Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy.

BACKGROUND: Longstanding morbid obesity can be associated with severe cardiomyopathy. However, the safety and efficacy of bariatric surgery in patients with severe cardiomyopathy has not been studied, and the effect of surgical weight loss on postoperative cardiac function is also unknown. In addition, morbidly obese patients have significantly increased mortality associated with cardiac transplantation, often precluding them from becoming recipients. METHODS: A retrospective study of patients with a left ventricular ejection fraction < or =35% who underwent bariatric surgery (1998-2005) was performed. Short-term morbidity/mortality, length of stay, excess weight loss, pre- and postoperative left ventricular ejection fraction, and New York Heart Association (NYHA) functional class were assessed. RESULTS: A total of 14 patients (10 men and 4 women) with a mean preoperative body mass index of 50.8 +/- 2.04 kg/m(2) underwent bariatric surgery (10 underwent laparoscopic Roux-en-Y gastric bypass, 1 open Roux-en-Y gastric bypass, 2 sleeve gastrectomy, and 1 laparoscopic gastric banding). The complications were pulmonary edema in 1, hypotension in 1, and transient renal insufficiency in 2. The median length of stay was 3.0 days (range 2-9). The mean excess weight loss at 6 months was 50.4%, with a decrease in the mean body mass index from 50.8 +/- 2.04 kg/m(2) to 36.8 +/- 1.72 kg/m(2). The mean left ventricular ejection fraction at 6 months had significantly improved from 23% +/- 2% to 32% +/- 4% (P = .04), correlating with improved functional capacity, as measured by the NYHA classification. Preoperatively, 2 patients (14%) had an NYHA classification of IV, 6 (43%) a classification of III, and 6 (43%) a classification of II. At 6 months postoperatively, no patient had an NYHA classification of IV, 2 (14%) had a classification of III, and 12 (86%) an NYHA classification of II. Two patients had undergone cardiac transplant evaluations preoperatively and underwent successful transplantation after weight loss. CONCLUSION: The results of our study have shown that bariatric surgery for patients with cardiomyopathy is feasible and effective. Surgically induced weight loss results in both subjective and objective improvement in cardiac function. In addition, surgical weight loss can provide a bridge to transplantation in patients who were prohibited secondary to their morbid obesity.     

Bariatric surgery in patients with liver cirrhosis

BackgroundData regarding the management of bariatric patients with cirrhosis are scarce, and there is no strong evidence that supports a specific approach for this group of patients. The aim of this study was to review our experience with cirrhotic patients undergoing bariatric surgery.MethodsA prospectively maintained database was reviewed to assess the outcomes of bariatric surgery for patients with known cirrhosis and for patients with cirrhosis discovered at surgery (unknown cirrhosis).ResultsFrom April 2004 to September 2011, 23 patients (12 with known cirrhosis and 11 with unknown cirrhosis) met inclusion criteria. There were 14 females and 9 males with a mean age of 51.5±8.3 and a mean body mass index of 48.2±8.6 kg/m2. Child-Pugh classes were A (n = 22) and B (n = 1). Patients had a high frequency of diabetes (83%), dyslipidemia (61%), and hypertension (83%). Procedures performed were laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 14), laparoscopic sleeve gastrectomy (LSG) (n = 8), and laparoscopic adjustable gastric banding (n = 1). Two patients underwent LSG successfully after transjugular intrahepatic portosystemic shunt. Mean length of hospital stay was 4.3±2.7 days. Complications developed in 8 patients. One patient died of unknown cause 9 months after surgery. No patients had liver decompensation after surgery. The patients lost 67.4%±30.9% of their excess weight at 12 months follow-up and 67.7%±24.8% at 37 months follow-up.ConclusionLRYGB and LSG can be performed without prohibitive complication rates in carefully selected patients with cirrhosis. In our experience, bariatric patients with cirrhosis achieved excellent weight loss and improvement in obesity-related co-morbidities.     

Bariatric surgery in patients with pulmonary hypertension

Background

Data regarding the outcomes of bariatric surgery in patients with pulmonary hypertension (PH) is limited. The aim of this study was to review our experience on bariatric surgery in patients with PH.

Bariatric surgery in patients with previous COVID-19 infection

BackgroundThe process of reintroducing bariatric surgery to our communities in a COVID-19 environment was particular to each country. Furthermore, no clear recommendation was made for patients with a previous COVID-19 infection and a favorable outcome who were seeking bariatric surgery.ObjectivesTo analyze the risks of specific complications for patients with previous COVID-19 infection who were admitted for bariatric surgery.SettingEight high-volume private centers from 5 countries.MethodsAll patients with morbid obesity and previous COVID-19 infection admitted for bariatric surgery were included in the current study. Patients were enrolled from 8 centers and 5 countries, and their electronic health data were reviewed retrospectively. The primary outcome was to identify early (<30 d) specific complications related to COVID-19 infection following bariatric surgery, and the secondary outcome was to analyze additional factors from work-ups that could prevent complications.ResultsThirty-five patients with a mean age of 40 years (range, 21–68 yr) and a mean body mass index of 44.3 kg/m² (±7.4 kg/m²) with previous COVID-19 infection underwent different bariatric procedures: 23 cases of sleeve (65.7 %), 7 cases of bypass, and 5 other cases. The symptomatology of the previous COVID-19 infection varied: 15 patients had no symptoms, 12 had fever and respiratory signs, 5 had only fever, 2 had digestive symptoms, and 1 had isolated respiratory signs. Only 5 patients (14.2 %) were hospitalized for COVID-19 infection, for a mean period of 8.8 days (range, 6–15 d). One patient was admitted to an intensive care unit and needed invasive mechanical ventilation. The mean interval time from COVID-19 infection to bariatric surgery was 11.3 weeks (3–34 wk). The mean hospital stay was 1.7 days (±1 d), and all patients were clinically evaluated 1 month following the bariatric procedure. There were 2 readmissions and 1 case of complication: that case was of a gastric leak treated with laparoscopic drainage and a repeated pigtail drain, with a favorable outcome. No cases of other specific complications or mortality were recorded.ConclusionMinor and moderate COVID-19 infections, especially the forms not complicated with invasive mechanical ventilation, should not preclude the indication for bariatric surgery. In our experience, a prior COVID-19 infection does not induce additional specific complications following bariatric surgery.     

Bariatric surgery in patients with obesity and end-stage renal disease

BackgroundBariatric surgery has been suggested as a treatment for obesity and end-stage renal disease (ESRD). Although the number of bariatric surgeries in patients with ESRD is increasing, its safety and effectiveness in these patients are still controversial and the surgical method of choice in these patients is under debate.ObjectivesTo compare the outcomes of bariatric surgery between patients with and without ESRD and to assess different methods of bariatric surgery in patients with ESRD.SettingMeta-analysis.MethodsA comprehensive search was conducted in Web of Science and Medline (via Pubmed) until May 2022. Tow meta-analyses were performed: A) to compare bariatric surgery outcomes among patients with and without ESRD, and B) to compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in patients with ESRD. Using a random-effect model, odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were computed for surgical and weight loss outcomes.ResultsOf 5895 articles, 6 studies were included in meta-analysis A and 8 studies in meta-analysis B. The risk of bias was moderate to serious among studies. Major postoperative complications (OR = 2.82; 95% CI = 1.66–4.77; P = .0001), reoperation (OR = 2.66; 95% CI = 1.99–3.56; P < .00001), readmission (OR = 2.37; 95% CI = 1.55–3.64; P < .0001), and in-hospital/90-d mortality (OR = 4.03; 95% CI = 1.80–9.03; P = .0007) were higher in patients with ESRD. Patients with ESRD also had a longer hospital stay (MD = 1.23; 95% CI = .32–2.14; P = .008). Bleeding, leakage, and total weight loss were comparable among groups. SG showed a 10% lower rate of overall complications and significantly shorter hospital stay than RYGB did. The quality of evidence was very low for the outcomesConclusionsBariatric surgery in patients with ESRD seems to have higher rates of major complications and perioperative mortality than in patients without ESRD, but a comparable rate of overall complications. SG has fewer postoperative complications and could be the method of choice in these patients. These findings should be interpreted cautiously in light of the moderate to high risk of bias in most included studies.     

Bariatric surgery

Bariatric surgery is a growing segment of minimally invasive surgery. Laparoscopic bariatric procedures are considered some of the most technically challenging surgeries, requiring advanced surgical skills. Successful care of the morbidly obese patient requires a multidisciplinary team approach. These unique requirements are difficult to meet during residency and surgeons interested in bariatric surgery should pursue fellowship training in bariatric surgery.     

Bariatric surgery

Obesity presents a growing public health crisis which has significant impact for individuals and healthcare provision worldwide. Mounting evidence from randomized controlled trials would suggest that bariatric surgery, irrespective of the procedure performed, is the most effective treatment currently available for obesity and related comorbidity. Given the increasing prevalence of obesity within all populations, clinicians in all specialties will treat patients with obesity and likely those who have had bariatric surgery. There are numerous barriers to improving obesity care, including stigma and a lack of understanding amongst healthcare professionals and patients regarding the safety, efficacy and indications for bariatric surgery. It is essential that doctors and surgeons caring for those with obesity have an understanding and appreciation of the procedures performed, including the mechanism of action and outcomes for patients. Finally, an understanding of the emergency postoperative complications will help further improve outcomes.     

Bariatric surgery

Obesity and metabolic syndrome is considered an epidemic in Western societies. An adult is considered to be obese with a BMI of 30 or above. Obesity imposes a significant human burden of disease, mortality, social exclusion and poor quality of life. It is closely associated with multiple comorbidities including type 2 diabetes, coronary heart disease, and poor health status, and has a substantial human cost by contributing to the onset of disease and premature mortality. Surgical interventions are significantly more effective than non-surgical therapies for the treatment of severe obesity, reduction of cardiovascular morbidities, prevention of some cancers, type 2 diabetes and improved quality of life. Although there are various surgical options, Roux-en-Y gastric bypass is considered the gold standard; sleeve gastrectomy is now the second most common procedure having replaced gastric banding with mini-gastric bypass the third worldwide. Endoscopic procedures are also growing in popularity but are still under research. A robust hospital infrastructure with multidisciplinary approach is crucial for a bariatric service including appropriate staffing and facilities to provide pre- and perioperative care. As the bariatric practice is increasing worldwide, it is essential to safeguard the standard of bariatric training to ensure surgical competence and patient safety.     

Bariatric surgery

Obesity is one of the most prevalent problems worldwide today, with the incidence fast increasing. As such, bariatric surgery is becoming a valuable alternative solution for those who have failed to lose weight by conservative means. Alongside obesity exist multiple comorbidities, both physical and mental, which have a significant affect upon the patient and need to be addressed before, during and after any operative intervention. This article outlines the problems associated with obesity, and discusses the most common operations in terms of risks and benefits. Finally, it explores the postoperative considerations that must be taken into account before embarking upon weight loss surgery.     

Bariatric surgery

Obesity is a progressive disease that shortens life expectancy and is associated with a wide range of medical problems ranging from diabetes and heart disease through to infertility and cancer. Losing weight can significantly improve or cure these conditions and helps to reduce the chances of future health problems developing. Anti-obesity drugs result in a 10% fall in body weight, but this degree of weight loss has never been shown to confer significant clinical benefit in patients with a body mass index exceeding 40 kg/m², for whom bariatric surgery is indicated. Gastric banding is less effective than other procedures and it takes longer for target weight loss to be reached, but it is the safest, quickest and least expensive bariatric procedure. Gastric bypass is a more effective option, as weight loss is more rapid and is generally complete within a year. However, the drawback is that the bypass carries more risk. It also induces a mild degree of malabsorption, and affects satiety signalling between the gut and brain. The duodenal switch (DS) shares some features with the gastric bypass in that both operations prevent calorie absorption, although this effect is much more marked after a DS. The advantage of this approach is that excellent, reliable weight loss can be achieved without the need to reduce the stomach (and thus portion) size dramatically. However, patients need to adhere to a strict high-protein diet with vitamin supplementation if nutritional problems are to be avoided.     

Bariatric surgery in Medicare patients: greater risks but substantial benefits

BackgroundRecent reports have documented greater mortality for bariatric surgery in Medicare (MC) patients compared with patients from other payors.MethodsWe reviewed our database for the mortality and outcomes of 282 MC and 3169 non-Medicare (NMC) patients undergoing bariatric surgery.ResultsOf the MC patients, 27 were >65 years of age, and 255 were receiving disability. The average age was 48.45 ± 11.8 years, and the average BMI was 52.4 ± 10.0 kg/m². NMC patients had average age of 40.0 ± 10.1 years and a BMI of 50.6 ± 9.1 kg/m². The co-morbidities were greater in the MC patients than in the NMC patients (hypertension 71.9% versus 48.4%, diabetes mellitus 39.72% versus 19.4%, obstructive sleep apnea 46.45% versus 28.46%, and obesity hypoventilation syndrome 9.93% versus 2.71%). The mortality rate was 2.48% in the MC patients and .76% in the NMC patients. Mortality was absent in MC patients >65 years old. The percentage of excess weight lost was less in the MC patients (60.8%) than in the NMC patients (66.5%, P <.0001). The resolution of diabetes mellitus also differed (64.86% for the MC patients and 77.18% for the NMC patients; P = .0329). The male MC patients had more prevalent co-morbidities than did the male NMC patients (hypertension 79.17% versus 58.85%; diabetes mellitus 36.11% versus 24.83%; obstructive sleep apnea 79.17% versus 54.51%; and obesity hypoventilation syndrome 26.39% versus 7.64%). The operative mortality rate was 5.6% for the male MC patients and 1.5% for the female MC patients. The weight loss was similar for the male MC and male NMC patients. The male MC patients had slightly better resolution of both hypertension (MC patients 54.8% versus NMC patients 26.7%, P = .0025) and diabetes mellitus (MC patients 30% versus NMC patients 22.5%, P = .745). When the patients were stratified into low-, intermediate-, and high-risk groups using a previously validated risk scale, patients with similar risk factors had similar mortality in both groups.ConclusionThe results of our study have shown that disabled MC patients have greater operative mortality than NMC patients that appears to be associated with more prevalent risk factors. However, the risk was counterbalanced by a substantial improvement in health.     

Bariatric surgery outcomes in geriatric patients: a contemporary,nationwide analysis

ObjectiveThis retrospective study sought to characterize the incidence of mortality in elderly patients following bariatric surgery and assessed the association of geriatric status with postoperative outcomes and resource use.BackgroundBariatric surgery is a safe and efficacious intervention for obesity and related diseases. The clinical and economic impact of geriatric status on bariatric surgery is largely unexplored.SettingAcademic, university-affiliated hospital; US.MethodsAdults (≥45 yr) undergoing elective laparoscopic gastric bypass or sleeve gastrectomy were identified in the 2016–2019 Nationwide Readmissions Database. Patients ≥65 years were categorized into the geriatric cohort. Multivariable linear and logistic models were developed to evaluate the independent association of geriatric status with outcomes of interest.ResultsOf an estimated number of 351,292 patients meeting inclusion criteria, 44,183 (12.6%) comprised the geriatric cohort. Of these patients, .3% died during the index hospitalization. Geriatric status was associated with significantly increased odds of in-hospital mortality (adjusted odds ratio [AOR] = 2.39, 95% confidence interval [CI]: 1.33–4.30), respiratory (AOR = 1.34, 95% CI: 1.13–1.59), infectious (AOR = 1.65, 95% CI: 1.25–2.17), and renal complications (AOR = 1.27, 95% CI: 1.12–1.46), and prolonged hospitalization (AOR = 1.35, 95% CI: 1.24–1.48). Elderly patients experienced a .19-day increment in the length of stay (95% CI: .11–.27) and $620 in attributable hospitalization costs (95% CI: 310–930).ConclusionsWhile overall rates of postoperative death and complications are low, geriatric patients experience significantly increased mortality, morbidity, and resource use following bariatric operations relative to younger adults. These findings may aid in shared decision-making for obesity management in geriatric patients.     

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.     

Bariatric surgery in patients with breast and endometrial cancer in California: population-based prevalence and survival

BackgroundThe number of bariatric surgeries performed in the United States has increased substantially since the 1990’s. However, the prevalence and prognostic impact of bariatric surgery, or weight loss surgery (WLS), among patients with cancer are not known.ObjectivesWe investigated the population-based prevalence of WLS in women with breast or endometrial cancer and conducted exploratory analysis to examine whether postdiagnosis WLS is associated with survival.SettingAdministrative statewide database.MethodsWLS records for women with nonmetastasized breast (n = 395,146) or endometrial (n = 69,859) cancer were identified from the 1991–2014 California Cancer Registry data linked with the California Office of Statewide Health Planning and Development database. Characteristics of the patients were examined according to history of WLS. Using body mass index data available since 2011, a retrospective cohort of patients with breast or endometrial cancer and obesity (n = 12,540) was established and followed until 2017 (5% lost to follow-up). Multivariable cause-specific Cox proportional hazards models were used to examine the associations between postdiagnostic WLS and time to death.ResultsWLS records were identified for 2844 (.7%) patients with breast cancer and 1140 (1.6%) patients with endometrial cancer; about half of the surgeries were performed after cancer diagnosis. Postdiagnosis WLS was performed in ～1% of patients with obesity and was associated with a decreased hazard for death (cause-specific hazard ratio = .37; 95% confidence interval = .014–.99; P = .049), adjusting for age, stage, co-morbidity, race/ethnicity, and socioeconomic status.ConclusionAbout 2000 patients with breast or endometrial cancer in California underwent post-diagnosis WLS between 1991 and 2014. Our data support survival benefits of WLS after breast and endometrial cancer diagnosis.     

Bariatric surgery reduces cancer risk in morbidly obese patients

BackgroundTo assess the effect of bariatric surgery on the cancer risk of patients with morbid obesity because evidence is mounting of an association between obesity and cancer.MethodsWe performed an observational 2-cohort study. The treatment cohort (n = 1035) included patients who had undergone bariatric surgery from 1986 to 2002. The control group (n = 5746) included age- and gender-matched morbidly obese patients who had not undergone weight-reduction surgery and who were identified from a single-payor administrative database. The subjects with physician or hospital visits for a cancer-related diagnosis or treatment within the 6 months previous to the beginning of the study were excluded. The cohorts were followed up for a maximum of 5 years from study inception.ResultsBariatric surgery resulted in a significant reduction in the mean percentage of excess weight loss (67.1%, P <.001). The surgery patients had significantly fewer physician/hospital visits for all cancer diagnoses (n = 21, 2.0%) compared with the controls (n = 487, 8.45%; relative risk .22, 95% confidence interval .143–.347; P = .001). The physician/hospital visits for common cancers such as breast cancer were significantly reduced in the surgery group (P = .001). For all other cancers, the physician/hospital visits showed a trend toward being lower in the surgery group. Because of the low frequencies, statistical significance could not be demonstrated for individual cancer diagnoses.ConclusionThe data suggest that bariatric surgery improves the cancer outcomes in some morbidly obese patients.