Derangement of esophageal anatomy and motility in morbidly obese patients: a prospective study based on high-resolution impedance manometry

BackgroundMorbidly obese patients often suffer from gastroesophageal reflux disease (GERD). High-resolution impedance manometry (HRIM) allows a comprehensive evaluation of esophageal motility and esophagogastric junction (EGJ) morphology and helps to clarify GERD pathophysiology.ObjectiveTo evaluate the esophageal function and EGJ anatomy in morbid obesity by HRIM.SettingUniversity Hospital, Taiwan.MethodsWe consecutively enrolled 57 morbidly obese patients planning to undergo bariatric surgery and 58 healthy volunteers in this prospective study. All patients responded to validated symptom questionnaires and underwent fasting blood tests, HRIM, and esophagogastroduodenoscopy. We compared anthropometric and HRIM parameters between the 2 groups, and analyzed correlations between the GERD symptom scores and clinical variables in the obese patients.ResultsThe obese patients, comprising 30 males (53%), had a median age of 35 years and body mass index of 40.5 kg/m². The 4-second integrated relaxation pressure in the lower esophageal sphincter was significantly higher in the patients than the volunteers (median: 10.8 versus 5.6 mm Hg; P < .001). EGJ outflow obstruction and ineffective esophageal motility were diagnosed in 16% and 11% of the patients, respectively, versus 5% and 28% of the volunteers (P = .022). Manometric hiatal hernia (m-HH) was present in 19 (33%) of the patients and none of the volunteers; all m-HH were associated with erosive esophagitis. Most of the patients were considered as no GERD by the validated questionnaires, regardless of the presence of m-HH and erosive esophagitis.ConclusionsThe obese patients had a higher lower esophageal sphincter 4-second integrated relaxation pressure and higher prevalence of EGJ outflow obstruction and m-HH than the healthy volunteers. The presence of m-HH was strongly associated with erosive esophagitis. The absence of GERD symptoms in morbid obesity was not necessarily suggestive of negative esophagogastroduodenoscopy and HRIM findings, and the discrepancy existed between esophagogastroduodenoscopy and HRIM for diagnosing HH. A comprehensive evaluation of the EGJ anatomy and esophageal function may be considered before bariatric surgery.     

Association between preoperative serum albumin levels with risk of death and postoperative complications after bariatric surgery: a retrospective cohort study

BackgroundHypoalbuminemia is common among individuals with obesity who qualify for bariatric surgery, but its relevance to clinical outcomes after bariatric surgery remains to be established.ObjectivesTo examine the association of preoperative serum albumin with 30-day postoperative outcomes.SettingData from the 2015–2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files were used.MethodsPreoperative serum albumin level was categorized as hypoalbuminemia (<3.5 g/dL), and normoalbuminemia (3.5–5.5 g/dL) among patients who underwent bariatric surgery. Multivariate logistic regression models were used to determine the association of preoperative hypoalbuminemia with 30-day postoperative mortality and other co-morbid outcomes.ResultsAmong 633,011 adult patients, 85.1% were women and the mean (standard deviation) age was 44.8 (12.0) years. The prevalence of hypoalbuminemia was 6.13% (n = 38,792). After adjustment for procedure type and demographic, lifestyle, and co-morbidity covariates, the odds ratio (OR) (95% confidence interval [CI]) for mortality was 1.42 (1.10, 1.82) for hypoalbuminemia. For all other outcomes, the ORs (95% CIs) for hypoalbuminemia ranged from 1.03 (.67–1.60) for cardiac arrest requiring CPR to 2.32 (1.66–3.25) for failure to be discharged by day 30. The ORs for several associations were higher for severe hypoalbuminemia than marginal hypoalbuminemia.ConclusionPreoperative hypoalbuminemia was associated with several negative 30-day postoperative bariatric surgery outcomes and tended to be worse for severe hypoalbuminemia compared with marginal hypoalbuminemia. These findings suggest that serum albumin may be a useful biomarker to screen for negative bariatric surgery outcomes.     

Preoperative immobility significantly impacts the risk of postoperative complications in bariatric surgery patients

Background

Preoperative immobility in general surgery patients has been associated with an increased risk of postoperative complications. It is unknown if immobility affects bariatric surgery outcomes.

Change in gastrointestinal symptoms over the first 5 years after bariatric surgery in a multicenter cohort of adolescents

BackgroundRoux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) are effective for weight loss in adolescents with severe obesity. However, little is known about adverse gastrointestinal symptoms (GIS) following these operations in adolescents. The objective was to examine GIS over 5 years after surgery and differences by surgery type.MethodsWe prospectively studied 228 adolescents (161 RYGB, 67 VSG) undergoing bariatric surgery. Gastrointestinal symptoms were assessed before surgery, at 6-months, and yearly to 5 years after surgery. Symptom severity was dichotomized for analysis. Analysis of post-surgery symptoms involved linear models adjusting for baseline symptoms, BMI, early post-operative complication, sex, and race.ResultsParticipants at surgery were 17 ± 1.6 years with preoperative BMI 53 ± 9.4 kg/m². From 6 months to 5 years, gastroesophageal reflux symptoms (GERS), nausea, bloating, and diarrhea increased. Crude prevalence rates of GERS increased from 4% (1% RYGB, 11% VSG) at 6-months post-surgery to 14% (10% RYGB, 26% VSG) at 5-years. In adjusted analyses, the VSG group experienced 4-fold (4.85 95% CI 2.63, 8.91, p < 0.0001) greater odds of GERS compared to RYGB.ConclusionsAdolescents who underwent VSG experienced greater risk of GERS compared to those undergoing RYGB. Adolescents undergoing VSG should be counseled preoperatively about GERS and objectively monitored postoperatively for gastroesophageal reflux when indicated.Clinical trial registrationClinicalTrials.gov, Identifier: NCT00474318, https://clinicaltrials.gov/ct2/show/NCT00474318?term=Teen-LABS&rank=1.Type of StudyTreatment Study.Level of EvidenceLevel II.     

The effect of bariatric surgery on opioid consumption in patients with obesity: a registry-based cohort study

BackgroundMisuse of opioid medication has become a major health crisis in several countries. A significant number of patients with obesity use opioid medications, mostly to alleviate symptoms due to obesity-related co-morbidities.ObjectiveTo compare patterns of opioid drug usage before and after bariatric surgery in this population, hypothesizing that weight loss and improvement of obesity-related co-morbidities could reduce opioid consumption.SettingThe Ontario Bariatric Registry (Ontario, Canada).MethodsIn this retrospective cohort study, the Ontario Bariatric Registry was used to compare opioid consumption in adult patients undergoing bariatric surgery between 2010 and 2021. The primary outcome was the number of patients using opioid medication at 1 year after surgery. Multiple logistic regression analyses were performed to identify potential predictors of opioid consumption.ResultsData of 11,179 patients were analyzed. Mean age was 45.7 ± 10.2 years, mean baseline body mass index was 48.9 ± 8 kg/m², and 83.6% of patients were female. Roux-en-Y gastric bypass was performed in the majority of patients (85.6%), followed by sleeve gastrectomy (14.2%). At baseline, opioids were used by 7.7% and nonopioid pain medications by 42.3% of patients. At 1 year after surgery, these numbers significantly decreased (Δ–1.9% and Δ–18.0%, respectively). The decrease in the consumption of nonopioid pain medication needs to be interpreted in the context of the contraindication to nonsteroidal anti-inflammatory drugs after Roux-en-Y gastric bypass, which was the most commonly performed procedure. Presence of musculoskeletal pain and use of nonopioid pain medication at baseline were identified as independent predictors of opioid consumption at 1 year after surgery.ConclusionsAt 1 year after bariatric surgery, a significant decrease in opioid and nonopioid pain medication consumption was seen among patients with obesity. Aggressive management of excess weight, especially with bariatric surgery, can potentially reduce the impact of the opioid crisis in this population.     

Intraoperative lidocaine infusion and 24-hour postoperative opioid consumption in obese patients undergoing laparoscopic bariatric surgery

BackgroundBariatric surgery is the most effective long-term treatment for obesity. Opioid-sparing anesthesia and multimodal analgesia such as lidocaine infusion have been recommended in these patients to reduce opioid-related complications. However, evidence supporting its use for bariatric surgery population is limited.ObjectiveTo investigate whether intraoperative lidocaine infusion is associated with decreasing opioid consumption in laparoscopic bariatric surgery.SettingA university hospital, California, USA.MethodsIn this retrospective cohort study, outcomes among consecutive obese patients undergoing laparoscopic bariatric surgery between January 2016 to December 2018 were evaluated to determine the impact of adjunctive intraoperative lidocaine infusion on 24-hour postoperative opioid consumption. Secondary outcomes, including opioid consumption during hospitalization, length of stay, and postoperative complications were determined. Post hoc analyses were performed exploring possible dose effects and drug-drug interactions. Univariable and multivariable analyses were performed to identify factors associated with opioid consumption.ResultsAmong 345 patients, 54 (15.7%) received intraoperative lidocaine infusion (L+) whereas 291 (84.3%) did not receive intraoperative lidocaine infusion (L−). Both L+ and L− groups shared similar demographic characteristics. The 24-hour postoperative opioid consumption was 17.6% lower in L+ (95% confidence interval −28.4 to −5.2, P = .007), but nonsignificantly lower in the multivariate model (12.8%, 95% confidence interval −24.4 to .5, P = .06). Opioid consumption during hospitalization, length of stay, and other clinically significant outcomes did not differ. However, subgroup analysis restricted to opioid-naïve patients indicated significantly reduced opioid consumption in the L+ group. Post hoc analysis suggested interaction between lidocaine and ketamine in decreasing 24-hour postoperative opioid consumption.ConclusionsIntraoperative lidocaine infusion was not significantly associated with decreasing 24-hour postoperative opioid consumption in obese patients undergoing laparoscopic bariatric surgery.     

Comments on: Preoperative upper gastrointestinal endoscopy in obese patients undergoing bariatric surgery: is it necessary?

BACKGROUND: Obesity has been shown to be an important risk factor for several gastrointestinal diseases. However, the indication for preoperative upper gastrointestinal endoscopy (UGE) for all patients before bariatric surgery is controversial. The aim of the present study was to evaluate the spectrum of gastrointestinal diseases detected during preoperative UGE in patients undergoing bariatric surgery and the relevance of this procedure. METHODS: A series of severely obese patients, who had undergone UGE before Roux-en-Y gastric bypass from October 2004 to May 2005 were consecutively enrolled in this study. The demographic and clinical data and endoscopic diagnoses were evaluated. Gastric biopsies were performed in elective patients according to the endoscopic findings. RESULTS: The study included 162 patients, 69.8% of whom were women. The mean age was 36.7 +/- 10.8 years. Abnormal findings were observed in 77.2% of patients. Esophagitis was present in 38.9%, gastritis in 51.2% (erosive gastritis in 49.3% and nonerosive gastritis in 50.7%), gastric ulcers in 1.9%, hiatal hernia, in 8.6%, gastric polyp in .6%, and duodenitis in 6.8% of patients. No patient had esophageal or gastric varices. Helicobacter pylori infection was investigated in 96 patients and was detected in 37.5%. Gastric biopsies were performed in 36 patients, with chronic inflammation found in 72.2%, inflammatory activity in 30.6%, and intestinal metaplasia in 11.1%. Glandular atrophy was not found in any patient. CONCLUSION: The results of our study have shown that the spectrum of gastrointestinal diseases observed in severely obese patients who underwent bariatric surgery is broad. Although this issue remains highly controversial, these findings suggest that systematic preoperative UGE and H. pylori testing should be performed in all patients scheduled to undergo bariatric surgery.     

Influence of Helicobacter pylori infection on gastrointestinal symptoms and complications in bariatric surgery patients: a review and meta-analysis

Background

Numerous papers have discussed the importance of preoperative detection and eradication of Helicobacter pylori (HP) in bariatric patients.

Relationship between bariatric surgery outcomes and the preoperative gastrointestinal microbiota: a cohort study

BackgroundThe composition of the gastrointestinal microbiota is associated with obesity. We hypothesized that the gut microbiota influences the outcomes of bariatric surgery.ObjectivesWe aimed to analyze using oral swabs and stool samples the microbiota of patients with morbid obesity who were undergoing laparoscopic sleeve gastrectomy (SG).SettingA university hospital in Poland.MethodsThis prospective cohort study was conducted between November 2018 and June 2019. Participants underwent SG or no surgery (controls). Results were then analyzed as a group 1 (surgical participants who achieved a percentage of excess weight loss [%EWL] >50%), group 2 (surgical participants who achieved a %EWL <50%), and group 3 (nonsurgical controls). %EWL was measured 6 months following surgery. Before surgery, oral swabs were obtained and stool samples were provided. The endpoint was the composition of the gut microbiota.ResultsGroup 1 comprised 19 participants, group 2 comprised 11 participants, and group 3 comprised 16 participants. No participants were lost to follow-up during the study. Participants in group 1 had an oral microbiota that was enriched in the phyla Proteobacteria, and Bacteroidetes. Their intestinal microbiota was enriched in the Proteobacteria. In contrast, the oral microbiota of group 2 was enriched in the Actinobacteria and the intestinal microbiota was enriched in the phyla Bacteroidetes and Firmicutes.ConclusionsThe compositions of the microbiota of the oral cavity and large intestine are related to the weight loss achieved following SG.     

Association between attention deficit hyperactivity disorder and outcomes after metabolic and bariatric surgery: a nationwide propensity-matched cohort study

BackgroundThe risks and benefits of metabolic and bariatric surgery for patients with attention deficit hyperactivity disorder (ADHD) remain to be investigated.ObjectiveThe aim of this study was to assess short- and long-term outcomes after metabolic and bariatric surgery in patients with previous ADHD compared with matched control individuals.SettingRegistry based.MethodsThis 2-staged matched-cohort study included all adults with a body mass index of ≥30 kg/m² who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy from 2007 until 2017 registered in the Scandinavian Obesity Surgery Registry. Patients with prescribed medication for ADHD were matched with control individuals without ADHD with a follow-up of up to 11 years after surgery.ResultsAmong 1431 patients with ADHD and 2862 control individuals (mean body mass index, 42 kg/m²; mean age, 35 years), no difference in weight loss or follow-up attendance over 2 years was seen. ADHD was associated with a higher risk for early postoperative complications (odds ratio [OR] = 1.31; 95% confidence interval [CI], 1.05–1.63), self-harm (hazards ratio [HR] = 1.39; 95% CI, 1.11–1.75), and substance abuse (HR = 1.34; 95% CI, 1.16–1.55), while associations with overall mortality (HR = 1.42; 95% CI, .99–2.03), major adverse cardiovascular and cerebrovascular events (HR = 1.93; 95% CI, .98–3.83), and effects on obesity-related diseases were uncertain. ADHD was associated with a lower health-related quality of life in all aspects before surgery. These differences increased for mental and obesity-related aspects but remained unchanged over time for physical aspects.ConclusionsCompared with patients without ADHD, patients treated pharmacologically for ADHD experience similar weight loss and remission of obesity-related diseases without an increased risk for serious complications but report a lower health-related quality of life and have an increased risk of substance abuse and self-harm. This further emphasizes the need for close follow-up care for this group of individuals     

极度肥胖合并阻塞性睡眠呼吸暂停患者减重代谢手术围术期管理流程

在拟行减重代谢手术（MBS）的肥胖患者尤其是极度肥胖患者（体质量指数≥50 kg/m²）中,阻塞性睡眠呼吸暂停（OSA）最常见、最危重的合并症之一,在减重人群中发病率高达35.0%~93.6%。MBS是唯一能够长期有效治疗极度肥胖同时缓解OSA病情的治疗手段,但OSA也会显著增加MBS围术期呼吸、心血管系统并发症发生率和病死率。为降低MBS围术期风险,针对OSA的围术期管理关键措施在于应在多学科诊治（MDT）基础上及时准确诊断和评估OSA,将OSA的诊疗和监测融入MBS围术期管理流程,规范个性化的精准治疗。本文结合相关文献和笔者单位临床经验,从术前、术中和术后管理三个方面介绍极度肥胖合并OSA的围术期管理流程,为精准评估最有效、安全的治疗方案提供线索和意见。     

Vitamin K1 monitoring in pregnancies after bariatric surgery: a prospective cohort study

BackgroundNeonatal intracranial bleedings and birth defects have been reported, possibly related to maternal vitamin K1 deficiency during pregnancy after bariatric surgery. The objective of this study was to investigate the effects of screening and supplementation on K1 serum levels in pregnant women with bariatric surgery, and to compare K1 levels and prothrombin time (PT %) in the first trimester with pregnant women without bariatric surgery.MethodsA prospective cohort study including 49 pregnant women with bariatric surgery. Nutritional deficiencies were prospectively screened. In case of observed low K1 serum levels, supplementation was provided. K1 serum levels and PT (%) during the first trimester were compared with a nonsurgical control group of 27 women.ResultsDuring the first trimester, most women had low K1 serum levels (<0.8 nmol/l). Mean vitamin K1 levels were significantly lower in the surgical group compared to the nonsurgical control group (.44 versus .64 nmol/l; P = .016). PT (%) remained in the normal range, The surgery group showed a higher mean PT compared to the controls (111.3 versus 98.9%; P<.001) Mean K1 serum levels in the study group were higher during the third than during the first trimester (P = .014). PT (%) was significantly higher during the second and third than during the first trimester (P = .004). Most of the coagulation factors, including II, V, VII, IX, and X, remained within normal ranges.ConclusionLow circulating K1 appears to be common in pregnant women with and without bariatric surgery. Supplementation during pregnancy can restore vitamin K1 in women with bariatric surgery, potentially protecting the fetus and newborn against intracranial hemorrhage.     

Obstructive sleep apnea remission following bariatric surgery: a national registry cohort study

BackgroundObstructive sleep apnea (OSA) is strongly associated with metabolic syndrome. Bariatric surgery is an effective available treatment for OSA; however, limited research predicts which patients undergoing bariatric surgery will undergo OSA resolution.ObjectivesTo determine perioperative predictors for OSA resolution following bariatric surgery using a national database.SettingUnited Kingdom national bariatric surgery database.MethodsThe UK National Bariatric Surgery Registry (NBSR) was interrogated to identify all patients with OSA that underwent primary bariatric surgery between January 2009 and June 2017. Those with at least 1 follow-up recording postoperative OSA status were selected for further analysis. Demographic, pre- and postoperative outcomes were collected and analyzed. Poisson multivariate regression was conducted to identify predictors of OSA remission.ResultsA total of 4015 bariatric cases were eligible for inclusion: 2482 (61.8%) patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), 1196 (29.8%) sleeve gastrectomy (LSG), and 337 (8.4%) adjustable gastric banding (LAGB). Overall, the mean excess weight loss (EWL) % for the whole group was 61.2 (SD ± 27.2). OSA resolution was recorded in 2377 (59.2%) patients. Following Poisson regression, LRYGB (risk ratio [RR], 1.49 confidence interval [CI] 1.25–1.78) and LSG (RR, 1.46 [CI 1.22–1.75] were associated with approximately 50% increased likelihood of OSA remission compared with LAGB. Greater weight loss following intervention was associated with greater likelihood of OSA remission, while both greater age and greater preoperative body mass index (BMI) were associated with reduced likelihood of OSA remission (P < .001).ConclusionThis study demonstrated that metabolic surgery results in OSA remission in the majority of patients with obesity. Younger age, lower BMI preprocedure, greater %EWL and the use of LSG or LRYGB positively predicted OSA remission.     

Medical management of patients after bariatric surgery: Principles and guidelines

Obesity is a major and growing health care concern. Large epidemiologic studies that evaluated the relationship between obesity and mortality, observed that a higher body-mass index(BMI) is associated with increased rate of death from several causes, among them cardiovascular disease; which is particularly true for those with morbid obesity. Being overweight was also associated with decreased survival in several studies. Unfortunately, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. All obese patients(BMI ≥ 30 kg/m2) should receive counseling on diet, lifestyle, exercise and goals for weight management. Individuals with BMI ≥ 40 kg/m2 and those with BMI 35 kg/m2 with obesity-related comorbidities; who failed diet, exercise, and drug therapy, should be considered for bariatric surgery. In current review article, we will shed light on important medical principles that each surgeon/gastroenterologist needs to know about bariatric surgical procedure, with special concern to the early post operative period. Additionally, we will explain the common complications that usually follow bariatric surgery and elucidate medical guidelines in their management. For the first 24 h after the bariatric surgery, the postoperative priorities include pain management, leakage, nausea and vomiting, intravenous fluid management, pulmonary hygiene, and ambulation. Patients maintain a low calorie liquid diet for the first few postoperative days that is gradually changed to soft solid food diet within two or three weeks following the bariatric surgery. Later, patients should be monitored for postoperative complications. Hypertension, diabetes, dumping syndrome, gastrointestinal and psychosomatic disorders are among the most important medical conditions discussed in this review.     

Outcomes with direct-acting oral anticoagulants in patients with a history of bariatric surgery: a retrospective cohort study

BackgroundPatients who undergo bariatric surgery have major physiologic changes in their gastrointestinal tract, which can theoretically alter drug absorption and pharmacokinetics. This is especially concerning for drugs with a narrow therapeutic index, as small changes in absorption can have significant effects on safety and efficacy. One class of interest is direct-acting oral anticoagulants (DOACs), for which there is a paucity of data in this population.ObjectiveTo characterize the use of DOACs (apixaban, dabigatran, rivaroxaban) in patients with a history of bariatric surgery and incidence of clotting and bleeding events.SettingPublic healthcare system/university hospital, United States.MethodsThis retrospective cohort study included adult patients who were prescribed a DOAC for the prophylaxis or treatment of venous thromboembolism or for stroke and systemic embolism prevention in atrial fibrillation between January 2011 and December 2018.ResultsA total of 191 patients with a history of bariatric surgery were included. Clotting events occurred in 11 of 191 patients (5.8%) receiving DOAC therapy, with a calculated clotting rate of 3.9 clots per 100 person-years. Bleeding events occurred in 42 of 191 patients (22%) receiving a DOAC, with a calculated bleeding rate of 17.1 bleeds per 100 person-years. The use of rivaroxaban versus apixaban was associated with a statistically significant increased risk of bleeding in patients with a history of bariatric surgery.ConclusionIn this retrospective cohort of bariatric surgery patients receiving DOACs, we found clotting rates consistent with expected rates and bleeding rates above expected rates based on historical data. We also found an increased risk of bleeding in rivaroxaban users compared with apixaban users. Careful evaluation of bleeding risks in bariatric surgery patients is encouraged.     

个体化呼气末正压通气对肥胖患者腹腔镜胃减容术后肺部并发症的影响

目的 研究个体化呼气末正压（PEEP）通气策略对肥胖患者腹腔镜胃减容术后肺部并发症（PPCs）的影响。
方法 选择行全身麻醉腹腔镜胃减容术的成年肥胖患者40例,男15例,女25例,年龄18～44岁,BMI 35～55 kg/m²,ASA Ⅱ或Ⅲ级。采用随机数字表法分为两组：个体化PEEP组（I组）和固定PEEP组（C组）,每组20例。I组在诱导插管后依据肺动态顺应性（Cdyn）个体化滴定最佳PEEP并维持此PEEP进行术中通气,C组以PEEP 8 cmH2O进行术中通气。记录插管后5 min、气腹后1 h的氧合指数、分流率以及气道峰压、气道平台压、驱动压、Cdyn等呼吸力学参数,记录术中低血压发生情况、输液量、血管活性药用量、机械通气时间和术后住院时间,记录术后第1天、第2天、第3天、第8天PPCs的发生情况以及术后8 d内PPCs累积发生率。
结果 I组PPCs累积发生率明显低于C组 ［13例（65%） vs 19例（95%）, P＜0.05］。气腹后1 h 时I组氧合指数、气道峰压、气道平台压、Cdyn均明显高于C组（P<0.05）,I组驱动压明显低于C组（P<0.05）。两组术中低血压发生率、输液量、去氧肾上腺素用量、机械通气时间和术后住院时间差异无统计学意义。
结论 个体化PEEP能够降低腹腔镜胃减容术患者PPCs发生率,并在不影响血流动力学稳定性的同时降低术中驱动压,改善氧合。     

术后加速康复策略对全身麻醉下减重手术患者术后恢复的影响

目的 分析术后加速康复(enhanced recovery after surgery,ERAS)策略的实施对病态 肥胖症患者行全身麻醉下减重手术术后恢复的影响.方法 北京协和医院自2012年1月以来在减重手术患者中推行ERAS策略,改变围术期管理方法.收集ERAS策略实施以来接受减重手术患者的围术期资料及住院费用信息,按照ERAS策略实施与否将患者分为ERAS组和非ERAS组,与ERAS实施前对比并作统计学分析.结果 共45例患者纳入研究,1例因术后并发症非计划入ICU治疗,住院时间及费用增加.无并发症的44例中,ERAS组患者的手术时间明显缩短(P＜0.05),术后计划带气管导管返ICU患者明显减少(P＜0.05),住院费用明显降低(P＜0.05).结论 在减重手术患者中推行ERAS策略后,患者的ICU住院比例降低,住院费用减少.     

The incidence and determinants of bariatric reoperations: a population-based cohort study

BackgroundBariatric surgery is the strongest evidence-based treatment available for obesity, but the long-term morbidity and durability of these procedures is being increasingly scrutinized.ObjectiveTo report the incidence, timing, indications, and risk factors for bariatric reoperations.SettingA state-wide, multicenter, retrospective study.MethodsUsing the Western Australian Department of Health Data Linkage Unit, all patients undergoing an index bariatric procedure where identified across a 10-year period (2007–2016).ResultsOf 24,766 patients who underwent bariatric surgery, 5001 patients (20.2%) required at least 1 bariatric reoperation. The 5-yearly rates were 19.6% (95% confidence interval [CI], 19.0%–20.2%) for a first revision, 58.2% (95%CI, 56.6%–59.8%) for a subsequent second revision, 38.3% (95%CI, 35.4%–41.2%) for a subsequent third revision, and 45.2% (95%CI, 39.9%–50.5%) for a subsequent fourth revision. Surgical complications (67.4%) were the main indication for any bariatric reoperation ahead of weight-related causes (32.6%). In a Cox regression analysis, being younger, female, without private health insurance, and having a gastric band as the initial bariatric procedure were all significant risk factors for bariatric reoperations. Compared with bariatric patients needing only an index procedure, patients requiring bariatric reoperations also had higher postoperative incidence rate ratios of endoscopic (incidence rate ratio 2.4; 95%CI, 2.3–2.5) and body contouring (incidence rate ratio 3.8; 95%CI, 3.5–4.1) procedures.ConclusionsPatients undergoing bariatric surgery had a high incidence of bariatric reoperations, predominantly for surgical complications. Of those patients who required bariatric reoperations, there were additional high rates of recurrent bariatric surgery, postoperative endoscopy, and body contouring procedures.     

Preoperative cardiac screening using NT-proBNP in obese patients 50 years and older undergoing bariatric surgery: a study of 310 consecutive patients

BackgroundObesity is associated with cardiovascular (CV) risk factors and diseases. Because bariatric surgery is increasingly performed in relatively elderly patients, a risk for pre- and postoperative CV complications exists.ObjectivesWe aimed to assess the value of plasma N-terminal-probrain natriuretic peptide (NT-proBNP) as a CV screening tool.SettingHigh-volume bariatric center.MethodsBetween June 2019 and January 2020, all consecutive bariatric patients 50 years and older underwent preoperative NT-proBNP assessment in this cohort study to screen for CV disease. Patients with elevated NT-proBNP (≥125 pg/mL) were referred for further cardiac evaluation, including electrocardiography and echocardiography.ResultsWe included 310 consecutive patients (median age, 56 years; 79% female; body mass index = 43±6.5 kg/m²). A history of CV disease was present in 21% of patients, mainly atrial fibrillation (7%) and coronary artery disease (10%). A total of 72 patients (23%) had elevated NT-proBNP levels, and 67 of them underwent further cardiac workup. Of these 67 patients, electrocardiography (ECG) showed atrial fibrillation in 7 patients (10%). On echocardiography, 3 patients had left ventricular ejection fraction (LVEF) <40%, 9 patients had LVEF 40%–49%, and 13 patients had LVEF ≥50% with structural and/or functional remodeling. In 2 patients, elevated NT-proBNP prompted workup leading to a diagnosis of coronary artery disease and consequent percutaneous coronary intervention in 1 patient.ConclusionsElevated NT-proBNP levels are present in 23% of patients 50 years and older undergoing bariatric surgery. In 37% of them, there was echocardiographic evidence for structural and/or functional remodeling. Further studies are needed to assess if these preliminary results warrant routine application of NT-proBNP to identify patients at risk for CV complications after bariatric surgery.