Does bariatric surgery reduce the risk of major cardiovascular events? A retrospective cohort study of morbidly obese surgical patients

BackgroundMorbid obesity is associated with the development of cardiovascular and cerebrovascular disease. Several studies have shown that bariatric surgery results in risk factor reduction; however, studies correlating bariatric surgery to the reduced rates of myocardial infarction, stroke, or death have been limited.MethodsWe conducted a large retrospective cohort study of bariatric (BAR) surgical patients (n = 4747) and morbidly obese orthopedic (n = 3066) and gastrointestinal (n = 1327) surgical controls. Data were obtained for all patients aged 40–79 years, from 1996 to 2008, with a diagnosis code of morbid obesity and a primary surgical procedure of interest. The data sources were the statewide South Carolina Universal Billing Code of 1992 inpatient hospitalization database and death records. The primary study outcome was the time-to-occurrence of the composite outcome of postoperative myocardial infarction, stroke, or death (all-cause).ResultsThe 5-year Kaplan-Meier life table estimate of the composite index of event-free survival in the BAR, orthopedic, and gastrointestinal cohorts was 84.8%, 72.8%, and 65.8%, respectively. After adjusting for baseline differences and potential confounders, the Cox proportional hazards ratio was .72 (95% confidence interval .58–.89) for BAR versus orthopedic and .48 (95% confidence interval .39–.61) for BAR versus gastrointestinal.ConclusionBariatric surgery was significantly associated with a 25–50% risk reduction in the composite index of postoperative myocardial infarction, stroke, or death compared with other morbidly obese surgical patients in South Carolina.     

Trends in risk factors for readmission after bariatric surgery 2015–2018

BackgroundReadmission after bariatric surgery is multifactorial. Understanding the trends in risk factors for readmission provides opportunity to optimize patients prior to surgery identify disparities in care, and improve outcomes.ObjectivesThis study compares trends in bariatric surgery as they relate to risk factors for all-cause readmission.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating facilities.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was used to analyze 760,076 bariatric cases from 854 centers. Demographics and 30-day unadjusted outcomes were compared between laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG), and Roux-en-Y gastric bypass (RYGB) performed between 2015 and 2018. A multiple logistic regression model determined predictors of readmission.ResultsA total of 574,453 bariatric cases met criteria, and all-cause readmission rates decreased from 4.2% in 2015 to 3.5% in 2018 (P < .0001). The percentage of non-Hispanic Black adults who underwent bariatric surgery increased from 16.7% of the total cohort in 2015 to 18.7% in 2018 (P < .0001). The percentage of Hispanic adults increased from 12.1% in 2015 to 13.8% in 2018 (P < .0001). The most common procedure performed was the LSG (71.5%), followed by RYGB (26.9%) and 1.6% LAGB (1.6%) (P < .0001). Men were protected from readmission compared with women (odds ratio [OR]: .87; 95% confidence interval [CI]: .84–.90). Non-Hispanic Black (OR: 1.52; 95% CI: 1.47–1.58)] and Hispanic adults (OR: 1.14; 95% CI: 1.09–1.19) were more likely to be readmitted compared with non-Hispanic White adults. LSG (OR: 1.27; 95% CI: 1.10–1.48) and RYGB (OR: 2.24; 95% CI: 1.93–2.60) were predictive of readmission compared with LAGB.ConclusionReadmission rates decreased over 4 years. Women, along with non-Hispanic Black and Hispanic adults, were more likely to be readmitted. Future research should focus on gender and racial disparities that impact readmission.     

Vascular calcification in the uremic patient: a cardiovascular risk?

BACKGROUND: Several factors suggest that the presence of vascular calcification (VC) is associated with a high risk of cardiac events in uremic patients. The aim of this study was to analyze the influence of VC on cardiac morbidity and mortality in our hemodialysis (HD) patients. METHODS: We studied 79 patients on HD: 43 males, mean age 48 +/- 15 years old, mean time on HD 83 +/- 63 months. The presence of VC was evaluated by radiologic series. Other cardiovascular risk factors analyzed were arterial hypertension, diabetes mellitus, obesity, cigarette smoking, anemia, and dyslipidemia. All patients underwent M-mode, two-dimensional, Doppler echocardiography. Patients were followed for two years. During this time, clinical information collected included predialysis blood pressure, incidence of ischemic heart disease, episodes of congestive heart failure, and mortality due to cardiovascular event. RESULTS: VC was observed in 55.7% of patients. Left ventricular hypertrophy, diastolic dysfunction, and cardiac valve calcification were significantly associated with VC. Ischemic heart disease (71.4% vs. 28.6%) and episodes of cardiac failure (0.41 vs. 0.18 per year; P < 0.05) appeared more frequently in the patient group with VC. VC was present in 80.6% of patients who developed episodes of heart failure. Eight patients died from cardiac disease; each of them had VC. CONCLUSION: The presence of VC can help to identify those HD patients with a higher cardiovascular risk.     

Patients with clinically metabolically healthy obesity are not necessarily healthy subclinically: further support for bariatric surgery in patients without metabolic disease?

Background

Nonalcoholic fatty liver disease (NAFLD) increases the risk of liver cirrhosis and hepatocellular carcinoma and is also strongly correlated with extrahepatic diseases, including cardiovascular disease and type 2 diabetes. This risk of NAFLD among obese individuals who are otherwise metabolically healthy is not well characterized.

Can anesthesia improve the outcome in high risk obstertric patients?

Obstetric anesthetists should have an infrastructure that allows for referral and assessment of high risk patients. Management plans should be agreed well before delivery. This information must be available to other members of the team. Protocol for common high risk problems should be agreed and introduced. Promoting regional blockade for Cesarean section will reduce maternal anesthetic mortality. Epidural anesthesia preserves fetal biochemistry better than other forms of anesthesia.     

Should bariatric surgery be offered for hepatocellular adenomas in obese patients?

BackgroundObesity and metabolic syndrome are increasingly recognized as risk factors for development of hepatocellular adenoma (HCA). The implications of weight loss on HCA regression has not been previously reviewed.ObjectivesTo analyze the effects of surgical and nonsurgical weight loss on HCA.SettingUniversity Tertiary Hospital.MethodsLiterature review of full-text articles from PubMed and Scopus on patients with HCA who underwent surgical or nonsurgical weight loss was performed. Only English language articles were included and editorial comments were excluded. Wilcoxon signed rank test was used for paired data analysis. Spearman correlation was used for correlation between percent excess weight loss (%EWL) and number and size of HCA lesions.ResultsOut of 4 studies, 7 patients were included in this review, all of whom were female. The median preintervention body mass index was 41 kg/m² compared with the postintervention body mass index of 28 kg/m² (P = .002). The %EWL following intervention positively correlated to reduction in number of HCA lesions (%) postintervention, with a Spearman correlation of .78 (P = .04). Similarly, %EWL postintervention was positively correlated, though not statistically significant, to reduction in lesion size (%), with a Spearman correlation of .46 (P = .29). All patients who were candidates for liver resection preintervention based on lesion size > 5 cm avoided liver resection postintervention following surgical and nonsurgical weight loss.ConclusionsEffective long-term weight loss by surgical and nonsurgical methods result in regression of HCAs. Weight loss could avoid major liver resections or decrease the morbidity associated with liver surgery. Bariatric surgery should be considered as an option for management of surgically challenging HCAs in carefully selected obese patients. Multicenter long-term trials, while adjusting for cofounding factors, are required to determine the effects of surgical compared with nonsurgical weight loss on maintenance of HCA regression.     

Can radical surgery improve survival in colorectal cancer?

Prospective, randomized trials that study the best surgical technique to prevent local and distal metastases in colorectal cancer have not yet been performed. Prevention of local recurrence must be a major effort achieved by radical resection of the tumor area, by minimizing the possibility of suture line recurrence and of tumor remnants in intramesenteric lymph nodes or surrounding tissue, and by avoiding spillage of tumor cells. Extended resections of mesenteric lymph nodes or pelvic lymphadenectomy did not prove to be of significant benefit in most retrospective studies. In the case of adjacent organ involvement, en bloc resection is indicated since long-term survival can be obtained. This operation can be performed with low operative mortality rates even in the case of pancreas or duodenum involvement as is shown in our series of 34 patients (3% operative mortality). Frozen sections of the resection area have to be included in the operative procedure. For prevention of distant metastases, the no-touch technique of Turnbull should be performed. In a prospective, randomized trial of 236 patients operated on for colon cancer, liver metastases appeared later and to a lesser degree in patients operated on with the no-touch isolation technique, particularly in the case of angioinvasive growth of the tumor.

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Resumen Aún no se han realizado ensayos clínicos prospectivos y aleatorizados con el fin de estudiar la mejor técnica quirúrgica para prevenir metástasis locales y distales en cáncer colorectal. La prevención de la recurrencia local debe ser un propósito mayor mediante la resectión radical del área tumoral, minimizando las posibilidades de recurrencia en la línea de sutura, eliminando remanentes del tumor en los ganglios linfáticos intramesentéricos o en los tejidos vecinos, y evitando la contaminación con células tumorales. Las resecciones extensas de los ganglios mesentéricos o las linfadenectomías pélvicas no han demostrado beneficio de significación en la mayoría de los estudios prospectivos. En casos de invasión de órganos adyacentes, la resección en bloque tiene justificación porque se pueden lograr supervivencias prolongadas. Esta operación puede ser realizada con una baja mortalidad operatoria aún en casos de invasión de páncreas o de duodeno, como se ve en nuestra serie de 34 pacientes con 3% de mortalidad operatoria. Cortes por congelación del área de resección deben ser incluidos en el procedimiento operatorio. Con el objeto de prevenir el desarrollo de metástasis distales debe realizarse la técnica de aislamiento (no touch) de Turnbull. En un ensayo clínico prospectivo con 236 pacientes operados por cáncer de colon, las metatasis hepáticas hicieron su aparicón mas tardíamente y en menor grado en los pacientes operados con la técnica de aislamiento, especialmente cuando hay crecimiento angioinvasivo del tumor.

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Résumé Des essais prospectifs randomisés pour étudier la meilleure opération susceptible de prévenir les métastases locales et distales en cas de cancer colo-rectal n'ont pas été entrepris. La prévention de la récidive locale doit être l'objectif à atteindre. Pour ce faire il convient de procéder à la résection radicale de la zone tumorale, de réduire au minimum la possibilité d'une récidive au niveau de la suture, d'éviter de laisser en place des éléments tumoraux dans les ganglions mésentériques et les tissus voisins, et de s'abstenir de tout essaimage des cellules tumorales. La résection étendue des ganglions mésentériques ou la lymphadenectomie pelvienne ne semble pas d'un grand bénéfice d'après les études rétrospectives. Lorsque les organes adjacents sont envahis, la résection en bloc est indiquée si l'on veut obtenir une bonne survie. Elle peut être entreprise avec un taux faible de mortalité même si le pancréas ou le duodénum est envahi ainsi que le montre notre série de 34 opérés dont le taux de mortalité a été de 3%. L'examen histologique extemporané de la zone réséquée lors de l'intervention fait partie intégrante de celle-ci. En ce qui concerne la prévention des métastases à distance, la technique no touch de Turnbull doit être appliquée. Dans un essai prospectif randomisé concernant 236 malades opérés de cancer du colon, les métastases hépatiques sont apparues plus tardivement et à un taux plus faible chez les sujets opérés en suivant ce principe. Ce fait a été observé particulièrement lorsqu'il s'agissait d'un processus tumoral à envahissement vasculaire.

     

Can technical factors explain the volume-outcome relationship in gastric bypass surgery?

BackgroundThe existence of a relationship between surgeon volume and patient outcome has been reported for different complex surgical operations. This relationship has also been confirmed for patients undergoing Roux-en-Y gastric bypass (RYGB) in the Longitudinal Assessment of Bariatric Surgery (LABS) study. Despite multiple studies demonstrating volume-outcome relationships, fewer studies investigate the causes of this relationship.ObjectiveThe purpose of the present study is to understand possible explanations for the volume-outcome relationship in LABS.MethodsLABS includes a 10-center, prospective study examining 30-day outcomes after bariatric surgery. The relationship between surgeon annual RYGB volume and incidence of a composite endpoint (CE) has been published previously. Technical aspects of RYGB surgery were compared between high and low volume surgeons. The previously published model was adjusted for select technical factors.ResultsHigh-volume surgeons (>100 RYGBs/yr) were more likely to perform a linear stapled gastrojejunostomy, use fibrin sealant, and place a drain at the gastrojejunostomy compared with low-volume surgeons (<25 RYGBs/yr), and less likely to perform an intraoperative leak test. After adjusting for the newly identified technical factors, the relative risk of CE was .93 per 10 RYGB/yr increase in volume, compared with .90 for clinical risk adjustment alone.ConclusionHigh-volume surgeons exhibited certain differences in technique compared with low-volume surgeons. After adjusting for these differences, the strength of the volume-outcome relationship previously found was reduced only slightly, suggesting that other factors are also involved.     

Laparoscopic bariatric surgery: what else are we uncovering? Liver pathology and preoperative indicators of advanced liver disease in morbidly obese patients

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the US, and obesity is the most common cause of NAFLD. Obesity and NAFLD are associated with hyperlipidemia, type 2 diabetes, and hypertension, all components of the metabolic syndrome. The purpose of this study was to examine the incidence of NAFLD among morbidly obese patients undergoing bariatric surgery and to determine if advanced liver disease can be predicted by demographics, comorbidities, and/or preoperative biochemical profiles. 135 nonconsecutive patients (109 female, average age 46) with mean body mass index (BMI) 50 (SD 7.6) who underwent liver biopsies during bariatric surgery were studied. Patient data including age, BMI, comorbidities, and preoperative liver function tests were analyzed against liver biopsy pathology. 86% of patients had abnormal liver biopsy results. 60% of patients had steatosis, and 27% had advanced liver disease (7% steatohepatitis, 16% fibrosis, and 4% cirrhosis). Patients were grouped according to liver biopsy pathology. Group A included patients with normal results and steatosis only. Group B included those patients with advanced liver disease:steatohepatitis, fibrosis, and cirrhosis. Of 37 patients in group B, 27% had abnormal preoperative liver function tests (LFTs) compared to 10% of patients in group A (p = 0.022). Patients in group B were more likely to have preoperative hyperlipidemia (p = 0.020) and were also found to have a significantly higher BMI (p = 0.042). Diabetes mellitus, male gender, and age were not predictive of advanced liver disease on liver biopsy, with p = 0.056, p = 0.074, p = 0.26, respectively. Liver disease is common in the morbidly obese. More than one quarter of morbidly obese patients undergoing bariatric surgery have advanced liver disease. Patients with increased preoperative LFTs, hyperlipidemia, and increased BMI are more likely to have non-alcoholic steatohepatitis, fibrosis, or cirrhosis on liver biopsy during weight loss surgery. Diabetes, male gender, and age did not predict advanced liver disease.     

Does high sensitive CRP improve cardiovascular risk prediction in metabolic syndrome among the aged?

Abstract

Objectives. To analyze whether an elevated level of high hsCRP has an additive effect on metabolic syndrome (MetS) in predicting future cardiovascular events (CVEs) as well as on all-cause mortality among the aged subjects. Design. A prospective, population-based study with a 9-year follow-up. The study population consisted of persons aged 64 and above in 1998–99 without vascular disease and CRP less than 10 mg/l at baseline (n = 733). Adjusted hazard ratios (HRs) and their 95% confidence intervals (CIs) for CVEs and all-cause mortality predicted by baseline MetS (defined by both International Diabetes Federation (IDF) and World Health Organization (WHO)) and hsCRP-level were estimated. Results. During the 9-year follow-up, a total of 142 CVEs and 206 deaths occurred. After multivariable adjustment, no significant interactions were found between hsCRP and MetS in CVEs (IDF: p = 0.828; WHO: p = 0.572) or in all-cause mortality (IDF: p = 0.113; WHO: p = 0.374). HsCRP was not associated with the occurrence of CVEs (IDF: HR = 1.10, 95% CI = 0.92–1.32, p = 0.281; WHO: HR = 1.10, 95% CI = 0.93–1.32, p = 0.247) or with all-cause mortality (IDF: HR = 1.12, 95% CI = 0.97–1.29, p = 0.134; WHO: HR = 1.11, 95% CI = 0.96–1.28, p = 0.146). Conclusions. It seems that hsCRP does not give any extra value in evaluation of CVE risk or all-cause mortality of older subjects with MetS.     

Can failed back surgery be prevented? Psychological risk factors for postoperative pain after back surgery

Aside from the surgical technique used, the development of peri- and postoperative pain and impairments in patients following intervertebral disk surgery is also determined to a crucial extent by psychological factors. Based on a systematic literature review, we checked whether evidence-based recommendations could be deduced on how to take into account psychological risk factors in back surgery in order to avoid postoperative complications, such as failed back surgery syndrome. The current state of research suggests three groups of risk factors: (1) negative psychological factors, (2) preexisting pain chronification, and (3) psychological disorders. In the case of elective intervertebral disk surgery, these factors should therefore be determined and identified preoperatively and taken into account in the indication for surgery. Multimodal treatments could conceivably prove to be more effective, or else psychological pain management therapy might be considered prior to surgery so as to avoid postoperative complications. If surgery is medically unavoidable despite existing risk factors, postoperative treatment should incorporate psychological pain management therapy at an early stage in the context of a multidisciplinary approach.     

Perioperative risk factors for 30-day mortality after bariatric surgery: is functional status important?

Background

Although the mortality from bariatric surgery is low, perioperative determinants of morbidity and mortality in the bariatric surgery population to date have not been fully defined. This study aimed to evaluate the factors capable of predicting perioperative mortality based on preoperative characteristics with a national patient sample.

Methods

From the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, all the primary bariatric procedures performed between 2007 and 2009 were identified. Using univariate analysis, factors associated with increased perioperative (30-day) mortality were identified. Logistic regression was used to select correlates of 30-day mortality, which were subsequently integrated into a simplified clinical scoring system based on the number of comorbid risk factors.

Results

The study identified 44,408 patients (79 % women, 21 % men) with a mean age of 45 ± 11 years. The cumulative 30-day perioperative mortality rate was 0.14 %. The majority of the procedures performed included laparoscopic gastric bypass (54 %) followed by laparoscopic gastric banding (33 %) and open gastric bypass (7 %). Independent predictors associated with significantly increased mortality included age >45 years [adjusted odds ratio (AOR), 2.45], male gender (AOR = 1.77), a body mass index (BMI) of 50 kg/m² or higher (AOR, 2.48), open bariatric procedures (AOR, 2.34), diabetes (AOR, 2.88), functional status of total dependency before surgery (AOR, 27.6), prior coronary intervention (AOR, 2.66), dyspnea at preoperative evaluation (AOR, 4.64), more than 10 % unintentional weight loss in 6 months (AOR, 13.5), and bleeding disorder (AOR, 2.63). Ethnicity, hypertension, alcohol abuse, liver disease, and smoking had no significant association with mortality in this study. Risk stratification based on the number of preoperative comorbid factors showed an exponential increase in mortality as follows: 0–1 comorbidities (0.03 %), 2–3 comorbidities (0.16 %), and 4 comorbidities or more (7.4 %).

Conclusion

This model provides a straightforward, precise, and easily applicable tool for identifying bariatric patients at low, intermediate, and high risk for in-hospital mortality. Notably, baseline functional status before surgery is the single most powerful predictor of perioperative survival and should be incorporated into risk stratification models.