Giulio Giambartolomei

High cardiovascular risk patients benefit more from bariatric surgery than low cardiovascular risk patients

IntroductionAtherosclerotic cardiovascular disease (ASCVD) and Framingham risk scores (FRS) are used to calculate 10-year risk of coronary death, nonfatal myocardial infarction, or fatal/nonfatal stroke. Our goal is to evaluate the association between preoperative cardiovascular risk and weight loss.MethodsWe retrospectively reviewed bariatric surgeries from 2010 to 2016. Patients who met criteria for calculating 10-year ASCVD score and FRS were included. Data collected included baseline demographics, perioperative parameters, and postoperative outcomes at 12xa0months. Simple linear regression and multiple linear regression models were applied to test influence of individual or multiple factors of interest on 12-month weight loss outcomes.ResultsOf 1330 bariatric patients studied, 360 patients met criteria for ASCVD and FRS calculation. Sleeve gastrectomy (LSG) was the most prevalent surgery 63.05%, followed by Roux-en-Y gastric bypass (LRYGB) 20.55%, revision procedures 11.9%, and adjustable gastric banding (LAGB) 4.4%. Initial BMI was 42.71u2009±u20097.85xa0kg/m2 for females and 42.72ku2009±u20097.42xa0kg/m2 for males, with a 12-month percentage of estimated BMI loss (%EBMIL) of 66.51% in females and 60.29% in males. Preoperative 10-year ASCVD score was higher in males than females with a 34.73% relative risk reduction (RRR) in males and 35.3% RRR in females at 12-month follow-up. Regarding FRS, preoperative risk was 33.13u2009±u200921.1% in males and 15.71u2009±u200914.52% in females, with an RRR of 25.8% in males and 32.2% in females. Univariate analysis of preoperative FRS and %EBMIL showed that for every percentage unit increase in the patient’s preoperative FRS, %EBMIL decreases 0.31 percentile unit (Pu2009<u20090.001). Furthermore, preoperative ASCVD score is also significantly associated with %EMBIL—for every percentage unit increase in preoperative ASCVD score, %EBMIL decreases 0.42 percentile credits.ConclusionStudy results suggest ASCVD and FRS are equally reduced after bariatric surgery, especially after LSG and LRYGB. Moreover, preoperative FRS and ASCVD risk score showed an inversely proportional relationship with %EBMIL loss at 12 months.

Laparoscopic Sleeve Gastrectomy versus Roux-en-Y Gastric Bypass in Cardiovascular Risk Reduction: A Match Control Study

BACKGROUNDnThere is a paucity of studies comparing risk reduction of the atherosclerotic cardiovascular disease (ASCVD) and Framingham-body mass index (BMI) Coronary Heart risk score after a laparoscopic Roux-en-Y gastric bypass (RYGB), and few studies have assessed the efficacy of laparoscopic sleeve gastrectomy (SG) in reducing cardiovascular risk.nnnOBJECTIVEnOur goal in this study was to compare the impact of SG and RYGB on cardiovascular risk reduction.nnnSETTINGnU.S. university hospital.nnnMETHODSnWe retrospectively reviewed the records of all SG or RYGB cases at our institution between 2010 and 2015. Patients who met the criteria for calculating the ASCVD 10-year and Framingham-BMI score were included in the study. Propensity score matching was used to match SG and RYGB on demographic characteristics and co-morbidities.nnnRESULTSnOf the 1330 bariatric patients reviewed in the study period, 219 (19.3%) patients met the criteria for risk score calculation. SG was the most prevalent surgery in 72.6% (Nu202f=u202f159) of cases compared with RYGB in 27.4% (Nu202f=u202f60) of cases. At 12-month follow-up, ASCVD 10-year score had an absolute risk reduction of 3.9 ± 6.5% in SG patients and 2.9 ± 5.8% in RYGB patients (Pu202f=u202f.3). Framingham-BMI score absolute risk reduction was 11.0 ± 12.0% in SG and 9.0 ± 11.0% in RYGB patients (Pu202f=u202f.4), and the decrease in estimated heart age was 12.1 ± 15.6 years in SG versus 9.2 ± 9.6 years in RYGB (Pu202f=u202f.1). The percentage of estimated BMI loss at 1 year was 68.1 ± 23.3% in SG versus 74.2 ± 24.8% in RYGB (Pu202f=u202f.1).nnnCONCLUSIONnOur results suggest that SG and RYGB are equally effective in improving cardiovascular risk and decreasing the estimated vascular/heart age at 12-month follow-up.

The Importance of the Biliopancreatic Limb Length in Gastric Bypass: A Systematic Review

BACKGROUNDnBariatric surgery has proven to be the most durable treatment for obesity, and it also provides improvement of obesitys associated co-morbidities. Although several mechanisms for its metabolic effects have been studied, the implications of the surgically constructed anatomy on its functioning physiology have not been elucidated. This leaves some uncertainty regarding the recommended limb lengths in Roux-en-Y gastric bypass. The alimentary limb length and function has been studied extensively, but few have studied the influences of the biliopancreatic limb length.nnnOBJECTIVEnTo present a systematic review of the literature comparing variations in length of BP limb and results in order to determine BP limb length influence.nnnSETTINGnAcademic Hospital, United States.nnnMETHODSnWe present a systematic review of all the articles comparing variations of the biliopancreatic limb length and their results.nnnRESULTSnThirteen articles were identified and analyzed. Most of the articles are prospective studies. Weight loss was superior in longer limbs.nnnCONCLUSIONnBased on our review of the subject, we can conclude that the release of enterohormones in response to a food load in the distal small bowel seems to play an important role in the remission of co-morbidities. Hence, the length of the biliopancreatic limb might affect this process.

Fundamentals of Patient Positioning and Skin Prep

Proper patient positioning is of paramount importance for the completion of a safe and successful operation. The technological advances in the operating room have significantly increased the safety for both patients and healthcare providers. However, the ever-growing volume of cases and their complexity require increase focus on patient care in the operating room (OR).

Gastro-Gastric Fistula Following Gastric Bypass

Gastro-gastric fistula is a complication that might happen after a bariatric procedure like Roux-en-Y gastric bypass. It is defined as an abnormal communication between the excluded gastric pouch and the gastric remnant after gastric bypass. Its incidence has substantially decreased since the technique evolved from a nondivided to a divided gastric pouch. The diagnosis of gastro-gastric fistula could be challenging because of the clinical presentation that varies depending on the etiology, the patient’s objective and subjective response, the time of onset, the medications administered, and the imaging sensitivity. Besides clinical evaluation, imaging studies like upper GI study and CT scan and esophagogastroduodenoscopy are useful tools in achieving a diagnosis. Finally, medical and surgical management are extensively discussed in this chapter.