Kimberley E. Steele

Impact of bariatric surgery on hypertensive disorders in pregnancy: retrospective analysis of insurance claims data.

Objective To determine whether women who had a delivery after bariatric surgery have lower rates of hypertensive disorders in pregnancy compared with women who had a delivery before bariatric surgery. Design Retrospective cohort study. Setting Claims data for 2002-6 from seven insurance plans in the United States. Participants 585 women aged 16-45 who had undergone bariatric surgery, had at least one pregnancy and delivery, and had continuous insurance coverage during pregnancy plus two weeks after delivery. Main outcome measure Hypertensive disorders in pregnancy defined with ICD-9 codes. The independent variable was the timing of delivery in relation to bariatric surgery, classified as deliveries before and after surgery. We used logistic regression to calculate odds ratios and confidence intervals for each type of hypertensive disorder in pregnancy. Results Among the 585 women who had undergone bariatric surgery and had a delivery, 269 delivered before surgery and 316 delivered after surgery. Gastric bypass was the surgery in 82% (477) of all women. Women who delivered before surgery were younger at the time of delivery (mean age 31.3 v 32.5) but had higher rates of pre-existing diabetes and gestational diabetes mellitus. Compared with women who delivered before surgery, women who delivered after surgery had substantially lower rates of pre-eclampsia and eclampsia (odds ratio 0.20, 95% confidence interval 0.09 to 0.44), chronic hypertension complicating pregnancy (0.39, 0.20 to 0.74), and gestational hypertension (0.16, 0.07 to 0.37), even after adjustment for age at delivery, multiple pregnancy (that is, twins or more), surgical procedure, pre-existing diabetes, and insurance plan. Conclusion In this retrospective analysis of US women, bariatric surgery was associated with lower rates of hypertensive disorders in subsequent pregnancy.

Flexible transgastric peritoneoscopy and liver biopsy: a feasibility study in human beings (with videos)

BACKGROUND Multiple studies have demonstrated the feasibility of natural orifice transluminal endoscopic surgery in animal models. OBJECTIVE To determine the feasibility of transgastric peritoneoscopy and liver biopsy in human beings. SETTING Our institutional review board approved the procedures in the operating room with the patients under general anesthesia. DESIGN AND INTERVENTIONS During laparoscopic gastric bypass surgery a flexible endoscope was introduced into the peritoneal cavity through the gastric-wall incision. A peritoneoscopy with a liver biopsy was performed, then the flexible endoscope was withdrawn into the stomach, and gastric bypass surgery was completed laparoscopically. PATIENTS Three patients who were morbidly obese (mean weight 115.22 +/- 9.07 kg [254 +/- 20 lb]). MAIN OUTCOME MEASUREMENTS The ability to navigate a flexible endoscope inside the peritoneal cavity, to visualize the intra-abdominal organs, and to perform a liver biopsy without laparoscopic assistance. RESULTS It was very easy to navigate the flexible endoscope inside the abdomen by using torque, advancement, and withdrawal of the endoscopic shaft, as well as by movement of the endoscope tip. The flexible endoscope provided an excellent view and adequate illumination of the peritoneal cavity. The orientation of the flexible endoscope inside the peritoneal cavity was technically easy, even in the retroflex position. Systematic visualization of the liver, the spleen, the omentum, and the small and large intestine was easily achieved through the flexible endoscope without laparoscopic assistance. A liver biopsy was successfully completed in all cases by obtaining adequate tissue samples for histologic examination. LIMITATION This was a pilot feasibility study. CONCLUSIONS Transgastric flexible endoscopic peritoneoscopy in human beings is technically feasible, simple, and can become a valuable tool that complements and facilitates laparoscopic interventions inside the peritoneal cavity.

Prevalence of and risk factors for hypoglycemic symptoms after gastric bypass and sleeve gastrectomy.

Objective To determine the prevalence of and risk factors for postprandial hypoglycemic symptoms among bariatric surgery patients. Design and Methods A questionnaire including the Edinburgh hypoglycemia scale was mailed to patients who underwent either Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG) at a single center. Based on the questionnaire, we categorized the patients as having high or low suspicion for post-surgical, postprandial hypoglycemic symptoms. Results Of the 1119 patients with valid addresses, 40.2% (N=450) responded. Among the respondents, 34.2% had a high suspicion for symptoms of post-bariatric surgery hypoglycemia. In multivariate analyses, in addition to female sex (p=0.001), RYGB (p=0.004), longer time since surgery (p=0.013), lack of diabetes (p=0.040), the high suspicion group was more likely to report preoperative symptoms of hypoglycemia (p<0.001), compared to the low suspicion group. Similar results were observed when the high suspicion group was restricted to those requiring assistance from others, syncope, seizure with severe symptoms or medically confirmed hypoglycemia (N=52). Conclusion One third of RYGB or VSG reported postprandial symptoms concerning for post-surgical hypoglycemia, which was related to the presence of pre-operative hypoglycemic symptoms. Pre-operative screening for hypoglycemic symptoms may identify a group of patients at increased risk of post-bariatric surgery hypoglycemia.To determine the prevalence of and risk factors for postprandial hypoglycemic symptoms among bariatric surgery patients.

The effect of gastric banding on kidney stone disease.

OBJECTIVES To evaluate the likelihood of being diagnosed with, or treated for, an upper urinary tract calculus after gastric banding. Bariatric surgical procedures are being increasingly utilized in the treatment of patients with morbid obesity. Certain malabsorptive bariatric procedures have been associated with an increased risk for kidney stone formation. However, the kidney stone risk of gastric banding, a restrictive bariatric procedure, is unknown. METHODS We identified 201 patients who underwent gastric banding and a control group of 201 obese patients who did not have bariatric surgery in a national private insurance claims database within a 5-year period from 2002-2006. All patients had at least 2 years of continuous claims data follow-up. Our 2 primary outcomes were the diagnosis and the surgical treatment of a urinary calculus. RESULTS After gastric banding, the diagnosis of an upper urinary tract calculus occurred in 3 subjects (1.49%), as compared with 12 subjects (5.97%) in the comparison cohort (P = .0179). One subject in each cohort (0.50%) underwent a surgical procedure for the treatment of an upper urinary tract (P = 1.0000). CONCLUSIONS Gastric banding is not associated with an increased risk for kidney stone disease or kidney stone surgery in the postoperative period. Additional long-term studies are required to confirm these findings.

Lower Circulating C1q/TNF-Related Protein-3 (CTRP3) Levels Are Associated with Obesity: A Cross-Sectional Study.

Purpose C1q/TNF-related protein-3 (CTRP3) is a novel adipokine that lowers blood glucose levels, reduces liver triglyceride synthesis, and is protective against hepatic steatosis in diet-induced obese mouse models. We hypothesized that higher circulating serum levels of CTRP3 would be associated with a lean body mass index (BMI) and a more favorable metabolic profile in humans. The aim of this study was to investigate CTRP3 levels in lean individuals compared to obese individuals. Methods This was a cross-sectional study of obese (n=44) and lean control patients (n=60). Fasting metabolic parameters were measured in all patients and serum CTRP3 levels were measured by ELISA. Results BMI of the lean group was 21.9 ± 0.2 kg/m2 and obese group was 45.2 ± 1.1 kg/m2. We found significantly lower circulating levels of CTRP3 in obese individuals (405 ± 8.3 vs. 436± 6.7ng/mL, p=0.004) compared to the lean group. Serum CTRP3 levels were inversely correlated with BMI (p=0.001), and triglycerides (p<0.001), and significantly associated with gender (p<0.01), ethnicity (p=0.05), HDL-cholesterol (p<0.01), and adiponectin (p<0.01). We found BMI (p<0.01), gender (p<0.01), and ethnicity (p<0.05) to be significant predictors of CTRP3 levels when controlling for age in multiple regression analysis. Conclusions CTRP3 is a beneficial adipokine whose circulating levels are significantly lower in obese individuals. Obesity causes dysregulation in adipokine production, including the down-regulation of CTRP3. Lower CTRP3 levels may contribute to the pathophysiology of metabolic disorders associated with obesity. Optimizing CTRP3 levels through novel therapies may improve obesity and its comorbidities.

Incidence and risk factors for inguinal and incisional hernia after laparoscopic radical prostatectomy

OBJECTIVES To examine the risk of postoperative hernia development in men undergoing transperitoneal and extraperitoneal laparoscopic radical prostatectomy (LRP). Open radical retropubic prostatectomy increases the risk of postoperative inguinal hernia development within the first 2 postoperative years. It is less clear to what extent minimally invasive radical prostatectomy techniques affect the incidence of hernia development. METHODS A total of 651 LRP patients were mailed follow-up surveys regarding hernia development. Of these 651 patients, 378 responded (58%). Of the 378 patients, 308 had complete medical records for review. The mean follow-up for the fully evaluable cohort was 33.9 months (median 29.5, range 3-87). The potential risk factors for hernia (ie, previous hernia, age, surgical approach, pelvic lymph node dissection, bladder neck contracture, and operative time) were evaluated as categorical and/or continuous variables and using the univariate Cox proportional hazard ratio and Kaplan-Meier analyses. Preoperatively diagnosed inguinal hernias were repaired laparoscopically at LRP. RESULTS The incidence of postoperative inguinal hernia was 5.2% (16 of 308). After transperitoneal LRP (n = 122), 7.4% (9/122) reported an inguinal hernia, a few (29%) of which occurred within 2 years after LRP. After extraperitoneal LRP (n = 186), only 3.8% (7/186) reported an inguinal hernia, all of which occurred within 2 years after LRP. Kaplan-Meier analysis, however, demonstrated no effect of the surgical approach on the inguinal hernia incidence (P = .65). No risk factor was significantly associated with the postoperative hernia risk. One incisional hernia was noted (0.3%, 1 of 308), at a 5-mm extraperitoneal port site. Of the 308 men in the present study, 21 (6.8%) had undergone synchronous hernia repair, with no recurrences. CONCLUSIONS The incidence of inguinal hernia after LRP was similar, regardless of the laparoscopic approach, and was comparable or lower than the risk noted in published open radical retropubic prostatectomy series. No specific risk factors for post-LRP inguinal hernia development were identified.

Defining recurrence after paraesophageal hernia repair: Correlating symptoms and radiographic findings

BACKGROUND Laparoscopic repair of paraesophageal hernia (PEH) has been shown to result in excellent relief of symptoms and improved quality of life (QOL) despite a high radiographically identified recurrence rate. Because there is no uniform definition of PEH recurrence, it is difficult to compare studies reporting on this. This study attempts to introduce consistency to the definition of PEH recurrence based on correlation of symptoms and radiographic findings. METHODS This is an analysis of data derived from an ongoing prospective study. From April 2009 to December 2012, we enrolled 101 patients who underwent elective laparoscopic PEH repair with bioprosthesis buttressed over a primary cruroplasty. A validated gastroesophageal reflux disease-specific QOL tool was administered to patients before, and at 2 and 12 months postoperatively. Upper gastrointestinal barium contrast examination (UGI) was performed at 1 year. RESULTS Of 101 patients, 13 were not available for follow-up, 58 reached the 1-year milestone for interval UGI, and 1 patient required reoperation for symptomatic recurrent PEH. There was no relationship between total QOL score and radiographic recurrent hernia (RRH); however, significant deterioration in many symptoms was seen in RRH > 2 cm. Based on these findings, we defined recurrence as RRH > 2 cm and calculated our recurrence rate as 28% (n = 16). CONCLUSION Our analysis of symptom scores after laparoscopic PEH repair suggests that significant worsening occurs with RRH > 2 cm. Given that there is no consistent description of recurrent PEH, we suggest this as a possible standardized definition. Overall, patients with recurrent PEHs continue to experience excellent QOL and rarely require reoperation.

Vitamin D status and supplementation before and after bariatric surgery: a comprehensive literature review

BACKGROUND Bariatric surgery is the most effective long-term weight loss method. The most common procedures are Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG). Bariatric patients are at high risk of vitamin D deficiency (VDD) and insufficiency (VDI), which are associated with skeletal and nonskeletal ailments. There is no consensus regarding the optimal treatment for VDD/VDI in bariatric patients. OBJECTIVES To critically examine the literature on vitamin D status (serum 25[OH]D concentrations) pre- and postbariatric surgery as well as supplementation regimens currently used. METHODS We searched PubMed, Embase, and Cochrane from inception to May 2015 for articles relating to vitamin D, RYGB, and VSG. Of 208 citations retrieved, 30 were included. RESULTS Preoperative VDD (<20 ng/mL) ranged from 13% to 90%, while VDI (<30 ng/mL) was found in up to 98%. Prevalence remained similar postoperatively and was highest after RYGB. Most studies found dosages<800 IU daily insufficient postbariatric surgery. Other studies examined the effectiveness of dosages between 1000 and 5000 IU daily, reaching similar conclusions. Several studies suggested using 50,000 IU weekly plus a daily dose. No studies reported optimization. CONCLUSIONS It is widely accepted that serum 25(OH)D concentrations above 30 ng/mL are optimal; however, current postbariatric vitamin D supplementation fails to raise 25(OH)D above that level universally. This review highlights both the great need and the lack of consensus on the optimal supplementation regimen (dosage and frequency) for pre- and postbariatric patients. Future studies should investigate multiple regimens and attempt to identify methods for personalizing these regimens if found necessary.

Lysyl Oxidase as a Serum Biomarker of Liver Fibrosis in Patients with Severe Obesity and Obstructive Sleep Apnea

STUDY OBJECTIVES Obstructive sleep apnea (OSA) is associated with the progression of nonalcoholic fatty liver disease (NAFLD). We hypothesized that the hypoxia of OSA increases hepatic production of lysyl oxidase (LOX), an enzyme that cross-links collagen, and that LOX may serve as a biomarker of hepatic fibrosis. DESIGN Thirty-five patients with severe obesity underwent liver biopsy, polysomnography, and serum LOX testing. A separate group with severe OSA had serum LOX measured before and after 3 mo of CPAP or no therapy, as did age-matched controls. LOX expression and secretion were measured in mouse hepatocytes following exposure to hypoxia. SETTING The Johns Hopkins Bayview Sleep Disorders Center, and the Hypertension Unit of the Heart Institute at the University of São Paulo Medical School. MEASUREMENTS AND RESULTS In the bariatric cohort, the apnea-hypopnea index was higher in patients with hepatic fibrosis than in those without fibrosis (42.7 ± 30.2 events/h, versus 16.2 ± 15.5 events/h; P = 0.002), as was serum LOX (84.64 ± 29.71 ng/mL, versus 45.46 ± 17.16 ng/mL; P < 0.001). In the sleep clinic sample, patients with severe OSA had higher baseline LOX than healthy controls (70.75 ng/mL versus 52.36 ng/mL, P = 0.046), and serum LOX decreased in patients with OSA on CPAP (mean decrease 20.49 ng/mL) but not in untreated patients (mean decrease 0.19 ng/mL). Hypoxic mouse hepatocytes demonstrated 5.9-fold increased LOX transcription (P = 0.046), and enhanced LOX protein secretion. CONCLUSIONS The hypoxic stress of obstructive sleep apnea may increase circulating lysyl oxidase (LOX) levels. LOX may serve as a biomarker of liver fibrosis in patients with severe obesity and nonalcoholic fatty liver disease.

Looking Beyond Age and Co-morbidities as Predictors of Outcomes in Paraesophageal Hernia Repair

IntroductionParaesophageal hernia (PEH) repair is a technically challenging operation. These patients are typically older and have more co-morbidities than patients undergoing anti-reflux operations for gastroesophageal reflux disease (GERD), and these factors are usually cited as the reason for worse outcomes for PEH patients. Clinically, it would be useful to identify potentially modifiable variables leading to improved outcomes.MethodsWe performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database over a 5-year period (2001–2005). Patients undergoing any anti-reflux operation with or without hiatal hernia repair were included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated with reflux disease or diaphragmatic hernia, emergency admissions, and age <18. Primary outcome was in-hospital mortality. Two sets of multivariate analyses were performed; one set adjusting for pre-treatment variables (age, gender, race, Charlson Comorbidity Index, hospital teaching status, hospital volume of anti-reflux surgery, calendar year) and a second set adjusting further for post-operative complications (splenectomy, esophageal laceration, pneumothorax, hemorrhage, cardiac, pulmonary, and thromboembolic events, (VTE)).ResultsOf the 23,458 patients, 6,706 patients had PEH. PEH patients are older (60.4 vs. 49.1, p < 0.001) and have significantly more co-morbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. However, further adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients, while adjustment for cardiac complications or pneumothorax did not eliminate the difference.ConclusionsWhile PEH patients have worse post-operative outcomes than GERD patients, we note that differences in mortality are explained by pulmonary complications, VTE, and hemorrhage. The impact of hemorrhagic complications on this group underscores the importance of careful dissection. Additionally, age and co-morbidities alone should not preclude a patient from PEH repair; rather, attention should be focused on peri-operative optimization of pulmonary status and prophylaxis of thromboembolic events.