Ann M. Rogers

Standardized outcomes reporting in metabolic and bariatric surgery

ASMBS, SOARD, outcome reporting standards Standardized outcomes reporting in metabolic and bariatric surgery Stacy A. Brethauer, MD*, Julie Kim, MD, Maher el Chaar, MD, Pavlos Papasavas, MD, Dan Eisenberg, MD, Ann Rogers, MD, Naveen Ballem, MD, Mark Kligman, MD, Shanu Kothari, MD for the ASMBS Clinical Issues Committee Bariatric and Metabolic Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio Department of Surgery, Tufts University, Boston, Massachusetts Department of Surgery, St. Luke’s Hospital, Allentown, Pennsylvania Department of Surgery, Hartford Hospital, Hartford, Connecticut Department of Surgery, Stanford University and Palo Alto VA Health Care Center, Palo Alto, California Department of Surgery, Penn State University, Hershey, Pennsylvania Center for Advanced Surgical Weight Loss, Montclair, New Jersey Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland Department of Surgery, Gundersen Health System, La Crosse, Wisconsin Received February 2, 2015; accepted February 2, 2015

Effects of Gastric Bypass Surgery on Female Reproductive Function

CONTEXT Reproductive function may improve after bariatric surgery, although the mechanisms and time-related changes are unclear. OBJECTIVE The objective of the study was to determine whether ovulation frequency/quality as well as associated reproductive parameters improve after Roux en Y gastric bypass surgery. DESIGN This was a prospective cohort study that enrolled female subjects from 2005 to 2008 with study visits at baseline and then 1, 3, 6, 12, and up to 24 months after surgery. SETTING The study was conducted at an academic health center. PATIENTS Twenty-nine obese, reproductive-aged women not using confounding medications participated in the study. MAIN OUTCOME MEASURES The primary outcome was integrated levels of urinary progestin (pregnanediol 3-glururonide) from daily urinary collections at 12 months postoperatively. Secondary outcomes were changes in vaginal bleeding, other biometric, hormonal, ultrasound, dual-energy x-ray absorptiometry measures, and Female Sexual Function Index. RESULTS Ninety percent of patients with morbid obesity had ovulatory cycles at baseline, and the ovulatory frequency and luteal phase quality (based on integrated pregnanediol 3-glururonide levels) were not modified by bariatric surgery. The follicular phase was shorter postoperatively [6.5 d shorter at 3 months and 7.9-8.9 d shorter at 6-24 months (P < 0.01)]. Biochemical hyperandrogenism improved, largely due to an immediate postoperative increase in serum SHBG levels (P < 0.01), with no change in clinical hyperandrogenism (sebum production, acne, hirsutism). Bone density was preserved, contrasting with a significant loss of lean muscle mass and fat (P < 0.001), reflecting preferential abdominal fat loss (P < 0.001). Female sexual function improved 28% (P = 0.02) by 12 months. CONCLUSIONS Ovulation persists despite morbid obesity and the changes from bypass surgery. Reproductive function after surgery is characterized by a shortened follicular phase and improved female sexual function.

Standardized outcomes reporting in metabolic and bariatric surgery.

When appropriate for the study design, the percentage of patients comprising the original study group who complete each follow-up period reported for the study should be reported (i.e., report the numerator and denominator available for follow-up at each time point reported). For prospective studies, percent follow-up should represent the percentage of patients from the original study group(s) who remained in the study until the study endpoint(s) are reached or for the final reported follow-up interval. The reasons for patient attrition from the study should be reported when possible. For

Alcohol Reward Is Increased after Roux-en-Y Gastric Bypass in Dietary Obese Rats with Differential Effects following Ghrelin Antagonism

Roux-en-Y gastric bypass (RYGB) is one of the most successful treatments for severe obesity and associated comorbidities. One potential adverse outcome, however, is increased risk for alcohol use. As such, we tested whether RYGB alters motivation to self-administer alcohol in outbred dietary obese rats, and investigated the involvement of the ghrelin system as a potential underlying mechanism. High fat (60%kcal from fat) diet-induced obese, non-diabetic male Sprague Dawley rats underwent RYGB (n = 9) or sham operation (Sham, n = 9) and were tested 4 months after surgery on a progressive ratio-10 (PR10) schedule of reinforcement operant task for 2, 4, and 8% ethanol. In addition, the effects of the ghrelin-1a-receptor antagonist D-[Lys3]-GHRP-6 (50, 100 nmol/kg, IP) were tested on PR10 responding for 4% ethanol. Compared to Sham, RYGB rats made significantly more active spout responses to earn reward, more consummatory licks on the ethanol spout, and achieved higher breakpoints. Pretreatment with a single peripheral injection of D-[Lys3]-GHRP-6 at either dose was ineffective in altering appetitive or consummatory responses to 4% ethanol in the Sham group. In contrast, RYGB rats demonstrated reduced operant performance to earn alcohol reward on the test day and reduced consummatory responses for two subsequent days following the drug. Sensitivity to threshold doses of D-[LYS3]-GHRP-6 suggests that an augmented ghrelin system may contribute to increased alcohol reward in RYGB. Further research is warranted to confirm applicability of these findings to humans and to explore ghrelin-receptor targets for treatment of alcohol-related disorders in RYGB patients.

Routine Drain Placement in Roux-en-Y Gastric Bypass: An Expanded Retrospective Comparative Study of 755 Patients and Review of the Literature

Routine drain use after laparoscopic Roux-en-y gastric bypass (LRYGB) is still practiced by many bariatric surgeons. After a patient in our program experienced intestinal obstruction secondary to a drain, we reevaluated our practice and hypothesized drains would be of no benefit and potentially harmful after LRYGB. Retrospective record review of all patients undergoing LRYGB from August 2005 to August 2009 was performed. As we changed our practice in December 2006, we have two comparable groups: one with a drain placed at surgery and one without. All operations were otherwise performed in an identical fashion by three fellowship-trained university surgeons. We compared outcomes between the two groups, particularly regarding gastrojejunal (GJ) leaks. Jejunojejunal (JJ) leaks, unlikely to be captured by these drains, were not studied. A total of 755 LRYGBs were performed during the study period, the first 272 patients with routine drains and the subsequent 483 without. Demographics were statistically similar between the two groups. There were four GJ leaks in the drain group (1.47%) and three in the nondrain group (0.62%). Among the drain patients, two required operation and two were treated nonoperatively. Among the nondrain patients, two required operation and one was treated nonoperatively. The leak and reoperation rates between the groups were not statistically different (p = 0.154 and p = 0.514). Routine drains likely have no benefit after LRYGB. Clinical parameters such as tachycardia, fever, oliguria, and increasing abdominal pain should guide further investigation for and treatment of a leak.

ASMBS updated position statement on insurance mandated preoperative weight loss requirements

ASMBS Guidelines/Statements ASMBS updated position statement on insurance mandated preoperative weight loss requirements Julie J. Kim, M.D., F.A.C.S., F.A.S.M.B.S.*, Ann M. Rogers, M.D., Naveen Ballem, M.D., Bruce Schirmer, M.D., on behalf of the American Society for Metabolic and Bariatric Surgery Clinical Issues Committee Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts Department of Surgery, Penn State University, Hershey, Pennsylvania Clara Mass Medical Center, Glen Ridge, New Jersey Department of Surgery, University of Virginia Health System, Charlottesville, Virginia Received April 18, 2016; accepted April 18, 2016

Roux-en-Y Gastric Bypass Increases Intravenous Ethanol Self-Administration in Dietary Obese Rats

Roux-en-Y gastric bypass surgery (RYGB) is an effective treatment for severe obesity. Clinical studies however have reported susceptibility to increased alcohol use after RYGB, and preclinical studies have shown increased alcohol intake in obese rats after RYGB. This could reflect a direct enhancement of alcohol’s rewarding effects in the brain or an indirect effect due to increased alcohol absorption after RGYB. To rule out the contribution that changes in alcohol absorption have on its rewarding effects, here we assessed the effects of RYGB on intravenously (IV) administered ethanol (1%). For this purpose, high fat (60% kcal from fat) diet-induced obese male Sprague Dawley rats were tested ∼2 months after RYGB or sham surgery (SHAM) using both fixed and progressive ratio schedules of reinforcement to evaluate if RGYB modified the reinforcing effects of IV ethanol. Compared to SHAM, RYGB rats made significantly more active spout responses to earn IV ethanol during the fixed ratio schedule, and achieved higher breakpoints during the progressive ratio schedule. Although additional studies are needed, our results provide preliminary evidence that RYGB increases the rewarding effects of alcohol independent of its effects on alcohol absorption.

Technique for transesophageal endoscopic cardiomyotomy (Heller myotomy): video presentation at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2008, Philadelphia, PA

BackgroundPrevious investigators have shown the feasibility of performing an esophageal myotomy using natural orifice translumenal endoscopic surgery (NOTES), but have been unsuccessful at extending the myotomy onto the body of the stomach.MethodsIn a nonsurvival porcine model, the authors used the self-approximating translumenal access technique (STAT) to create a submucosal tunnel in the upper esophagus and to extend it onto the body of the stomach allowing a complete cardiomyotomy.ResultsThe STAT approach was successfully used to create a submucosal tunnel and perform a complete myotomy of the gastroesophageal junction without complication.ConclusionsA complete Heller-type cardiomyotomy can be successfully performed using transesophegeal NOTES.

When Is a Petersen's Hernia Not a Petersen's Hernia

F e a v Chir 1900;62:95. urious about the origin of the eponymous “Petersen’s heria” so frequently noted in the bariatric literature, we perormed a literature search for the original description of this ernia. What we found was surprising, not only because of the emote publication date of the article, but because on translaion from the original German, Dr Petersen’s actual description f the hernia bears little if any similarity to modern usage of he terms Petersen’s hernia, 3,4,6,8-10,12,13,15,17,19,21,24,26-28,31,33,34,35 efect,space,site,or indow used to describe internal hernia formation after Rouxn-Y gastric bypass (RYGB) procedures. In 1900, DrWalther Petersen, first clinical assistant surgeon t the Surgical Clinic in Heidelberg, Germany published a 0-page article entitled “Ueber Darmverschlingung nach der astro-Enterostomie” (“Concerning Twisting of the Intesines Following a Gastroenterostomy”). In it, he described hree similar cases of internal small bowel herniation fter creation of a loop gastrojejunostomy. All three cases esulted in death, and Dr Petersen subsequently decribed the autopsy findings in great detail. Within the rticle, he acknowledged previously published forms of nternal herniation after this procedure, but differentited his observations from earlier reports with this tatement:

Roux-en-Y gastric bypass 10-year follow-up: the found population.

BACKGROUND The long-term durability of Roux-en-Y gastric bypass (RYGB) remains ill-defined in the American population secondary to poor follow-up after bariatric surgery. OBJECTIVES This study evaluated the population lost to follow-up to better define the long-term durability of RYGB for weight loss and co-morbidity amelioration. METHODS All patients (n = 1087) undergoing RYGB at a single institution between 1985 and 2004 were evaluated. Univariate differences in preoperative co-morbidities, postoperative complications, annual weight loss, and 10-year co-morbidities were analyzed to compare outcomes between patients with routine follow-up and those without. Using electronic medical record review for all encounters at our academic medical center and telephone survey, we obtained data for patients lost to follow-up. RESULTS Among 1087 RYGB patients, 151 (14%) had consistent 10-year follow-up in our prospectively collected database, with yearly clinic visits beyond 2 years postoperatively. Electronic medical record review and telephone survey data were collected on an additional 500 (46%) patients, resulting in 60% of patients having 10-year follow-up after RYGB. There was no statistical difference in any preoperative or postoperative variables between the 2 groups. We found no difference in co-morbidity prevalence preoperatively or at 10 years between groups. Examination of percent excess body mass index lost at yearly intervals revealed no difference between the groups at each interval up to 10 years (P = .36). CONCLUSION We found no difference in 10-year outcomes, including weight loss and co-morbidity reduction, between patients with routine clinic visits and those lost to follow-up. These 10-year data address the gap in knowledge resulting from poor long-term follow-up after bariatric surgery.