively and at 6 and 12 months postoperatively. LPIR was measured by nuclear magnetic resonance spectroscopy.ResultsAmong 53 women (Roux-en-Y gastric bypass, n = 22; sleeve gastrectomy, n = 31), mean age was 32 ± 7 years and body mass index 44.1 ± 6.4 kg/m². LPIR was reduced by 35 ± 4% and 46 ± 4% at 6 and 12 months after surgery, respectively, with no difference by procedure. Twenty-seven of 53 patients met International Diabetes Federation criteria for metabolic syndrome preoperatively and had concomitant higher homeostatic model assessment for insulin resistance, glycosylated hemoglobin, nonhigh-density lipoprotein-cholesterol and LPIR. Twenty-five of 27 patients experienced resolution of metabolic syndrome postoperatively. Concordantly, the preoperative differences in homeostatic model assessment for insulin resistance, glycosylated hemoglobin, and nonhigh-density lipoprotein-cholesterol between those with and without metabolic syndrome resolved at 6 and 12 months. In contrast, patients with metabolic syndrome preoperatively exhibited greater LPIR scores at 6 and 12 months postoperatively.ConclusionThis is the first study to demonstrate improvement in insulin resistance, as measured by LPIR, after bariatric surgery with no difference by procedure. This measure, but not traditional markers, was persistently higher in patients with a preoperative metabolic syndrome diagnosis, despite resolution of the condition.     

Body mass index and diabetes status do not affect postoperative infection rates after bariatric surgery

BackgroundObesity predisposes general surgical patients to infections such as surgical site infection and respiratory tract infection. The infection rates vary by surgical approach and the type of surgery undertaken. Bariatric surgery is increasingly used to treat obesity and obesity related co-morbidities. However, little is known about the relationship between postoperative infections and patient characteristics, such as body mass index (BMI) or diabetes status, in bariatric cohorts. The objective of this study was to examine the rates of all postoperative infection in patients after bariatric surgery in relation to known risk factors.ResultsA total of 815 patients were included in the final analysis. During the first month after surgery, 5.2% of patients experienced an infection-related event, and surgery-related infections were most prevalent. Between the second and twelfth month postoperatively, a further 4.7% of patients experienced an infection-related event, and nonsurgical related infections were most prevalent.Infection was associated with increased length of stay in Roux-en-Y gastric bypass (RYGB) (P<.001) and sleeve gastrectomy (SG) (P = .011) but not in laparoscopic adjustable gastric banding (LAGB) (P = .41). Diabetes status and BMI were not associated with increased infection rates during the first month after surgery.ConclusionInfection rates after bariatric surgery are relatively low and are associated with a prolonged length of hospital stay. Reassuringly, neither diabetic status nor BMI appear to increase the risk of postoperative infection after bariatric surgery.     

Atrial dysrhythmias are independent predictors of serious complications and 30-day mortality after elective bariatric surgery: a retrospective study of 731,981 patients

ObjectivesThe objectives of this study were to characterize the prevalence of atrial dysrhythmias for elective bariatric surgery patients and to explore their impact on postoperative outcomes.SettingData was extracted from the North American Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2019.MethodsAll primary Roux-en-Y gastric bypass and sleeve gastrectomy procedures were included. Patients with atrial dysrhythmias (ADs) were identified as patients coded as receiving preoperative therapeutic anticoagulation without a prior history of deep vein thrombosis, venous thromboembolism, pulmonary embolism, or other conditions requiring anticoagulation. Multivariable logistic regression analysis was used to determine the impact of preoperative ADs on postoperative complications and 30-day mortality.ResultsWe evaluated 731,981 patients, of whom 13,591 (1.9%) had preoperative ADs. Patients with ADs were more likely to be older, have a higher body mass index, and be male. Metabolic co-morbidities also were more common in those with ADs, as demonstrated by the higher rates of medication use and insulin-dependent diabetes, hypertension, dyslipidemia, and sleep apnea. After adjusting for co-morbidities using multivariable logistic regression, AD was the single greatest independent predictor of serious complications and 30-day mortality.ConclusionsADs were observed in approximately 2% of MBSAQIP patients. ADs are among the greatest independent predictors of serious complications and mortality, suggesting that these patients are associated with a higher perioperative risk profile warranting further optimization.     

Fecal metagenomics and metabolomics reveal gut microbial changes after bariatric surgery

BackgroundEvidence from longitudinal patient studies regarding gut microbial changes after bariatric surgery is limited.ObjectiveTo examine intraindividual changes in fecal microbiome and metabolites among patients undergoing Roux-en-Y gastric bypass or vertical sleeve gastrectomy.SettingObservational study.MethodsTwenty patients were enrolled and provided stool samples before and 1 week, 1 month, and/or 3 months after surgery. Shallow shotgun metagenomics and untargeted fecal metabolomics were performed. Zero-inflated generalized additive models and linear mixed models were applied to identify fecal microbiome and metabolites changes, with adjustment for potential confounders and correction for multiple testing.ResultsWe enrolled 16 women and 4 men, including 16 white and 4 black participants (median age = 45 years; presurgery body mass index = 47.7 kg/m²). Ten patients had Roux-en-Y gastric bypass, 10 had vertical sleeve gastrectomy, and 14 patients provided postsurgery stool samples. Of 47 samples, median sequencing depth was 6.3 million reads and 1073 metabolites were identified. Microbiome alpha-diversity increased after surgery, especially at 3 months. Significant genus-level changes included increases in Odoribacter, Streptococcus, Anaerotruncus, Alistipes, Klebsiella, and Bifidobacterium, while decreases in Bacteroides, Coprocosccus, Dorea, and Faecalibacterium. Large increases in Streptococcus, Akkermansia, and Prevotella were observed at 3 months. Beta-diversity and fecal metabolites were also changed, including reduced caffeine metabolites, indoles, and butyrate.ConclusionsDespite small sample size and missing repeated samples in some participants, our pilot study showed significant postsurgery changes in fecal microbiome and metabolites among bariatric surgery patients. Future large-scale, longitudinal studies are warranted to investigate gut microbial changes and their associations with metabolic outcomes after bariatric surgery.     

Changes in total sperm count after gastric bypass and sleeve gastrectomy: the BARIASPERM prospective study

BackgroundThe massive weight loss induced by bariatric surgery is associated with major benefits, but the effect on semen variables is still uncertain.ObjectivesTo explore semen modifications with gastric bypass and sleeve gastrectomy.SettingFive French University Hospitals.MethodsMale candidates for bariatric surgery with no history of infertility were recruited in this controlled prospective study. Sperm characteristics were collected before surgery and then 6 months and up to 12 months after surgery.ResultsForty-six adult men who underwent gastric bypass (n = 20) or sleeve gastrectomy (n = 26) were included. Total sperm count tended to be lower at 6 months and showed a significant decrease at 12 months in both surgery groups, at ?69.5 million (?96.8 to ?42.2 million; P = 0.0021). Total sperm count at 12 months relative to baseline was ?41.4 million (P = .0391) after gastric bypass and ?91.1 million (P = .0080) after sleeve gastrectomy. This was counterbalanced by an associated resolution of hypogonadism and decrease of DNA fragmentation in most patients with time after surgery.ConclusionImprovement in some semen variables after bariatric surgery observed in 3 previous studies is in contrast to the lower mean total sperm count found in this study at 1 year. The possible reversibility of this effect in the long term and the impact of surgery on fertility both remain unknown.     

Hypoalbuminemia as a risk factor for complications in revisional/conversional bariatric surgery: an MBSAQIP analysis

BackgroundHypoalbuminemia (HA) is a risk factor for serious complications after elective bariatric surgery. Patients undergoing revisional/conversional bariatric surgery may represent a higher-risk group who often have underlying co-morbid medical illnesses and more complex surgery.ObjectivesThis study investigated the postoperative complications in patients with HA undergoing revisional/conversional bariatric surgery.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), years 2015–2019.MethodsThe MBSAQIP database was used to evaluate patients undergoing non-banding revisional/conversional bariatric surgery between 2015 and 2019. Patients were categorized by serum albumin (≤3.5 g/dL). Variables were assessed via bivariate analysis and multivariable regression. Propensity score matching was conducted to compare gastric bypass (RYGB) to sleeve gastrectomy (VSG).ResultsOne hundred forty-seven thousand four hundred thirty patients underwent revisional/conversional procedures. After applied exclusions, 58,777 patients were available for analysis. The HA group had a significantly (P < .05) higher prevalence of being black (22.95% versus 17.76%), renal insufficiency (1.08% versus .36%), smoking history (9.47% versus 6.91%), chronic obstructive pulmonary disease (COPD) (2.54% versus 1.33%), and history of deep vein thrombosis (DVT) (4.03% versus 2.3%). Postoperative complications associated with HA included perioperative blood transfusion (3.1% versus 1.27%; P < .001), 30day readmission (10.87 versus 6.77%; P < .001), 30day reoperation (4.9% versus 3.18%; P < .001), and 30day mortality (.40% versus .14%; P < .0001). HA was a significant predictor of 30day readmission in the RYGB versus VSG matched cohort (odds ratio [OR], 1.30; 95% confidence interval [CI], [1.14, 1.48]; P < .001).ConclusionsHA is a risk factor requiring attention for patients undergoing revisional/conversional bariatric surgery and optimization of nutritional status or medical comorbidities associated with HA prior to bariatric surgery may help avoid postoperative complications.     

Evolution and Outcomes of a Canadian Pediatric Bariatric Surgery Program

PurposeAn interdisciplinary obesity management program was established in 2007 at our quaternary hospital, including bariatric surgery for selected adolescent patients. We report the evolution of surgical management within the program and outcomes following bariatric surgery.MethodsThis was a retrospective review of adolescents who underwent bariatric surgery between 2007 and 2017. All cases were performed by a pediatric surgeon and an adult bariatric surgeon. Baseline demographics, BMI, co-morbidities, and post-operative outcomes were recorded.ResultsThirty-eight patients underwent bariatric surgery. Median age at entrance into the program was 16.5 (range, 12.1–17.4) years and at time of surgery was 17.4 (range, 13.6–18.8) years. Eight patients had laparoscopic adjustable gastric banding (LAGB) from 2007 to 10. Between 2011 and 2017, 18 had laparoscopic sleeve gastrectomy (LSG), and 12 had laparoscopic Roux-en-Y gastric bypass (RYGB). There were no intraoperative complications or conversions. Postoperative complications included wound infection, bleeding requiring transfusion and re-exploration, and internal hernia. Of patients who had LAGB, 2 required surgical revision, and 3 underwent subsequent removal.ConclusionsAdolescent bariatric surgery in the context of a multidisciplinary obesity management program is safe and effective. RYGB and sleeve gastrectomy are associated with superior weight loss in the immediate post-operative period and at most recent follow-up and lower reoperation rates than gastric banding.Level of EvidenceIII.     

Effect of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834,647 patients

BackgroundCOVID-19 has transformed surgical care, yet little is known regarding implications for bariatric surgery.ObjectiveWe sought to characterize the effect of COVID-19 on bariatric surgery delivery and outcomes.SettingThe Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 885 centers in North America.MethodsThe MBSAQIP database was evaluated with 2 cohorts described: the COVID-19 and the pre–COVID-19, with patients receiving surgery in 2020 and 2015–2019, respectively. Yearly operative trends were characterized, and bivariate analysis compared demographics and postoperative outcomes. Multivariable modeling evaluated 30-day readmission, reintervention, and reoperation rates and factors associated with undergoing Roux-en-Y gastric bypass.ResultsWe evaluated 834,647 patients, with 155,830 undergoing bariatric surgery during the 2020 pandemic year. A 12.1% reduction in total cases (177,208 in 2019 versus 155,830 in 2020; P < .001) and 13.8% reduction in cases per center occurred (204.2 cases per center in 2019 versus 176.1 cases per center in 2020; P < .001). Patients receiving bariatric surgery during the pandemic were younger and had fewer co-morbidities. Use of sleeve gastrectomy increased (74.5% versus 72.5%; P < .001), and surgery during COVID-19 was associated with reduced Roux-en-Y gastric bypass procedure selection (odds ratio = .83; 95% CI: .82–.84; P < .001). Length of stay decreased significantly (1.4 ± 1.4 days versus 1.6 ± 1.4 days; P < .001), yet postoperative outcomes were similar. After adjusting for co-morbidities, patients during COVID-19 had decreased 30-day odds of readmission and reintervention and a small increase in odds of reoperation.ConclusionThe COVID-19 pandemic dramatically changed bariatric surgery delivery. Further studies evaluating the long-term effects of these changes are warranted.