Christopher R. Daigle

Risk prediction of complications of metabolic syndrome before and 6 years after gastric bypass

BACKGROUND Roux-en-Y gastric bypass (RYGB) surgery has been shown to have favorable effects on components of metabolic syndrome. However, the long-term effect of RYGB on predicted risk of end-organ complications is less clear. The objective of this study was to examine long-term changes in predicted risk of metabolic syndrome-related complications after RYGB. METHODS The predicted risk of metabolic syndrome-related complications in a cohort of 131 diabetic patients was compared between baseline and last follow-up points after RYGB using validated risk assessment tools. RESULTS After a median postsurgical follow-up time of 6 years (range, 5-9), a mean percent excess weight loss of 60.7 ± 25.1% was associated with a diabetes remission rate of 61%. At long-term follow-up, the levels of glycated hemoglobin, low-density lipoprotein, and blood pressure were within the recommended American Diabetes Associations goals in 85%, 73%, and 63% of patients, respectively (P<.001). RYGB was associated with a relative risk reduction of 27% for 10-year overall risk of coronary heart disease (CHD), stroke, and peripheral vascular disease; 20% for 10-year risk of CHD; 40% for 10-year risk of myocardial infarction; 42% for 10-year risk of stroke; 47% for 4-year risk of intermittent claudication; 45% for 5-year risk of moderate-severe kidney disease; and 18% for 5-year risk of cardiovascular mortality. Four-year risk of diabetic retinopathy was also significantly decreased. CONCLUSION RYGB in diabetic patients results in remarkable control of diabetes, dyslipidemia, and hypertension, and is associated with a significant reduction in predicted risk of major complications including nephropathy, retinopathy, and cardiovascular disease and mortality in the range of 18-47% at long-term follow-up.

Safety and effectiveness of bariatric surgery in dialysis patients and kidney transplantation candidates

BACKGROUND Chronic renal disease is known to adversely affect the results of bariatric surgery. There is a paucity of literature on the safety and effectiveness of bariatric surgery on dialysis patients who are at very advanced stages in their renal disease. The objective of this study was to determine the safety and effectiveness of bariatric surgery in dialysis patients. METHODS A retrospective review of a prospectively collected database was conducted for dialysis patients who underwent bariatric surgery between January 2006 and January 2012. Age, gender, body mass index (BMI), cause of renal failure, associated co-morbidities, type of surgery, early and late complications, and mortality were collected. RESULTS Of the 3048 patients undergoing bariatric surgery during the study period, 21 dialysis patients (.7%) were identified. Eighteen patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), 2 patients underwent laparoscopic sleeve gastrectomy, and 1 patient underwent laparoscopic adjustable gastric banding. Mean preoperative BMI was 47.1±5.5 kg/m(2), and BMI decreased to 35.3±8.4 kg/m(2) after a mean follow-up period of 27.6 months (range = 1.4-78.0 mo). Early major complications (<30 days of surgery) occurred in 2 patients (1 anastomotic leak and 1 anastomotic stricture). Four patients had a late complication, including 1 marginal ulcer with bleeding managed endoscopically, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, 1 cholecystitis requiring cholecystectomy, and 1 anastomotic stricture requiring endoscopic dilation. There was 1 death in this cohort, at 45 days after LRYGB, that was unrelated to a surgery. CONCLUSIONS Chronic renal failure requiring dialysis should not be considered a contraindication to bariatric surgery. Our experience with this patient population has shown excellent medium-term weight loss and an acceptable (albeit increased) risk/benefit ratio.

Critical appraisal of salvage banding for weight loss failure after gastric bypass

BACKGROUND Placement of an adjustable gastric band (AGB) over the gastric pouch after RYGB failure has had varied results. The aim of this study was to evaluate safety and outcomes of AGB after RYGB failure. METHODS Twenty-eight patients who underwent laparoscopic placement of an AGB around the gastric pouch as a revisional procedure for inadequate weight loss or recidivism after RYGB between 2008-2011 were identified. RESULTS Twenty-four (86%) patients had a dilated gastric pouch and/or stoma. The mean operative and adhesiolysis times were 137.9±52.3 minutes and 83±51 minutes, respectively. History of a previous open RYGB was associated with a longer adhesiolysis time (P = .03). Three (11%) major intraoperative and 5 (18%) early postoperative complications occurred. Late complications (all requiring band removal) were observed in 6 (21%) patients and included ineffectiveness (n = 2), dysphagia/esophageal dilation (n = 2), band erosion (n = 1), and peritonitis (n = 1). In all 4 patients with a normal-sized pouch and stoma at the time of band placement, the band was removed. After a mean follow-up of 38.3±14.8 months, the mean body mass index (BMI) change and median excess weight loss (EWL) after salvage banding were -3.6±4.5 kg/m(2) and 12.7%, respectively. In the subset of patients with a dilated pouch/stoma, BMI less than 42 kg/m(2) at the time of band placement was associated with a significantly higher EWL (41.4%±37.0%) compared with a baseline BMI>42 kg/m(2) (12.1%±7.2%, P = .03). CONCLUSIONS Salvage banding is technically challenging due to dense adhesions, carries significant morbidity, and is associated with only 13% additional EWL. However, this approach may still be an option in carefully selected patients, such as those with previous laparoscopic RYGB who have a dilated pouch and/or stoma and lower BMI.

The incidence of hiatal hernia and technical feasibility of repair during bariatric surgery.

PURPOSE To evaluate the incidence and outcomes of hiatal hernias (HH) that are repaired concomitantly during bariatric surgery. METHODS We identified patients who had concomitant HH repair during bariatric surgery from 2010 to 2014. Data collected included baseline demographics, perioperative parameters, type of HH repair, and postoperative outcomes. RESULTS A total of 83 underwent concomitant HH during study period. The male-to-female ratio was 1:8, mean age was 57.2 ± 10.0 years, and mean body mass index was 44.5 ± 7.9 kg/m(2). A total of 61 patients had laparoscopic Roux-en-Y gastric bypass, and 22 had laparoscopic sleeve gastrectomy. HH was diagnosed before bariatric surgery in 32 (39%) subjects, whereas 51 (61%) were diagnosed intraoperatively. Primary hernia repair was performed with anterior reconstruction in 45 (54%) patients, posterior in 21 (25%), and additional mesh placement in 7 (8%). A total of 24 early minor postoperative symptoms were reported. At 12 month follow-up, mean body mass index improved to 30.0 ± 6.2 kg/m(2), and anti-reflux medication was decreased from 84% preoperatively to 52%. Late postoperative complications were observed in 3 patients. A comparative analysis with a matched 1:1 control group displayed no significant differences in operative time (P = .07), duration of stay (P = .9), intraoperative complications, or early (P = .09) and late post-operative symptoms (P = .3). In addition, no differences were noted in terms of weight-loss outcomes. CONCLUSION The true incidence of HH may be underestimated before bariatric surgery. Combined repair of HH during bariatric surgery appears safe and feasible.

The effect of bariatric surgery on gout: a comparative study

BACKGROUND Obesity is a risk factor for the development of gout. An increased incidence of early gouty attacks after bariatric surgery has been reported, but the data is sparse. The effect of weight loss surgery on the behavior of gout beyond the immediate postoperative phase remains unclear. The objective of this study was to evaluate the pre- and postoperative frequency and features of gouty attacks in bariatric surgery patients. METHODS Charts were reviewed to identify patients who had gout before bariatric surgery. Demographic and gout-related parameters were recorded. The comparison group consisted of obese individuals with gout who underwent nonbariatric upper abdominal procedures. RESULTS Ninety-nine morbidly obese patients who underwent bariatric surgery had gout. The comparison group consisted of 56 patients. The incidence of early gouty attack in the first month after surgery was significantly higher in the bariatric group than the nonbariatric group (17.5% versus 1.8%, P = .003). In the bariatric group, 23.8% of patients had at least one gouty attack during the 12-month period before surgery, which dropped to 8.0% during postoperative months 1-13 (P = .005). There was no significant difference in the number of gouty attacks in the comparison group before and after surgery (18.2% versus 11.1%, P = .33). There was a significant reduction in uric acid levels 13-months after bariatric surgery compared with baseline values (9.1±2.0 versus 5.6±2.5 mg/dL, P = .007). CONCLUSION The frequency of early postoperative gout attacks after bariatric surgery is significantly higher than that of patients undergoing other procedures. However, the incidence decreases significantly after the first postoperative month up to 1 year.

Bariatric and metabolic outcomes in the super-obese elderly

BACKGROUND Numerous reports address bariatric outcomes in super-obese or elderly patients, but data addressing this high-risk combination is lacking. OBJECTIVE The objective of this study was to assess outcomes of bariatric surgery in the super-obese elderly. SETTING Academic institution, United States. METHODS All primary bariatric cases performed on patients aged 65 years or older with a body mass index (BMI) ≥ 50 kg/m(2) were retrospectively analyzed. Surgical approaches included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). RESULTS Thirty patients (26 female, 4 male) with a mean age of 67.1 ± 2.7 years and BMI of 55.9 ± 3.9 kg/m(2), who had LRYGB (n = 16), LSG (n = 6), or LAGB (n = 8), were identified. There were no deaths, conversions, or intraoperative complications. Three patients were lost to follow-up after the 3-month visit. The early (<30 d) major morbidity rate was 10.0%. At a median follow-up of 37 (range, 6-95) months, the cohort had a mean BMI of 42.3 ± 6.7 kg/m(2), which corresponded to a mean percent excess weight loss of 44.5% ± 20.5% and mean percent total weight loss of 24.4% ± 12.2%. The most percent excess weight loss was achieved after LRYGB (54.1% ± 19.4%), followed by LSG (48.3% ± 10.2%) and then LAGB (26.2% ± 14.4%). Diabetic medication reduction in number and/or dosage was observed in 40% (6/15) patients, and 33% (5/15) of patients were completely off antidiabetic agents. CONCLUSIONS Although further research is needed, the present data suggest that successful weight loss and metabolic improvement can be achieved safely in the high-risk population of super-obese elderly.

MANAGEMENT OF ENDOCRINE DISEASE: Metabolic effects of bariatric surgery

Obesity is associated with an increased risk of type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, osteoarthritis, numerous cancers and increased mortality. It is estimated that at least 2.8 million adults die each year due to obesity-related cardiovascular disease. Increasing in parallel with the global obesity problem is metabolic syndrome, which has also reached epidemic levels. Numerous studies have demonstrated that bariatric surgery is associated with significant and durable weight loss with associated improvement of obesity-related comorbidities. This review aims to summarize the effects of bariatric surgery on the components of metabolic syndrome (hyperglycemia, hyperlipidemia and hypertension), weight loss, perioperative morbidity and mortality, and the long-term impact on cardiovascular risk and mortality.

Surgical management of gastrogastric fistula.

BACKGROUND Gastrogastric fistula (GGF) is a rare complication after Roux-en-Y gastric bypass (RYGB) that can be challenging to treat. OBJECTIVE The aim of this study is to examine our surgical experience in the management of GGF after RYGB. SETTING Academic center, United States. METHODS We report a consecutive series of 36 patients who underwent surgery for GGF at our institution between 2005 and 2013. RESULTS The cohort had a mean age of 48.0±10.8 years, mean body mass index (BMI) of 34.6±11.3 kg/m(2), and an average number of 5.0±2.0 co-morbidities at the time of GGF revision. Of the 36 patients, 16 (44.4%) had previous open RYGB. Endoscopy confirmed GGF in 26 patients (72.2%), whereas upper gastrointestinal (GI) series indicated GGF in 21 of 30 cases (70.0%). The GGF surgery was on average 6.4±3.8 years after the primary procedure. All patients underwent surgical management either in the form of a redo gastrojejunal anastomosis with excision of fistula (77.7%) or a remnant gastrectomy with excision of fistula (22.2%). Mean operative time, blood loss, and length of stay were 248.4±103.3 minutes, 232.7±270.2 mL, and 8.5±8.6 days, respectively. One major intraoperative and 6 early postoperative complications occurred. After a mean follow-up of 38.4±30.0 months, the mean BMI was 35.5±6.2 kg/m(2) in patients with weight regain before GGF revision (P<.05) versus 25.0±6.1 kg/m(2) in patients without weight regain (P = .7). CONCLUSION GGF is a rare complication of RYGB. Surgical treatment should be tailored to the presenting symptoms and associated anatomic abnormality. Anastomotic revisions are associated with higher complication rates.

Bariatric surgery outcomes in patients with systemic lupus erythematosus

BACKGROUND Obesity is common among systemic lupus erythematosus (SLE) patients. An increased perioperative risk after major surgery in SLE has been reported. The aim of this study was to describe postoperative outcomes among SLE patients undergoing bariatric surgery. METHODS Charts were reviewed to identify patients with an active diagnosis of SLE before bariatric surgery. Demographic variables, perioperative data, and SLE-related parameters were extracted. RESULTS Thirty-one morbidly obese patients who underwent bariatric surgery between 2005 and 2013 had a SLE diagnosis. Twenty-three patients had laparoscopic Roux-en-Y gastric bypass (RYGBP), 3 underwent laparoscopic revisional surgery for failed bariatric procedure, 3 had laparoscopic sleeve gastrectomy and 1 underwent laparoscopic adjustable gastric banding. Mean age, body mass index, and excess weight (kg) at baseline were 52.8±9.4 years, 44.3±9 kg/m(2), and 52.5±25.7 kg, respectively. Of these 31 patients, 24 (77.4%) were taking immunosuppressive medications at the time of surgery. Early major postoperative complications occurred in 4 patients (12.9%), with 3 requiring reoperation (9.6%). Multivariate analysis identified immunosuppressive therapy to be significantly associated with postoperative complications (P = .05). At a mean follow-up of 3 years, 13 patients (42%) showed reduction in the number of immunosuppressive medications and 6 (19.3%) were off steroids completely. After bariatric surgery, mean body mass index decreased to 34.2±8.2 kg/m(2) (P<.005) and excess weight loss was 51.2%± 33.4%. CONCLUSION Results suggest that weight loss after bariatric surgery is associated with decreased SLE immunosuppression medication requirements; however, the risks are higher. Bariatric surgery in this patient population should be approached with caution.

Citation classics: Top 50 cited articles in bariatric and metabolic surgery

BACKGROUND The number of times an article has been cited reflects its influence in a specific field. The aim of this study was to identify and characterize the most highly cited articles published on bariatric and metabolic surgery. METHODS The 50 most frequently cited articles in bariatric and metabolic surgery were identified from the Scopus database in December 2013. RESULTS The median number of citations was 383.5 (range 275-2482). Most of the articles were published from 2000-2012 (n = 35), followed by 1990-1999 (n = 12), then before 1990 (n = 3). These citation classics came from 8 countries, with the majority originating from the United States (n = 34), followed by Sweden (n = 4) and Australia (n = 4). The 50 articles were published in 20 journals, led by New England Journal of Medicine (n = 9) and Annals of Surgery (n = 9). Only 10 of the articles were published in obesity-specific journals. The level of evidence of the 49 clinical publications and 1 animal study consisted of level I (n = 5), II (n = 11), III (n = 9), IV (n = 19), and V (n = 6). Meta-analyses were 16% of the total citations. Metabolic (n = 12) and survival (n = 6) effects of surgery were among the most common fields of study. CONCLUSION Extending from the early 1950s through the voluminous growth period of the early 2000s, the field of bariatric and metabolic surgery led to the emergence of many top-cited scientific articles. These articles have provided the scientific basis for the only currently effective treatment for severe obesity. Articles published in high-impact journals, innovative observational studies, meta-analyses, survival analyses, and research on postoperative metabolic changes are most likely to be cited in the field of bariatric surgery.