Pregnancy outcomes after bariatric surgery: maternal, fetal, and infant implications.

Obese women who become pregnant face many health risks, including gestational diabetes, pregnancy-induced hypertension, and pre-eclampsia. These women also have a greater incidence of preterm labor, cesarean sections, and perioperative morbidity. Infants born to obese women have increased rates of macrosomia and congenital anomalies, as well as life-long complications such as obesity and its associated morbidities. With the increase in numbers of weight loss operations being performed in women of child-bearing age, physicians will have to address patient concerns regarding the safety of pregnancy after surgery. Many of the proposed health benefits of weight loss after surgery could translate to decreased rates of complications experienced by obese pregnant women. Case reports and small series have emerged documenting pregnancy courses after bariatric surgery. We reviewed the studies that reported pregnancy outcomes compiled from PubMed and Ovid databases to help draw conclusions regarding the maternal, fetal, and infant safety in women after bariatric surgery. The observations from these studies have shown that the health risks experienced by obese women during pregnancy are reduced after weight loss surgery. Additionally, there does not appear to be any increased risk regarding fetal or infant outcome.     

The risk of inflammatory bowel disease after bariatric surgery

BackgroundThe association between bariatric surgery and new onset of inflammatory bowel disease has so far only been sparsely studied and with conflicting results.ObjectivesTo investigate the association between bariatric surgery and inflammatory bowel disease in a large population-based cohort.SettingNationwide in Sweden.MethodsThis population-based retrospective cohort study included Swedish individuals registered in the Scandinavian Obesity Surgery Registry who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy during 2007–2018. Ten control individuals from the general population were matched according to age, sex, and region of residence at time of exposure. The study population was followed until 2019 with regard to the development of inflammatory bowel disease. Cox proportional hazards models were used to compare disease-free survival time between subgroups and control individuals for each outcome.ResultsThe final cohort consisted of 64,188 exposed individuals with a total follow-up of 346,860 person-years and 634,530 controls with total follow-up of 3,444,186 person-years. Individuals who underwent Roux-en-Y-gastric bypass had an increased risk of later development of Crohn’s disease (hazard ratio [HR] 1.8, 95% CI 1.5–2.2) and unclassified inflammatory bowel disease (HR 2.7, 95% CI 2.0–3.7) but not ulcerative colitis (HR .9, 95% CI .8–1.1) compared with control individuals, whereas individuals who underwent sleeve gastrectomy had an increased risk of ulcerative colitis (HR 1.8, 95% CI 1.1–3.1) but not Crohn’s disease (HR .8, 95% CI .3–2.1) and unclassified inflammatory bowel disease (HR 2.5, 95% CI .8–7.8).ConclusionsRoux-en-Y gastric bypass was associated with increased risk of Crohn’s disease and unclassified inflammatory bowel disease, whereas sleeve gastrectomy was associated with increased risk of ulcerative colitis only.     

Pregnancy characteristics and outcomes after bariatric surgery: national-level analysis in the United States

BackgroundBariatric surgery is an effective surgical treatment for weight reduction in individuals with obesity. Pregnancy outcomes related to prior bariatric surgery are currently under active investigation.ObjectiveTo assess national-level trends, characteristics, and outcomes of pregnancy after bariatric surgery in the United States.SettingRetrospective cohort study queried the National Inpatient Sample.MethodsThe study population was 14,648,135 patients who had vaginal or cesarean delivery from January 2016 to December 2019. Exposure allocation was based on the history of bariatric surgery. The main outcomes were (1) trends and characteristics related to bariatric surgery, assessed with multivariable binary logistic regression model; and (2) Centers for Disease Control and Prevention–defined severe maternal morbidity, assessed by propensity score matching and generalized estimating equation.ResultsA total of 53,950 (.4%) patients had prior bariatric surgery. The number of patients with prior bariatric surgery increased from .3% to .5%, and this trend remained independent in multivariable analysis (P < .001). Patients who had bariatric surgery were also more likely to be older and have obesity, medical co-morbidities, fetal growth restriction, preterm birth, and cesarean delivery compared with those without bariatric surgery (all, P < .05). In a propensity score matched model, patients who had bariatric surgery were more likely to receive blood product transfusion (2.3% versus 1.6%; odds ratio = 1.45; 95% confidence interval, 1.19–1.77), but severe maternal morbidity other than blood product transfusion was comparable to those without (1.1% versus 1.4%; odds ratio = .80; 95% confidence interval, .63–1.02).ConclusionThere is a gradual increase of pregnancy after bariatric surgery in recent years in the United States.     

Cholecystectomy increases the risk of dumping syndrome and postbariatric hypoglycemia after bariatric surgery

BackgroundDumping syndrome (DS) and postbariatric hypoglycemia (PBH) are frequent complications of bariatric surgery. Bile acids (BA) have been implicated in their pathogenesis because both bariatric surgery and cholecystectomy (CCx) are known to modulate human BA metabolism.ObjectivesOur investigation aimed to compare the prevalence of self-reported complaints of DS and PBH in postbariatric patients with and without CCx.SettingA large peripheral hospital in the Netherlands.MethodsAll patients who underwent bariatric surgery in 2008–2011 received standardized questionnaires on DS/PBH complaints. The relative risk (RR) of CCx was calculated as the risk of perceived DS and PBH in patients with and without CCx.ResultsOf 590 participants, 146 (25%) had CCx before assessment of DS/PBH complaints. Participants were mostly female (82%) with median age of 46 years (interquartile range, 39–53). The RR for DS after CCx was higher in patients with body mass index <30 kg/m² at the study (RR, 1.59; 95% CI, 1.04–2.42; P = .007) and in primary Roux-and-Y gastric bypass surgery patients (RR, 1.63; 95% CI, 1.10–2.42; P = .018). Detailed analysis of the latter group associated women, age younger than 50 years, without diabetes and (most prominently) with excess weight loss ≥70% (RR, 2.73; 95% CI, 1.57–4.77; P = .0004) with greater risk of DS. The RR for PBH was higher after CCx in sleeve gastrectomy patients (RR, 4.5; 95% CI, 1.00–20.3; P = .036).ConclusionHigh suspicion of DS and PBH after CCx is increased after bariatric surgery in certain subgroups, suggesting involvement of altered BA metabolism in their pathophysiology.     

Duration of surgery independently influences risk of venous thromboembolism after laparoscopic bariatric surgery

BackgroundObesity is a recognized risk factor for venous thromboembolism (VTE). The aims of the present study were to determine the risk factors for symptomatic VTE in morbidly obese patients undergoing laparoscopic bariatric surgery.MethodsThis was a retrospective study that included consecutive patients who had undergone bariatric surgery from January 2007 to May 2010. Thromboprophylaxis included routine application of low-molecular-weight heparin, pneumatic calf compression, and early ambulation. Extensive measures, such as temporary insertion of a caval filter (n = 5) and anticoagulation (n = 11), were used in selected higher risk patients. The patients were followed up for a minimum of 3 months after surgery to determine the incidence of clinical VTE. The results are presented as the mean and range.ResultsA total of 500 consecutive patients aged 44.7 years (range 19–77) with a body mass index of 49.2 kg/m² (range 32.1–84.3) underwent laparoscopic bariatric surgery (442 gastric bypass, 20 sleeve gastrectomy, and 38 gastric banding). No conversions to open surgery occurred, and the operative time, morbidity rate, and mortality rate was 93.7 minutes (range 20–325), 2.8%, and .2%, respectively. No clinical deep vein thrombosis was encountered, although 3 patients (.6%) developed pulmonary embolism. Cox regression multivariate analysis identified the operative time as the only independent predictor of postoperative VTE (relative risk .0002 per min, P = .009). Multivariate analysis identified the body mass index as an independent predictor of the operating time.ConclusionIncreasing obesity was associated with a longer operative time, which consequently increased the risk of VTE.     

Psoriasis improvement after bariatric surgery

BackgroundPsoriasis is a chronic inflammatory skin disease known to be associated with obesity and metabolic syndrome. Single case reports and small series suggest remission or improvement after bariatric surgery, hypothetically through a GLP-1 mediated mechanism. The objective of this study was to investigate on the effect of bariatric surgery on the clinical behavior of psoriasis in obese patients.MethodsA total of 33 morbidly obese individuals with psoriasis who were on active medical treatment were identified. Demographic characteristics and follow-up data were extracted from our database. Medication usage and percentage of affected body surface area (%ABSA) were recorded preoperatively and at least 6 months after bariatric surgery.ResultsNine (27.2%) patients were on systemic therapy at baseline. At a mean follow-up time of 26.2±20.3 months, a mean excess weight loss (EWL) of 48.7± 26.6% was achieved. This was associated with improvement of psoriasis based on downgrade of medication and %ABSA in 30.3% and 26.1% of patients, respectively. In total, 13 of 33 patients (39.4%) had improvement based on either criteria. Eight (24.2%) patients were not on any psoriasis medication at the latest follow-up (P = .001). Older age at the time of surgery (54.8±8.1 versus 48.1±10.4 years, P = .047), Roux-en-Y gastric bypass versus nonbypass procedures (52.4% versus 16.7%, P = .043), and greater EWL (64.2±26.0% versus 43.4± 23.6%, P = .036) predicted improvement. Only 1 (3%) patient experienced worsening after surgery.ConclusionAlmost 40% of our cohort showed improvement of psoriasis several months after bariatric surgery. Improvement is directly related to the degree of postoperative weight loss and is associated with the Roux-en-Y configuration.     

Diabetes remission after bariatric surgery

Over the last decade, obesity rates have continued to rise in the United States as well as worldwide and are showing no signs of slowing down. This rise is in parallel with the increasing rates of type 2 diabetes mellitus (T2DM). Given the association between obesity and T2DM and their strong correlation with increased morbidity and mortality in addition to healthcare expenditure, it is important to recognize the most effective ways to combat them. Thus, we performed a review of literature that focused on assessing the outcomes of T2DM following bariatric surgery. Available evidence suggests that bariatric surgery provides better T2DM resolution in obese patients when compared to best medical management alone. Additionally, Biliopancreatic diversion with duodenal switch as well as Roux-en-Y gastric bypass have demonstrated higher rates of T2DM resolution when compared with other bariatric procedures.     

Pregnancy after bariatric surgery in women with rheumatic diseases and association with adverse birth outcomes

BackgroundAutoimmune rheumatic diseases (ARDs) and bariatric surgery are each risk factors for adverse birth outcomes. To date, no study has investigated their combined impact on birth outcomes.ObjectivesThe objective of this study was to evaluate the impact of bariatric surgery on pregnancy outcomes in women with an ARD. As a secondary comparison, we assessed the risk of bariatric surgery on the same outcomes in women without an ARD.SettingRecords maintained by the California Office of Statewide Health Planning and Development.MethodsThis cohort study included infants born between 20–44 weeks of gestation in California between 2011–2018. Risks of adverse pregnancy outcomes were evaluated for women with a history of bariatric surgery as compared to women without a history of bariatric surgery, stratified by ARD, using log-linear regression with a Poisson distribution.ResultsThe study included 3,574,165 infants, of whom 10,823 (0.3%) were born to women who had an ARD and 13,529 (0.38%) to women with a history of bariatric surgery. There were 155 infants born to women (0.0043%) with both an ARD and a history of bariatric surgery. In women with an ARD and without bariatric surgery, the prevalence of preterm births was 18%, compared to 17.4% in women with both ARD and bariatric surgery; in women without ARD but with prior bariatric surgery, the prevalence of preterm births was 13.7%, compared to 8.2% in women without bariatric surgery. Except for neonatal intensive care unit (NICU) admissions, women with an ARD and history of bariatric surgery were not at a statistically increased risk of having other adverse pregnancy outcomes as compared to women with an ARD and no history of bariatric surgery.ConclusionOur study shows that women with ARD already have a high occurrence of several adverse birth outcomes, and this was not further increased by a history of bariatric surgery. The infants born to women with a history of ARD and bariatric surgery were admitted to the NICU significantly more than the infants born to women with an ARD and no history of bariatric surgery.     

Nutritional deficiencies after bariatric surgery

A current review of nutritional complications following bariatric procedures is presented, focusing on the most common and clinically important deficiencies. A brief outline of nutritional supplementation protocol is presented, highlighting the need for a standardized, national or international set of guidelines for pre- and postoperative nutritional screening and appropriate supplementation.     

Perioperative blood transfusion increases risk of surgical site infection after bariatric surgery

BackgroundSurgical site infection (SSI) is an important marker of postoperative morbidity and overall quality of care. Transfusion-related immunomodulation can lead to weakened immunity in response to blood transfusion and predispose patients to SSIs.ObjectivesThe aim of this study was to determine the impact of perioperative blood transfusions on SSIs in bariatric surgery patients.SettingNational data set.MethodsThe American College of Surgeons National Surgical Quality Improvement Program data sets were queried for laparoscopic and open bariatric operations between 2012 and 2014. Univariate analyses identified perioperative variables associated with postoperative SSIs. Multivariate regression analyses determined the effect of perioperative blood transfusions on postoperative SSI.ResultsThe study cohort included 59,424 patients: 480 (8.1%) biliopancreatic diversions, 28,268 (44.2%) gastric bypasses, 30,258 (50.9%) sleeve gastrectomies, and 418 (7.0%) bariatric revisions. Of the patients, 1107 (1.9%) developed a SSI: 662 (1.1%) superficial, 89 (0.1%) deep, and 356 (.6%) organ space. Patients receiving a perioperative blood transfusion were more likely to develop any type of SSI, organ space being most prevalent (Fig. 1). Among organ space SSIs, 198 (55.6%) were gastric bypasses and 125 (35.1%) were sleeve gastrectomies.ConclusionsBariatric surgery patients who receive a perioperative blood transfusion are at higher risk of developing SSIs, particularly organ space. The majority of organ space SSIs occur after gastric bypass, likely secondary to infected intra-abdominal hematomas. Close monitoring of postoperative signs of infection in these patients is important to determine if additional interventions are warranted.     

Pancreas transplantation after bariatric surgery

Obese transplant candidates are at increased risk for perioperative and postoperative complications. In many transplant programs, morbid obesity is considered to be an exclusion criterion for transplantation. The only potential option that would grant these patients access to transplant is weight loss. Non-operative weight loss strategies such as behavioral modifications, exercise, diet, or medication have only very limited success in achieving long-term weight loss. In contrast, bariatric surgery was shown to achieve not only more excessive weight loss, but more importantly, this weight loss can be sustained for longer periods of time. Therefore, bariatric surgery presents an attractive option for weight loss for morbidly obese transplant candidates. We report our experience with four patients who underwent bariatric surgery prior to successful pancreas transplantation. Even though gastric bypass and laparoscopic adjustable gastric band present as equivalent alternatives for weight reduction, we believe that in the population of morbidly obese diabetic patients who are possible candidates for pancreas transplantation, laparoscopic adjustable gastric band placement is the more suitable procedure.     

Laparoscopic cholecystectomy after bariatric surgery

Background: This prospective study determines the value of laparoscopic cholecystectomy (LC) in patients with cholelithiasis after bariatric surgery. Methods: Eighty-four consecutive patients who underwent bariatric surgery without concomitant cholecystectomy were studied. Patients were divided in two groups; group A including 50 patients (59.5%) without gallbladder disease, and group B included 34 patients (40.5%) with symptomatic cholelithiasis within 2 years postoperatively. Characteristics of both groups were compared and analyzed by the use of chi-square tests. Results: In all 34 patients in group B LC was attempted, and the procedure was successful in 28 (82.4%). LC was converted to open procedure in 6 patients (17.6%). Two patients with choledocholithiasic obstructive jaundice underwent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy prior to laparoscopic management. The mean operative time was 75 ± 12 min, and the mean hospitalization was 2.8 ± 1.1 days. Conclusion: Morbidly obese patients undergoing bariatric surgery are at high risk for developing symptomatic cholelithiasis postoperatively, which usually takes the form of acute cholecystitis. LC is feasible, effective, and seems to be the procedure of choice despite the technical difficulties.     

Pregnancy outcomes and nutritional indices after 3 types of bariatric surgery performed at a single institution

BackgroundNutritional status during pregnancy and the effects of nutritional deficiencies on pregnancy outcomes after bariatric surgery is an important issue that warrants further study. The objective of this study was to investigate pregnancy outcomes and nutritional indices after restrictive and malabsorptive procedures.MethodsWe investigated pregnancy outcomes of 113 women who gave birth to 150 children after biliopancreatic diversion (BPD), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) between June 1994 and December 2011. Biochemical indices and pregnancy outcomes were compared among the different types of surgery and to overall 20-year hospital data, as well as to 56 presurgery pregnancies in 36 women of the same group.ResultsAnemia was observed in 24.2% and 15.6% of pregnancies after BPD and RYGB, respectively. Vitamin B₁₂ levels decreased postoperatively in all groups, with no further decrease during pregnancy; however, low levels were observed not only after BPD (11.7%) and RYGB (15.6%), but also after SG (13.3%). Folic acid levels increased. Serum albumin levels decreased in all groups during pregnancy, but hypoproteinemia was seen only after BPD. Neonates after BPD had significantly lower average birth weight without a higher frequency of low birth weight defined as<2500 g. A comparison of neonatal data between babies born before surgery and siblings born after surgery (AS) showed that AS newborns had lower average birth weight with no significant differences in body length or head circumference and no cases of macrosomia.ConclusionOur study showed reasonably good pregnancy outcomes in this sample population after all types of bariatric surgery provided nutritional supplement guidelines are followed. Closer monitoring is required in pregnancies after malabsorptive procedures especially regarding protein nutrition.     

Pregnancy after laparoscopic bariatric surgery: comparative study of adjustable gastric banding and Roux-en-Y gastric bypass

BackgroundApproximately 80% of patients undergoing bariatric surgery are women, and about one half of these are of reproductive age. The purpose of the present study was to compare laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in a series of morbidly obese women with respect to maternal and neonatal outcomes at a university hospital in France.MethodsFrom January 2004 to December 2008, the data from women who had undergone LAGB or LRYGB at our center and were pregnant were collected, including age, parity, gravidity, weight, body mass index (BMI) before surgery and at scheduled intervals after surgery (1, 3, 6, 12, and 18 mo and yearly thereafter), interval from surgery to conception, weight and BMI at conception, weight and weight gain during pregnancy, weight and BMI at 2 weeks after pregnancy, complications during pregnancy, gestational age, method of delivery, fetal birth weight, and fetal outcome.ResultsThere were 42 pregnancies in 36 women, 22 in women who had undergone LAGB and 20 who had undergone LRYGB. The LAGB and LRYGB groups were comparable for all analyzed variables, except that the preoperative weight and BMI were greater in the LRYGB group. No differences in weight or BMI were found at conception or after pregnancy. No difference was found between the 2 groups in terms of obstetric complications or neonatal outcomes. A high frequency of cesarean deliveries was necessary in both groups.ConclusionsThe results of the present study have shown that no significant difference exists in the obstetric and birth outcomes between women who have undergone LRYGB and those who have undergone LAGB.