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

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

Is bariatric surgery safe in patients who refuse blood transfusion?

BackgroundA small, but significant, number of patients undergoing bariatric surgery refuse blood transfusion for religious or other personal reasons. Jehovah's Witnesses number more than 1 million members in the United States alone. The reported rates of hemorrhage vary from .5% to 4% after bariatric surgery, with transfusion required in one half of these cases. Pharmacologic prophylaxis against venous thromboembolism could further increase the perioperative bleeding risk. Our objective was to report the perioperative outcomes of bariatric surgery who refuse blood transfusion at a bariatric center of excellence, private practice in the United States.MethodsA retrospective review of all patients who refused blood transfusion when undergoing bariatric surgery during a 10-year period was conducted. Patients were identified from a prospectively maintained database by the bloodless surgery program at Legacy Good Samaritan Hospital. Data were collected on demographics, co-morbidities, laboratory values, medication use, blood loss, and 30-day complications.ResultsThirty-five bloodless surgery patients underwent bariatric surgery from 2000 to 2009. Of these 35 patients, 21 underwent laparoscopic adjustable gastric banding and 14 Roux-en-Y gastric bypass. Before 2006, only pneumatic compression devices were applied for venous thromboembolism prophylaxis (n = 6). Subsequently, combination venous thromboembolism prophylaxis was performed with fondaparinux sodium 2.5 mg for RYGB or enoxaparin 40 mg for LAGB (n = 29). One RYGB patient developed postoperative hemorrhage requiring reoperation. No venous thromboembolisms or deaths occurred.ConclusionBariatric surgery can be performed in patients who refuse blood transfusion with acceptable postoperative morbidity. Larger studies are necessary to confirm the safety of this approach and to examine the effect of pharmacologic thromboprophylaxis in this patient group.     

Metabolic outcomes after bariatric surgery for Indigenous patients in Ontario

BackgroundIn 2013, 18% of Canadian adults had obesity (body mass index [BMI] >30 kg/m²), compared with 25.7% of Canada's Indigenous population. Bariatric surgery is an effective treatment for obesity, but has not been studied in Canadian Indigenous populations.ObjectivesTo determine the effects of bariatric surgery in the Indigenous Ontario population.SettingMulticenter data from the publicly funded Ontario bariatric program and registry.MethodsProspectively collected data using all surgical patients between March 2010 and 2018 was included in initial analysis and included the following postoperative outcomes: diabetes, hypertension, and gastroesophageal reflux disease. Demographic characteristics, baseline characteristics, and univariate outcomes were assessed using Pearson Χ² or t tests. Multivariable regression for BMI change was used with complete case analysis and multiple imputation.ResultsOf 16,629 individuals initially identified, 338 self-identified as Indigenous, 13,502 as Non-Indigenous, and 2789 omitted ethnicity and were excluded. Baseline demographic characteristics were not statistically different; rates of hypertension (P = .03) and diabetes (P < .001) were higher in the Indigenous population. Univariable analysis showed similar 1-year BMI change (Indigenous: 15.8 ± 6.0 kg/m²; Non-Indigenous: 16.1 ± 5.6 kg/m², P = .362). After adjustment, BMI change was not different between groups at 6 months (effect size = .07, 95% confidence interval ?.45 to .58, P = .803) and 1 year (effect size = ?.24, 95% confidence interval ?.93 to .45, P = .489). Rates of co-morbidities were similar at 1 year between the 2 populations, despite differences at baseline. Six-month and 1-year follow-up rates were higher in the Non-Indigenous population (P < .001, P = .005, respectively).ConclusionsWeight loss and resolution of obesity-related co-morbidities are similar in Indigenous and Non-Indigenous patients. Access to surgery, patient selection, and long-term results merit further investigation.     

Trends in utilization of bariatric surgery, 2009–2012

Background

Utilization of bariatric surgery has changed dramatically over the past two decades. The aim of this study was to update the trends in volume and procedural type of bariatric surgery in the USA. Data were derived from the National Inpatient Sample from 2009 through 2012.

Methods

We used ICD-9 diagnosis and procedural codes to identify all hospitalizations during which a bariatric procedure was performed for the treatment of severe obesity. The data were reviewed for patient demographics and characteristics, annual number of bariatric operations, and specific procedural types and proportion of laparoscopic cases. The US Census data were used to calculate the population-based annual rate of bariatric surgery per 100,000 adults.

Results

Between 2009 and 2012, the number of inpatient bariatric operations ranged between 81,005 and 114,780 cases annually. During this time period, the annual rate of bariatric procedures was highest for 2012 at 47.3 procedures per 100,000 adults. The bariatric surgery approach most commonly performed continues to be laparoscopic, ranging between 93.1 and 97.1 %. In 2012, there was a precipitous reduction in the number of gastric bypass and gastric banding operations and replaced by an increase in the number of sleeve gastrectomy operation. The in-hospital mortality rate remains low, ranging from 0.07 to 0.10 %.

Conclusions

In the USA, the annual volume of inpatient bariatric surgery continues to be stable. Utilization of the laparoscopic approach to bariatric surgery remains high, while the in-hospital mortality continues to be low at ≤0.10 % throughout the 4-year period.

     

Is bariatric surgery safe in patients with history of cardiac revascularization?

BackgroundThe number of patients undergoing bariatric surgery with prior cardiac revascularization (CR) is rising. However, scarce data exist regarding the safety of bariatric procedures in these patients.ObjectivesThe aim of this study is to compare postoperative cardiovascular and noncardiovascular outcomes among patients with different CR procedures.SettingAcademic hospital, United States.MethodsWe retrospectively reviewed 2884 patients undergoing bariatric surgery from 2009–2018. Patients with prior CR were included and stratified into groups: coronary artery bypass graft (CABG), percutaneous coronary intervention with stent (PCI), and CABG + PCI. We described patient demographic characteristics, co-morbidities, smoking status, history of myocardial infarction, type of bariatric surgery, number of vessels grafted/stents, time from CR to bariatric surgery, length of stay, and cardiovascular and noncardiovascular 30-day outcomes. A control group composed of patients without prior CR undergoing bariatric surgery was used to compare the rate of complications to the total patients with prior CR. For continuous and categorical variables, t test and χ² tests were performed, respectively.ResultsWe identified 76 patients with prior CR undergoing bariatric surgery. The mean patient age was 61.4 ± 7.9 years, the mean body mass index was 41.7 ± 6.5 kg/m², and male sex was predominant (71.1%). Among these, 50% (n = 38) had PCI, 39.4% (n = 30) had CABG, and 10.5% (n = 8) had CABG + PCI. Early cardiovascular complications rate included ST-segment-elevation myocardial infarction (n = 2), pulmonary embolism (n = 1), supraventricular arrhythmia (n = 2), ventricular arrhythmia (n = 1), and pacemaker/defibrillator-insertion (n = 1). The overall rate of cardiovascular and noncardiovascular complications was 9.2% (n = 7) and 10.5% (n = 8) during the 30 days. Mortality rate was 0%. Comparison of rate of complications between groups did not show any statistical difference; no significant difference was found when comparing patients with prior CR to the 76 patients in the control group (P > .05).ConclusionsAlthough revascularized individuals have severe co-morbidities and are high-risk patients, bariatric surgery remains safe in this population when outcomes are compared with bariatric patients without prior CR.     

Is bariatric surgery effective for co-morbidity resolution in the super-obese patients?

Background

Type 2 diabetes (T2D), obstructive sleep apnea (OSA), hypertension (HTN), and hyperlipidemia (HLD) are common co-morbidities that are strongly associated with obesity.

Enteral stents in the management of post–bariatric surgery leaks

A post–bariatric surgery leak is a rare but grave condition and remains every bariatric surgeon’s nightmare. Endoscopic therapy with the insertion of self-expandable stents provides an effective minimally invasive approach for the management of leaks. Self-expandable stents, however, are still hampered by their tendency for migration and are not always well tolerated. Recently, double-pigtail stents have been proposed as an alternative endoscopic therapeutic modality. Both types of stents have been shown to be very effective in the management of leaks; however, most studies have pooled gastrointestinal leaks due to different etiologies together. In this article, we review the current status and foreseen innovations in gastrointestinal stenting for post–bariatric surgery leaks.     

Resident first assistance in bariatric surgery: do patients pay a price?

BackgroundFirst assistance during metabolic and bariatric surgery (MBS) often consists of either a general surgery resident (GSR), minimally invasive surgery fellow (MISF), or advanced practice provider (APP). While APPs may be consistent members of the bariatric team, GSRs and MISFs are often rotating members. It is unclear to what extent the inclusion of APPs versus surgical trainees (GSRs or MISFs) affect surgical outcomes.ObjectivesThe aim of this study was to determine the effect of first assistant type on adverse outcomes following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).SettingAcademic hospital.MethodsFrom the 2015–2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program databases, we identified conventional laparoscopic and robot-assisted SG or RYGB performed with an APP, GSR, or MISF as first assistant. Patient demographics, co-morbidities, and operative characteristics were used to create 1:1 case-matched first-assistant cohorts, and perioperative outcomes were compared. Variables were compared using the χ² test, Mann-Whitney U test, and regression models. Analyses were performed with StataMP 17. A P value <.05 and a 95% confidence interval exclusive of 1 or 0 were considered statistically significant.ResultsOf 414,623 included cases, an APP, GSR, and MISF served as first assistant in 58%, 28%, and 14%, respectively. Mean operative length was longer in GSR (P < .001) and MISF (P < .001) versus APP cases and similar between GSR and MISF cases (P = .08). Compared with an APP as first assistant, the odds of approach conversion (P < .001), readmission (P < .001), and overall morbidity (P < .001) were significantly higher in GSR and MISF cases. Compared with an APP, GSR cases also were associated with higher odds of admission to the intensive care unit (P < .001), reintervention (P < .001), bleeding (P = .002), venous thromboembolism (P < .001), and surgical site infection (P < .001). Most outcomes were similar between GSR and MISF as first assistant cases.ConclusionsWhile training future surgeons is an important aspect of bariatric surgery, inexperienced trainees or shifting roles within a surgical team may confer increased surgical risks to patients. Strategies are needed to optimize patient safety while maintaining a robust resident experience.     

Are male patients undergoing bariatric surgery less healthy than female patients?

BackgroundMale patients are underrepresented in bariatric surgery (BS) despite a relatively equal proportion of men and women experiencing obesity.ObjectivesDifferences in frequency and severity of obesity-associated medical problems (OAMPs) between men and women undergoing BS or in a control group (HELIUS [HEalthy Life In an Urban Setting]) were evaluated. The hypothesis was that men undergoing BS are less healthy than women.SettingA cross-sectional study of 2 cohorts undergoing BS in 2013 (BS2013) and 2019 (BS2019) and a control group of patients with severe obesity from a general population (HELIUS).MethodsCharacteristics concerning weight and OAMPs, medication usage, intoxications, postoperative complications (for BS2019) were compared between men and women. Members of the HELIUS cohort were tested for eligibility for BS.ResultsOf 3244 patients included, the majority were female (>78.4%). Median (interquartile range) age and body mass index (kg/m²) in male versus female patients were 47.0 (41.0–53.8) versus 43.0 (36.0–51.0) years and 41.5 (38.4–45.2) versus 42.3 (40.2–45.9), respectively, in BS2013, and 52.0 (39.8–57.0) versus 45.0 (35.0–53.0) years and 40.4 (37.4–43.8) versus 41.3 (39.0–44.1) in BS2019 (P < .05). The rates of men with OAMPs were 71.4% and 82.0% compared with 50.2% and 56.9% of women in BS2013 and BS2019, respectively. Overall medication usage was higher in male patients (P = .014). In BS2019, male patients exhibited a higher median HbA1C (P < .001) and blood pressure (P = .003) and used more antihypertensives and antidiabetics (P = .004). Postoperative complications did not differ between men and women. In the control cohort, 66.5% of men and 66.6% of women were eligible for BS.ConclusionMen undergoing BS more often experience OAMPs than women, and OAMPs are more advanced in men.     

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

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

Patients’ preferences for information in bariatric surgery

Background

The decision to undergo bariatric surgery is multifactorial and made both by patient and doctor. Information is of the utmost importance for this decision.

Is bariatric surgery safe in academic centers?

Contemporary outcomes of bariatric surgery are not well defined. Our aim was to document the outcomes of bariatric surgery on the basis of surgeon caseload and affiliation. We analyzed prospectively collected Florida-wide hospital discharge data. Forty-four surgeons undertook bariatric surgery in 933 patients during 1999. The ten surgeons who averaged more than two operations/month undertook 764 operations; 162 (17%) were done by academic surgeons. Complications [14% vs 7% (P = 0.008, chi-square)], length of stay (5 +/- 0.7 vs 4 +/- 0.1 days), and hospital charges (in thousands) ($31 +/- 4.0 vs $24 +/- 0.4) were greater in academic than in community-based centers (P < 0.05, Wilcoxon rank-sum). However, 36 per cent of patients operated upon by academic surgeons had a high Severity Index compared with only 16 per cent of patients operated upon by community-based surgeons (P < 0.001, chi-square). In high-risk patients complications (40% vs 46%), length of stay (7 +/- 1.0 vs 6 +/- 0.4 days), and hospital charges (in thousands) ($42 +/- 6 vs $35 +/- 2) were similar between academic and community-based surgeons. We conclude that outcomes of bariatric surgery in high-risk patients are similar among academic and community-based surgeons. Academic surgeons undertake bariatric surgery in high-risk patients more frequently than community-based surgeons, which underlies their increased complication rate. These prospectively collected data reflect surgical outcomes more accurately than clinical series and will impact our practice of bariatric surgery.