Are there Predictive Factors of Severe Liver Fibrosis in Morbidly Obese Patients with Non-alcoholic Steatohepatitis?

Background: Non-alcoholic steatohepatitis (NASH) is a clinicopathological entity characterized by the presence of steatosis and lobular and/or portal inflammation with or without fibrosis. Patients with non-alcoholic fatty liver and fibrosis on liver biopsy have increased liver-related deaths. Methods: 181 wedge liver biopsies, taken at the time of bariatric surgery from patients with a mean body mass index (BMI) of 47, were studied. In all cases, the liver biopsy was performed without knowledge of the patient's clinical and biochemical data, which were then examined with univariate and multivariate analysis. Results: Diagnosis of NASH was established in 105 patients (91%); 74 patients (70%) showed mild steatosis, 20 (19%) had moderate inflammation and fibrosis, and 11 (10%) had steatosis with severe fibrosis. None of the liver biopsies showed cirrhosis. Age was the only independent predictor of moderate and severe fibrosis (p=0.001). Conclusions: Since only age was a predictor of moderate or severe fibrosis, and no clinical or biochemical abnormalities detected slowly progressive hepatic fibrosis, liver biopsy is the only means of detecting progression to more advanced liver disease in a NASH patient.     

Are Morbidly Obese Patients Equally Benefitting From Care Improvements in Total Hip Arthroplasty?

BackgroundMorbidly obese patients have increased rates of complications following primary total hip arthroplasty (THA) and it is not clear whether improvements in THA care pathways are equally benefitting these patients. The purpose of this study is to assess if reductions in complications have similarly improved for both morbidly obese and non-morbidly obese patients after THA.MethodsPatients undergoing primary THA between 2011 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by body mass index (BMI) <40 and ≥40 kg/m². Thirty-day rates of infectious complications, readmissions, reoperation, and any complication were assessed. Trends in complications were compared utilizing odds ratios and multivariate analyses.ResultsIn total, 234,334 patients underwent THA and 16,979 (7.8%) had BMI ≥40 kg/m². Patients with BMI ≥40 kg/m² were at significantly higher odds for readmission, reoperation, and infectious complications. Odds for any complication were lower for morbidly obese patients in 2011, not different from 2012 to 2014, and higher from 2015 to 2019 compared to lower BMI patients. Odds for any non-transfusion complication were higher for morbidly obese patients and there was no improvement for either group over the study period. There were improvements in rates of readmission and reoperation for patients with BMI <40 kg/m² and readmission for BMI >40 kg/m².ConclusionOdds for readmission and reoperation for non-morbidly obese patients and readmission for morbidly obese patients improved from 2011 to 2019. Reductions in transfusions are largely responsible for improvements in overall complication rates. Although morbidly obese patients remain at higher risk for complications, there does not appear to be a growing disparity in outcomes between morbidly obese and non-morbidly obese patients.     

Is it More Difficult to Cannulate the Right Internal Jugular Vein in Morbidly Obese Patients than in Nonobese Patients?

BACKGROUND: The placement of an internal jugular vein (IJV) catheter is considered to be more difficult in morbidly obese patients. The objective of this study was to compare the success of simulated IJV puncture between morbidly obese patients and a nonobese control group. METHODS: Thirty-four morbidly obese patients with body mass index (BMI, kg/m(2)) >/=40 were compared with 36 patients with BMI < 30. Right IJV puncture was simulated using an ultrasound probe directed towards the sternal notch at the midpoint between the sternal notch and the mastoid process. The investigator placing the probe was blinded as to the image being created on the ultrasound machine. Success rate was assessed at three different head rotation angles from midline; 0 degrees , 30 degrees , and 60 degrees . RESULTS: There was no statistically significant difference in successful simulated IJV puncture between two groups for any of the head positions. However, there was a higher incidence of the carotid artery (CA) puncture in the morbidly obese patient group when the head rotation was advanced from neutral position to 60 degrees (p < 0.05). In addition, the ultrasound showed significantly more overlapping of the IJV over the CA in morbidly obese patients at 0 degrees (p < 0.05) and 30 degrees (p < 0.05). Our results show no statistically significant difference in success rate of IJV puncture between morbidly obese patients and nonobese patients. Keeping the head in a neutral position in morbidly obese patients minimizes the overlapping of the IJV over the CA and the risk of CA puncture. CONCLUSION: However, due to the fact that even in the neutral position there is a significant increase in overlap between IJV and CA, we recommend the use of ultrasound guidance for IJV cannulation in obese patients.     

Management of Ulcerative Colitis in the Morbidly Obese Patient: Is Bariatric Surgery Indicated?

Ulcerative colitis and obesity share a systemic chronic inflammatory response manifested by increased inflammatory markers. There are data suggesting a benefit in both diseases after inflammatory markers are decreased. We present a 39-year-old morbidly obese male with a history of ulcerative colitis who manifested significant symptomatic improvement after an 86.8% excess weight loss following gastric bypass surgery. We believe that this result may have been due to a reduction of inflammatory markers secondary to considerable weight loss. Although to our knowledge there are no publications showing a direct relationship between symptomatic improvement of ulcerative colitis and weight loss in the obese patient, we believe that weight loss surgery could become a promising tool in the treatment of ulcerative colitis when associated with morbid obesity.     

Investigating Nutritional Deficiencies in a Group of Patients 3 Years Post Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure has shown to be effective in achieving significant weight loss and resolving obesity-related co-morbidities. However, its nutrition consequences have not been extensively explored. This study aims to investigate weight loss and evolution of nutritional deficiencies in a group of patients 3 years post LSG.

Methods

Retrospective data of a group of patients, 3 years following LSG as a stand-alone procedure was collected. Data included anthropometry, nutritional markers (hemoglobin, iron studies, folate, calcium, iPTH, vitamins D, and B₁₂), and compliancy with supplementations.

Results

Ninety-one patients (male/female; 28:63), aged 51.9?±?11.4 years with a BMI of 42.8?±?6.1 kg/m² were identified to be 3 years post LSG. Percentage of weight loss at 1 and 3 years post-operatively was 29.8?±?7.0 and 25.9?±?8.8 %, respectively. Pre-operatively, the abnormalities included low hemoglobin (4 %), ferritin (6 %), vitamin B₁₂ (1 %), vitamin D (46 %), and elevated iPTH (25 %). At 3 years post-operatively, the abnormal laboratory values included low hemoglobin (14 % females, P?=?0.021), ferritin (24 %, P?=?0.011), vitamin D (20 %, P?=?0.018), and elevated iPTH (17 %, P?=?0.010). Compliancy with multivitamin supplementation was noted in 66 % of patients.

Conclusion

In these patients, LSG resulted in pronounced weight loss at 1 year post-operatively, and most of this was maintained at 3 years. Nutritional deficiencies are prevalent among patients prior to bariatric surgery. These deficiencies may persist or exacerbate post-operatively. Routine nutrition monitoring and supplementations are essential to prevent and treat these deficiencies.

     

Laparoscopic Roux-en-Y Gastric Bypass in Morbidly Obese Patients ≥55 Years Old

Background Advanced age is considered a relative contraindication to bariatric surgery at some institutions because of concerns about higher morbidity and less than optimal weight loss. The aim of our study was to evaluate the operative outcomes, length of stay, weight loss, and improvement of comorbidities in patients ≥55 years old who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery in our institution. Methods Retrospective data on 33 patients (26 women and 7 men) ≥55 years of age who underwent LRYGB from January 2003 to December 2006 were reviewed. Results Average patient age was 59 years (range 55–68 years), and the mean preoperative body mass index was 47 kg/m² (range 41.1–55.8 kg/m²). The median length of hospital stay was 3 days. There were no intraoperative or postoperative deaths. Early complications were one anastomotic leak, two upper gastrointestinal bleedings, and two readmissions for intractable vomiting. Late complications included four anastomotic strictures and one small bowel obstruction. Patients were followed for a mean 13 months (range 3–24 months). The mean excess body weight (EBW) loss was 13.5 kg (23%), 23.3 kg (39.8%), 33.3 kg (58.1%), 39.8 kg (66.8%), 40.1 kg (69.5%), and 40.8 kg (75.3%) at 1, 3, 6, 9, 12 and 24 months, respectively. Diabetes mellitus improved in 19 (100%) patients and completely resolved in 10 (53%). Hypertension improved in 18 (64%) patients, completely resolved in 9 (32%) and was unchanged in 10 (36%). Conclusions LRYGB is safe and effective in morbidly obese patients ≥55 years of age.     

Zinc and Copper Serum Levels of Morbidly Obese Patients Before and After Biliopancreatic Diversion: 4?Years of Follow-up

Background

Zinc and copper are two essential trace elements. However, few studies have been conducted specifically to investigate these deficiencies in patients who underwent bariatric surgery. The aim of our work was to describe the influence of biliopancreatic diversion (BPD) on serum copper and zinc levels during 4 years.

Methods

We have analyzed a consecutive series of 65 patients who have been followed-up for 4 years after undergoing open BPD.

Results

The final (4 years) initial excess weight percent loss was 63.5%. A significant improvement of BMI, weight, waist circumference, and fat mass was detected. The preoperative average zinc (42.2?±?53.2 ??g/dl) and copper (61.3?±?58.6 ??g/dl) levels are under the lower limit of the normal values. These data show a deficient micronutrient status in morbidly obese patients, 73.8% of patients had low basal zinc values and 67.8% low basal copper values. Values of both micronutrients at different times (6 months, 1, 2, 3, and 4 years) were lower than basal value.

Conclusion

BPD is an effective method of sustainable weight loss. Otherwise, a high prevalence of zinc and copper basal deficiencies in morbidly obese seeking bariatric surgery was detected. These deficiencies of copper and zinc increased during the 4 years of follow-up after BDP.     

Prophylactic Cholecystectomy,a Mandatory Step in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass?

Background  

The aim of this study was to determine the incidence of symptomatic gallstone disease requiring cholecystectomy (CCE) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) and to identify the peri-operative risk factors associated with postoperative symptomatic gallstone disease.     

Laparoscopic Vertical Banded Gastroplasty - an Effective Long-Term Therapy for Morbidly Obese Patients?

Background:Vertical banded gastroplasty (VBG) has previously been documented as an effective treatment for morbid obesity.We have described a laparoscopic technique to perform this operation. Followup data are now presented. Methods: A consecutive series of 139 morbidly obese patients were operated on with laparoscopic VBG. The patients were assessed with respect to peri- and postoperative morbidity, postoperative recovery and weight reduction up to 5 years thereafter. Results: Conversions to an open operation (n=6) and early reoperations (n=3) occurred in the early part of the series. Late complications were observed in 8 patients. The average weight reduction after 1 year was 50% of excess body weight, which remained also after 2 years.The continued follow-up covering 3 to 5 years postoperatively revealed a moderate weight gain in about 20% of patients. Conclusion: VBG can be safely performed by use of the laparoscopic technique. The average weight reduction after 1 and 2 years was 50% of excess body weight, whereafter tendency to partial weight gain was noted, suggesting an outcome comparable to that documented after the open surgical approach.     

Improvement of Physical Functioning of Morbidly Obese Patients Who Have Undergone a Lap-Band® Operation: One-Year Study

Background: The Netherlands has a population of 20,000 morbidly obese patients, an average of 350 of whom per year undergo a stomach reduction operation involving the surgical placement of a Lap-Band?. The quality of life (QOL) of a sample of female patients who underwent this operation was studied in a 1-year postoperative study. Methods: The Medical Outcome Study Short Form-36 (MOS SF-36) was used to assess 1-year postoperative quality of life among a sample of 39 female patients aged 19-53 years. QOL was measured at most 20 h preoperatively and 1 year postoperatively using a randomized pretest/posttest design. Statistical data, after transformation, were analyzed with SPSS Version 7.5 for Windows 95. Results: The response rate of 92.9% of patients polled was good, in contrast to earlier findings with this measuring instrument. Mean body mass index (BMI) declined from 40.86 kg/m² preoperatively to 33.14 kg/m² 1 year postoperatively. QOL improved on all scores in the MOS SF-36. Internal consistency of the scales used was high. Conclusions: The response rate to the MOS SF-36 questionnaire was high. The surgical placement of a Lap-Band? resulted in a significant improvement of QOL (1 year postoperatively) on all scores used. The internal consistency of the scales used was high.     

Is There Any Role of Resecting the Stomach to Ameliorate Weight Loss and Sugar Control in Morbidly Obese Diabetic Patients?

Background  Among the restrictive procedures the role of restrictive vs. resecting the stomach is still ambiguous. This study evaluate which is the role of the stomach with respect to blood glucose levels (BG) and percent excess weight loss (EWL) over the 18 months after restrictive procedures in morbid obese diabetic patients. Methods  We retrospectively compared a group of patients who underwent partial gastrectomy (just part of the gastric body) with gastric banding (GBSR; n = 27), sleeve gastrectomy (part of gastric body and complete fundus resection; LSG; n = 53) to laparoscopic gastric banding (LAGB; n = 100). Differences among groups at 3, 6, 12, and 18 months were evaluated by analysis of variance. The three cohorts were diabetic patients similar in BMI, age, and gender. Results  At 12 and 18 months, LSG had higher EWL (P < 0.05) and lower BG (P < 0.05) than did either LAGB or GBSR. There were no operative deaths. Complications: LAGB—two staple-line oozing, two wound infections; LSG—one hemorrhage, two staple-line oozing, two leaks; GBSR—one hemorrhage, two wound infections. All complications were readily treated. Conclusions  LSG provides better weight loss and glucose control at 1 year and 1.5 years after surgery than does either LAGB or GBSR, suggesting that gastric fundus resection plays an important, not yet well-defined, role.     

LMA Supreme™ Versus Facemask Ventilation Performed by Novices: A Comparative Study in Morbidly Obese Patients Showing Difficult Ventilation Predictors

Background

We designed a study to compare ventilation characteristics performed in morbidly obese patients by medical students via the facemask to that via the LMA Supreme®.

Methods

This prospective, randomized, crossover study included 31 ASA I–III morbidly patients showing difficult mask ventilation predictors. After induction of anesthesia, ten medical students with no previous clinical experience in airway management, clinically educated to facemask ventilation maneuvers, and theoretically educated to laryngeal mask use were supervised by a senior anesthesiologist during performance of 60 s facemask and LMA Supreme® ventilation in a randomly assigned order. Ventilation quality and difficulty were measured using an original score calculated as the sum of seven indicators (0?=?no ventilation and complications, 12?=?optimal and safe ventilation) and a visual analog scale (VAS; 0?=?no difficult–100?=?impossible), respectively. Values are presented as means (standard deviation) or medians [extremes].

Results

Mean age and body mass index of the patients were 39 years (12 years) and 44 kg m^?2 (7 kg m^?2), respectively. One patient was excluded because of ventilation difficulty experienced by the senior anesthesiologist. Medical students successfully established ventilation with the LMA Supreme® in all the 30 patients after a delay of 21 s (9 s) compared to 34 s (14 s) with the facemask (P?P?Conclusions We showed that the LMA Supreme? placed in novice hands systematically promoted easier ventilation of better quality than the facemask in morbidly obese patients showing difficult mask ventilation predictors. Our data suggest that the LMA Supreme? could be considered as a standard airway management tool for both elective and rescue airway management of morbidly obese patients.     

Is Routine Invasive Monitoring Indicated in Surgery for the Morbidly Obese?

Background: Morbid obesity is generally considered to be a surgical and anesthetic risk. Some surgeons have advised the routine use of invasive monitoring for morbidly obese individuals undergoing surgery. The purpose of this study was to identify morbidly obese individuals undergoing primary gastric bypass procedures who required central or other forms of invasive monitoring for their management. Methods: We reviewed a series of 521 morbidly obese individuals undergoing consecutively performed primary vertical banded gastroplasty-gastric bypasses, a form of gastric bypass (performed at two community hospitals), for patients who had central, arterial, or urinary catheters placed during their hospital course for monitoring purposes. The patient population was also analyzed for age, preoperative co-morbidities, body mass index, length of operation, and for whether technical complications were encountered intraoperatively. Results: At one of the two hospitals, 10% of patients had arterial catheters placed intraoperatively. In each case, the catheters were removed in the recovery room. At the second hospital, no patient had invasive monitoring intraoperatively. In the entire study group, only five patients required the use of invasive monitoring postoperatively. In each of these patients, technical perioperative complications occurred. The five patients and two hospital groups did not differ significantly in age, sex, number of co-morbidities or preoperative BMI from the study group as a whole. Conclusion: Morbid obesity itself is not an indication for invasive monitoring. The majority of morbidly obese individuals can be safely managed through primary gastric bypass procedures without invasive monitoring.     

Nutritional Deficiencies following Bariatric Surgery: What Have We Learned?

Deficiencies in vitamins and other nutrients are common following the Roux-en-Y gastric bypass (RYGBP), biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPDDS), and may become clinically significant if not recognized and treated with supplementation. This paper presents a review of the current literature and evidence of the most commonly deficient vitamins and minerals following weight loss surgery, including protein, iron, vitamin B₁₂, folate, calcium, the fat-soluble vitamins (A, D, E, K), and other micronutrients. The deficiencies appear to be more substantial following malabsorptive procedures such as BPD, but occur with restrictive procedures as well. The review suggests that further studies are needed to evaluate the clinical significance of the nutritional deficiencies, and to determine guidelines for supplementation.