Zubaidah Nor Hanipah

Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity

Objective: To construct and validate a scoring system for evidence-based selection of bariatric and metabolic surgery procedures according to severity of type 2 diabetes (T2DM). Background: Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) account for >95% of bariatric procedures in United States in patients with T2DM. To date, there is no validated model to guide procedure selection based on long-term glucose control in patients with T2DM. Methods: A total of 659 patients with T2DM who underwent RYGB and SG at an academic center in the United States and had a minimum 5-year follow-up (2005–2011) were analyzed to generate the model. The validation dataset consisted of 241 patients from an academic center in Spain where similar criteria were applied. Results: At median postoperative follow-up of 7 years (range 5–12), diabetes remission (HbA1C <6.5% off medications) was observed in 49% after RYGB and 28% after SG (P < 0.001). Four independent predictors of long-term remission including preoperative duration of T2DM (P < 0.0001), preoperative number of diabetes medications (P < 0.0001), insulin use (P = 0.002), and glycemic control (HbA1C < 7%) (P = 0.002) were used to develop the Individualized Metabolic Surgery (IMS) score using a nomogram. Patients were then categorized into 3 stages of diabetes severity. In mild T2DM (IMS score ⩽25), both procedures significantly improved T2DM. In severe T2DM (IMS score >95), when clinical features suggest limited functional &bgr;-cell reserve, both procedures had similarly low efficacy for diabetes remission. There was an intermediate group, however, in which RYGB was significantly more effective than SG, likely related to its more pronounced neurohormonal effects. Findings were externally validated and procedure recommendations for each severity stage were provided. Conclusions: This is the largest reported cohort (n = 900) with long-term postoperative glycemic follow-up, which, for the first time, categorizes T2DM into 3 validated severity stages for evidence-based procedure selection.

Efficacy of adjuvant weight loss medication after bariatric surgery

BACKGROUND Some patients do not achieve optimal weight loss or regain weight after bariatric surgery. In this study, we aimed to determine the effectiveness of adjuvant weight loss medications after surgery for this group of patients. SETTING An academic medical center. METHODS Weight changes of patients who received weight loss medications after bariatric surgery from 2012 to 2015 at a single center were studied. RESULTS Weight loss medications prescribed for 209 patients were phentermine (n = 156, 74.6%), phentermine/topiramate extended release (n = 25, 12%), lorcaserin (n = 18, 8.6%), and naltrexone slow-release/bupropion slow-release (n = 10, 4.8%). Of patients, 37% lost>5% of their total weight 1 year after pharmacotherapy was prescribed. There were significant differences in weight loss at 1 year in gastric banding versus sleeve gastrectomy patients (4.6% versus .3%, P = .02) and Roux-en-Y gastric bypass versus sleeve gastrectomy patients (2.8% versus .3%, P = .01).There was a significant positive correlation between body mass index at the start of adjuvant pharmacotherapy and total weight loss at 1 year (P = .025). CONCLUSION Adjuvant weight loss medications halted weight regain in patients who underwent bariatric surgery. More than one third achieved>5% weight loss with the addition of weight loss medication. The observed response was significantly better in gastric bypass and gastric banding patients compared with sleeve gastrectomy patients. Furthermore, adjuvant pharmacotherapy was more effective in patients with higher body mass index. Given the low risk of medications compared with revisional surgery, it can be a reasonable option in the appropriate patients. Further studies are necessary to determine the optimal medication and timing of adjuvant pharmacotherapy after bariatric surgery.

Adjustments to warfarin dosing after gastric bypass and sleeve gastrectomy

BACKGROUND Warfarin dosing after bariatric surgery may be influenced by alterations in gastrointestinal pH, transit time, absorptive surface area, gut microbiota, food intake, and adipose tissue. OBJECTIVES The aim of this study was to describe trends in warfarin dosing after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). SETTING Single academic center. METHODS All patients chronically on warfarin anticoagulation before RYGB or SG were retrospectively identified. Indications for anticoagulation, history of bleeding or thrombotic events, perioperative complications, and warfarin dosing were collected. RESULTS Fifty-three patients (RYGB n = 31, SG n = 22) on chronic warfarin therapy were identified (56.6% female, mean 54.4 ± 11.7 yr of age). Of this cohort, 34.0% had prior venous thromboembolic events, 43.4% had atrial fibrillation, and 5.7% had mechanical cardiac valves. Preoperatively, the average daily dose of warfarin was similar in the RYGB group (8.3 ± 4.1 mg) and SG group (6.9 ± 2.8 mg). One month after surgery, mean daily dose of warfarin was reduced 24.1% in the RYGB group (P<.001) and 23.2% in the SG group (P = .002). At 12 months postoperatively, the required daily warfarin dose compared with baseline remained statistically different (RYGB: 6.8 ± 3.8 mg; SG: 6.1 ± 2.0 mg). CONCLUSIONS The warfarin dose is expected to be decreased by approximately 25% from preoperative levels after both RYGB and SG. Lower dose requirement within the first month after bariatric surgery is followed by a trend toward increased warfarin dose requirements, but remain less than baseline. Because dose requirements change constantly over time, frequent postoperative monitoring of the international normalized ratio is recommended.

Patients with clinically metabolically healthy obesity are not necessarily healthy subclinically: further support for bariatric surgery in patients without metabolic disease?

BACKGROUND Nonalcoholic fatty liver disease (NAFLD) increases the risk of liver cirrhosis and hepatocellular carcinoma and is also strongly correlated with extrahepatic diseases, including cardiovascular disease and type 2 diabetes. This risk of NAFLD among obese individuals who are otherwise metabolically healthy is not well characterized. OBJECTIVES To determine the prevalence and characteristics of NAFLD in individuals with metabolically healthy obesity. SETTING A tertiary, academic, referral hospital. METHODS All patients who underwent bariatric surgery with intraoperative liver biopsy from 2008 to 2015 were identified. Patients with preoperative hypertension, dyslipidemia, or prediabetes/diabetes were excluded to identify a cohort of metabolically healthy obesity patients. Liver biopsy reports were reviewed to determine the prevalence of NAFLD. RESULTS A total of 270 patients (7.0% of the total bariatric surgery patients) met the strict inclusion criteria for metabolically healthy obesity. The average age was 38 ± 10 years and the average body mass index was 47 ± 7 kg/m2. Abnormal alanine aminotransferase (>45 U/L) and asparate aminotransferase levels (>40 U/L) were observed in 28 (10.4%) and 18 (6.7%) patients, respectively. A total of 96 (35.5%) patients had NAFLD with NALFD Activity Scores 0 to 2 (n = 61), 3 to 4 (n = 25), and 5 to 8 (n = 10). A total of 62 (23%) patients had lobular inflammation, 23 (8.5%) had hepatocyte ballooning, 22 (8.2%) had steatohepatitis, and 12 (4.4%) had liver fibrosis. CONCLUSION Even with the use of strict criteria to eliminate all patients with any metabolic problems, a significant proportion of metabolically healthy patients had unsuspected NAFLD. The need and clinical utility of routine screening of obese patients for fatty liver disease and the role of bariatric surgery in the management of NAFLD warrants further investigation.

Clinical features of symptomatic hypoglycemia observed after bariatric surgery

BACKGROUND Literature directly looking at post-bariatric surgery hypoglycemia consists mostly of small case series. The rate, severity, and outcomes of treatment in a large bariatric population are less characterized. OBJECTIVE To determine the rate of post-bariatric surgery hypoglycemia, its clinical features and management outcomes over a 13-year period at our institution. SETTING An academic center in the United States. METHODS Patients who underwent bariatric surgery at a single academic center between 2002 and 2015 and had a postdischarge glucose level of ≤70 mg/dL were studied. RESULTS Of 6024 patients who underwent bariatric procedure, 118 patients (2.0%) had a postoperative glucose level ≤70 mg/dL. Eighty-three patients (1.4%) had symptomatic hypoglycemia. The known underlying causes of symptomatic hypoglycemia included postprandial hyperinsulinemic hypoglycemia (n = 32, 38%), infection (n = 8, 10%), diabetic medications (n = 8, 10%), and poor oral intake (n = 8, 10%). Overall, 9 patients required intervention for nutritional supplementation including enteral (n = 9) and intermittent parenteral (n = 2) nutrition. No patients required reversal of their bariatric surgeries or pancreatic resection for management of hypoglycemia. The majority of the symptomatic patients had resolution of their symptoms (n = 76, 92%). Thirty-two patients had postprandial hypoglycemia with a median onset of hypoglycemia after bariatric surgery of 790 days (interquartile range 388-1334). All 32 patients with postprandial hypoglycemia had dietary adjustment and 53% received pharmacotherapy, which resulted in complete resolution of hypoglycemia (n = 29, 91%) and resolution with minimal disability (n = 3, 9%). CONCLUSION The rate of symptomatic hypoglycemia and postprandial hypoglycemia after bariatric surgery were 1.4% and .5%. The majority of patients were successfully managed with dietary counseling, nutritional intervention, and occasionally pharmacotherapy. No surgical reversal or pancreatic procedures were performed.

Reply Letter to the Editor “The Outcome of Bariatric Surgery in Patients Aged 75 years and Older”

We greatly appreciate the comments on our study BThe Outcome of Bariatric Surgery in Patients Aged 75 years and Older.^ All the patients who are registered in our bariatric program will have preoperative nutritional and metabolic assessment prior to their bariatric procedures. We did not perform preoperative or postoperative body composition assessment such as skeletal muscle mass or functional test to assess muscle function. However, all the patients in this study (n = 19) were fully ambulatory prior to bariatric surgery. Studies have shown that weight loss after bariatric surgery results in the loss of both fat and fat-free mass [1–4]. However, fat-free mass after surgical weight loss procedures does not extend beyond the initial weight loss period [2, 3]. Davidson et al. [1] showed that the fat-free mass and skeletal muscle are maintained or decrease minimally after 1–5 years after bariatric surgery. There are few validated physical activity questionnaires such as the Community Health Activities Model Program for Seniors (CHAMPS) and health-related quality of life (SF-36) that have been used to measure postoperative recovery [5]. The 6-min walking test (6MWT) measures functional walking capacity, which correlates with CHAMPS [5]. In the future, we hope to incorporate these assessments to measure the outcome of functional physical capacity after bariatric surgery. During the preoperative dietician assessment, all the patients in our program are recommended to perform aerobic exercises for at least 150 min per week or at least 8000– 10,000 steps per day. We do not have an accurate data compliance with their exercise regime, but we doubt the patients are doing them regularly. Unfortunately, we do not have data available on the total number of patients aged 75 years and above who registered in our bariatric program. Our database only captures the patients who had bariatric surgery. Therefore, we do not know how many patients aged 75 years and above were seeking bariatric surgery.

Master’s Program Bariatric Pathway: Roux-En-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric/metabolic procedures, with most performed laparoscopically. It is an effective bariatric procedure with excellent long-term weight loss and improvement in comorbidities, especially type 2 diabetes (T2D) and gastroesophageal reflux disease (GERD). It does, however, have a longer learning curve compared to sleeve gastrectomy and gastric banding. Advance training is recommended to achieve good patient outcomes.

Completion Gastrectomy with Esophagojejunostomy for Management of Complications of Benign Foregut Surgery

BACKGROUND With the worldwide epidemic of obesity, an increasing number of bariatric operations and antireflux fundoplications are being performed. Despite low morbidity of the primary foregut surgery, completion gastrectomy may be necessary as a definitive procedure for complications of prior foregut surgery; however, the literature evaluating outcomes after completion gastrectomy with esophagojejunostomy (EJ) for benign diseases is limited. We present our experience of completion gastrectomy with Roux-en-Y EJ in the setting of benign disease at a single tertiary center. METHODS AND PROCEDURES All patients who underwent total, proximal, or completion gastrectomy with EJ for complications of benign foregut surgery from January 2006 to December 2015 were retrospectively identified. All cancer operations were excluded. RESULTS There were 23 patients who underwent gastrectomy with EJ (13 laparoscopic EJ [LEJ] and 10 open EJ). The index operations included 12 antireflux, 9 bariatric, and 2 peptic ulcer disease surgeries. Seventy-eight percent of patients had surgical or endoscopic interventions before EJ, with a median of one prior intervention and a median interval from the index operation to EJ of 25 months (interquartile range 9-87). The 30-day perioperative complication rate was 30% with 17% classified being major (Clavien-Dindo ≥ III) and no 30-day perioperative mortality. Comparing laparoscopic and open approaches showed similar operative times, estimated blood loss, and overall complication rate. LEJ was associated with a shorter length of stay (LOS) (P < .001), fewer postoperative ICU days (P = .002), fewer 6-month complication rates (P < .007), and decreased readmission rate (P = .024). CONCLUSION Our series demonstrates that EJ is a reasonable option for reoperative foregut surgery. The laparoscopic approach appears to be associated with decreased LOS and readmissions.

Bariatric surgery in patients with cirrhosis

Obesity, nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) have been increasing globally leading to higher incidences of liver cirrhosis. Bariatric/Metabolic surgery is an effective long-term treatment of obesity, type 2 diabetes, and associated comorbidities providing significant cardiovascular risk reduction. Multiple studies have demonstrated significant histological improvement in NASH following metabolic surgery. Although patients with cirrhosis undergoing metabolic surgery have a higher perioperative risk than the general population, reported mortality and complication rates are less than expected compared to other major abdominal procedures. A multidisciplinary team approach is recommended for the management of bariatric surgery patients with cirrhosis in order to optimize outcomes.