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Madenci AL, Kurgansky KE, Dickerman BA, Gerlovin H, Wanis KN, Smith AD, Trinqart L, Gagnon DR, Cho K, Gaziano JM, Casas JP, Robins JM, Hernán MA. Estimating the Effect of Bariatric Surgery on Cardiovascular Events Using Observational Data? Epidemiology 2024; 35:721-729. [PMID: 39024034 DOI: 10.1097/ede.0000000000001765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND Observational studies have reported strongly protective effects of bariatric surgery on cardiovascular disease, but with oversimplified definitions of the intervention, eligibility criteria, and follow-up, which deviate from those in a randomized trial. We describe an attempt to estimate the effect of bariatric surgery on cardiovascular disease without introducing these sources of bias, which may not be entirely possible with existing observational data. METHODS We propose two target trials among persons with diabetes: (1) bariatric operation (vs. no operation) among individuals who have undergone preoperative preparation (lifestyle modifications and screening) and (2) preoperative preparation and a bariatric operation (vs. neither preoperative nor operative component). We emulated both target trials using observational data of US veterans. RESULTS Comparing bariatric surgery with no surgery (target trial #1; 8,087 individuals), the 7-year cardiovascular risk was 18.0% (95% CI = 6.9, 32.7) in the surgery group and 18.9% (95% CI = 17.7, 20.1) in the no-surgery group (risk difference -0.9, 95% CI = -12.0, 14.0). Comparing preoperative components plus surgery vs. neither (target trial #2; 10,065 individuals), the 7-year cardiovascular risk was 17.4% (95% CI = 13.6, 22.0) in the surgery group and 18.8% (95% CI = 17.8, 19.9) in the no-surgery group (risk difference -1.4, 95% CI = -5.1, 3.2). Body mass index and hemoglobin A1c were reduced with bariatric interventions in both emulations. CONCLUSIONS Within limitations of available observational data, our estimates do not provide evidence that bariatric surgery reduces cardiovascular disease and support equipoise for a randomized trial of bariatric surgery for cardiovascular disease prevention.
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Affiliation(s)
- Arin L Madenci
- From the CAUSALab, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | - Barbra A Dickerman
- From the CAUSALab, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Kerollos Nashat Wanis
- From the CAUSALab, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Surgery, Western University, London, ON
| | - Ann D Smith
- Veterans Affairs Boston Healthcare System, Boston, MA
| | - Ludovic Trinqart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - David R Gagnon
- Veterans Affairs Boston Healthcare System, Boston, MA
- Boston University School of Public Health, Boston, MA
| | - Kelly Cho
- Veterans Affairs Boston Healthcare System, Boston, MA
| | - J Michael Gaziano
- Veterans Affairs Boston Healthcare System, Boston, MA
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Juan P Casas
- Veterans Affairs Boston Healthcare System, Boston, MA
| | - James M Robins
- From the CAUSALab, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Miguel A Hernán
- From the CAUSALab, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
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Ghannadi S, Selk-Ghaffari M, Ejtahed HS, Khalaji K, Hoseini Tavassol Z, Pourgharib Shahi MH, Hasani-Ranjbar S. Evaluation of the Effect of the Pre-Operative Exercise Training on Weight Loss, Quality of Life, and Cardiopulmonary Parameter in Bariatric Metabolic Surgery: A Systematic Review and Meta-Analysis. Obes Surg 2024; 34:2670-2684. [PMID: 38856886 DOI: 10.1007/s11695-024-07333-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/11/2024]
Abstract
The purpose of this study is to assess the impact of pre-surgery exercise training on cardiopulmonary fitness. Ten articles (six RCTs and four non-RCTs) involving 281 individuals were finally included in the synthesis. Regarding the effect on VO2 peak, overall standardized mean differences were 0.71 (95% CI, 0.31 to 1.11, n = 103) with heterogeneity (I2 = 0%, P = 0.49). For 6MWT, overall weighted mean differences (distance in meters) were 31.87 (95% CI, 27.84 to 35.89, n = 100) with heterogeneity (I2 = 0%, P = 0.96). Engaging in pre-bariatric metabolic surgery exercise training might improve anthropometric parameters and cardiopulmonary fitness with no significant changes in components of quality of life. However, considering high levels of heterogeneity, the results should be generalized cautiously.
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Affiliation(s)
- Shima Ghannadi
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Selk-Ghaffari
- Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hanieh-Sadat Ejtahed
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Khalaji
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Osteoporosis Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Hoseini Tavassol
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Shirin Hasani-Ranjbar
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Saleh OS, Farag YMK, Medhati P, Tavakkoli A. Impact of Preoperative Weight Loss on 30-Day Complication Rate after Bariatric Surgery. J Am Coll Surg 2024; 238:993-999. [PMID: 38345226 DOI: 10.1097/xcs.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND The aim of this study is to evaluate the impact of preoperative weight loss on surgical outcomes and operating room (OR) times after primary bariatric procedures, including laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (RYGB). STUDY DESIGN A retrospective cohort study uses the 2021 MBSAQIP dataset. Preoperative total weight loss (TWL)% was calculated. Patients were then divided in to 4 groups: those with no weight loss, lost <0 to <5%, lost ≥5% to <10%, or lost ≥10% TWL preoperatively. These groups were then stratified into those with BMI less than 50 kg/m 2 and those with BMI 50 kg/m 2 or more and 30-day outcomes and OR times were compared. RESULTS Analysis included 171,010 patients. For BMI less than 50 kg/m 2 , preoperative weight loss led to no consistent improvement in surgical outcomes. Although >0% to <5% TWL led to a decrease in intra- and postoperative occurrences after RYGB and a decrease in reoperation rates after LSG, these observations were not seen in those with higher degree of weight loss. In patients with BMI 50 kg/m 2 or more, preoperative weight loss showed a consistent improvement in reintervention rates after LSG, and readmission rates after RYGB. There was no improvement in other outcomes, however, irrespective of degree of preoperative weight loss. CONCLUSIONS In patients undergoing primary bariatric surgery, preoperative weight loss does not lead to a consistent improvement in outcomes or OR times. In those with BMI 50 kg/m 2 or more, there may be improvement in select outcomes that is procedure-specific. Overall, these data do not support a uniform policy of preoperative weight loss, although selective use in some high-risk patients may be appropriate.
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Affiliation(s)
- Omnia S Saleh
- From the Department of Surgery, Laboratory for Surgical and Metabolic Research (Saleh, Medhati, Tavakkoli), Harvard Medical School, Boston, MA
| | - Youssef M K Farag
- Brigham and Women's Hospital, Postgraduate Medical Education (Farag), Harvard Medical School, Boston, MA
- Bayer US LLC, Cambridge, MA (Farag)
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Farag)
| | - Pourya Medhati
- From the Department of Surgery, Laboratory for Surgical and Metabolic Research (Saleh, Medhati, Tavakkoli), Harvard Medical School, Boston, MA
| | - Ali Tavakkoli
- From the Department of Surgery, Laboratory for Surgical and Metabolic Research (Saleh, Medhati, Tavakkoli), Harvard Medical School, Boston, MA
- Division of General and GI Surgery (Tavakkoli), Harvard Medical School, Boston, MA
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Feng T, Hu S, Song C, Zhong M. Establishment of a novel weight reduction model after laparoscopic sleeve gastrectomy based on abdominal fat area. Front Surg 2024; 11:1390045. [PMID: 38826810 PMCID: PMC11140024 DOI: 10.3389/fsurg.2024.1390045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/17/2024] [Indexed: 06/04/2024] Open
Abstract
In light of ongoing research elucidating the intricacies of obesity and metabolic syndrome, the role of abdominal fat (especially visceral fat) has been particularly prominent. Studies have revealed that visceral adipose tissue can accelerate the development of metabolic syndrome by releasing various bioactive compounds and hormones, such as lipocalin, leptin and interleukin. A retrospective analysis was performed on the clinical data of 167 patients with obesity. Among them, 105 patients who satisfied predefined inclusion and exclusion criteria were included. The parameters evaluated included total abdominal fat area (TAFA), laboratory indicators and anthropometric measurements. Weight reduction was quantified through percent total weight loss (%TWL) and percent excess weight loss (%EWL) postoperatively. Binary logistic regression analysis and receiver operating characteristic (ROC) curve analysis were employed to identify predictors of weight loss. Binary logistic regression analysis emphasized that total abdominal fat area was an independent predictor of %EWL ≥75% (p < 0.001). Total abdominal fat area (p = 0.033) and BMI (p = 0.003) were independent predictors of %TWL ≥30%. In our cohort, %TWL ≥30% at 1 year after surgery was closely related to the abdominal fat area and BMI. Based on these results, we formulated a novel model based on these factors, exhibiting superior predictive value for excellent weight loss.
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Affiliation(s)
- Tianyi Feng
- Department of General Surgery, Shandong Provincial Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Sanyuan Hu
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Changrong Song
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong Province, China
| | - Mingwei Zhong
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong Province, China
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Muñoz MPS, Blandón JDR, Gutierrez ISC, Mendoza CMM, Aguiñaga MSA, Orozco CAO. Liraglutide effectiveness in preoperative weight-loss for patients with severe obesity undergoing bariatric-metabolic surgery. Updates Surg 2024:10.1007/s13304-024-01828-0. [PMID: 38573447 DOI: 10.1007/s13304-024-01828-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024]
Abstract
Preoperative management of patients living with severe obesity can be challenging; in this context, the preoperative weight loss may help to obtain better outcomes and less morbidity for bariatric surgery. Therefore, we evaluated the effectiveness of GLP-1 analogue Liraglutide in preoperative weight loss. We performed a single-center, quasi-experimental prospective study. Eligible participants were adults in preoperative management for bariatric-metabolic surgery with body-mass index ≥ 48 kg/m2. All patients were assigned liraglutide treatment, with an initial dose of 0.6 mg subcutaneous per day, the dose was increased each week until reaching 3.0 mg for 12 weeks. Weight loss and body composition were evaluated monthly using bioelectric impedance (BIA) (InBody 770 Scale®). We analyzed data using descriptive statistics, central tendency measures and dispersion for quantitative variables and absolute and relative frequencies for qualitative variables. A total of 37 individuals were included in this study, 28 (76%) were female and 9 (24%) were males, with an average age of 44 years. About the BMI, 19 patients (51%) had a BMI > 50 kg/m2, 10 (27%) > 40 kg/m2 and 8 (22%) > 60 kg/m2; with a total average BMI of 56.04 kg/m2. The initial weight was 147.4 ± 14.9 kg which decreased to 139.3 ± 16.8 kg; after 3 months of liraglutide administration. A total of 35 patients had some degree of weight loss (94.6%), while 2 (5.40%) had no weight changes. The total weight loss was 5.50% at 3 months of liraglutide treatment. Liraglutide could be an effective adjuvant therapy for preoperative weight loss in patients living with severe obesity.
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Affiliation(s)
- Martha Patricia Sánchez Muñoz
- Bariatric and Metabolic Surgery Department, Nuevo Hospital Civil de Guadalajara "Dr Juan I Menchaca", Guadalajara, Jalisco, Mexico
| | | | | | - Carlos Manuel Moreno Mendoza
- Bariatric and Metabolic Surgery Department, Nuevo Hospital Civil de Guadalajara "Dr Juan I Menchaca", Guadalajara, Jalisco, Mexico
| | - Ma Soledad Aldana Aguiñaga
- Bariatric and Metabolic Surgery Department, Nuevo Hospital Civil de Guadalajara "Dr Juan I Menchaca", Guadalajara, Jalisco, Mexico
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Wong J, Li X, Arterburn DE, Li D, Messenger-Jones E, Wang R, Toh S. Using Claims Data to Predict Pre-Operative BMI Among Bariatric Surgery Patients: Development of the BMI Before Bariatric Surgery Scoring System (B3S3). Pragmat Obs Res 2024; 15:65-78. [PMID: 38559704 PMCID: PMC10981874 DOI: 10.2147/por.s450229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/19/2024] [Indexed: 04/04/2024] Open
Abstract
Background Lack of body mass index (BMI) measurements limits the utility of claims data for bariatric surgery research, but pre-operative BMI may be imputed due to existence of weight-related diagnosis codes and BMI-related reimbursement requirements. We used a machine learning pipeline to create a claims-based scoring system to predict pre-operative BMI, as documented in the electronic health record (EHR), among patients undergoing a new bariatric surgery. Methods Using the Optum Labs Data Warehouse, containing linked de-identified claims and EHR data for commercial or Medicare Advantage enrollees, we identified adults undergoing a new bariatric surgery between January 2011 and June 2018 with a BMI measurement in linked EHR data ≤30 days before the index surgery (n=3226). We constructed predictors from claims data and applied a machine learning pipeline to create a scoring system for pre-operative BMI, the B3S3. We evaluated the B3S3 and a simple linear regression model (benchmark) in test patients whose index surgery occurred concurrent (2011-2017) or prospective (2018) to the training data. Results The machine learning pipeline yielded a final scoring system that included weight-related diagnosis codes, age, and number of days hospitalized and distinct drugs dispensed in the past 6 months. In concurrent test data, the B3S3 had excellent performance (R2 0.862, 95% confidence interval [CI] 0.815-0.898) and calibration. The benchmark algorithm had good performance (R2 0.750, 95% CI 0.686-0.799) and calibration but both aspects were inferior to the B3S3. Findings in prospective test data were similar. Conclusion The B3S3 is an accessible tool that researchers can use with claims data to obtain granular and accurate predicted values of pre-operative BMI, which may enhance confounding control and investigation of effect modification by baseline obesity levels in bariatric surgery studies utilizing claims data.
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Affiliation(s)
- Jenna Wong
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Optum Labs Visiting Fellow, Eden Prairie, MN, USA
| | - Xiaojuan Li
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Dongdong Li
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
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7
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Krause M, Mehdipour S, Veerapong J, Baumgartner JM, Lowy AM, Gabriel RA. Development of a predictive model for risk stratification of acute kidney injury in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Sci Rep 2024; 14:6630. [PMID: 38503776 PMCID: PMC10951241 DOI: 10.1038/s41598-024-54979-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/19/2024] [Indexed: 03/21/2024] Open
Abstract
Acute kidney injury (AKI) following hyperthermic intraperitoneal chemotherapy (HIPEC) is common. Identifying patients at risk could have implications for surgical and anesthetic management. We aimed to develop a predictive model that could predict AKI based on patients' preoperative characteristics and intraperitoneal chemotherapy regimen. We retrospectively gathered data of adult patients undergoing HIPEC at our health system between November 2013 and April 2022. Next, we developed a model predicting postoperative AKI using multivariable logistic regression and calculated the performance of the model (area under the receiver operating characteristics curve [AUC]) via tenfold cross-validation. A total of 412 patients were included, of which 36 (8.7%) developed postoperative AKI. Based on our multivariable logistic regression model, multiple preoperative and intraoperative characteristics were associated with AKI. We included the total intraoperative cisplatin dose, body mass index, male sex, and preoperative hemoglobin level in the final model. The mean area under the receiver operating characteristics curve value was 0.82 (95% confidence interval 0.71-0.93). Our risk model predicted AKI with high accuracy in patients undergoing HIPEC in our institution. The external validity of our model should now be tested in independent and prospective patient cohorts.
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Affiliation(s)
- Martin Krause
- Division of Perioperative Informatics, Department of Anesthesiology, University of California San Diego, 200 West Arbor Drive, San Diego, CA, 80203, USA.
| | - Soraya Mehdipour
- Division of Perioperative Informatics, Department of Anesthesiology, University of California San Diego, 200 West Arbor Drive, San Diego, CA, 80203, USA
| | - Jula Veerapong
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Andrew M Lowy
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Division of Perioperative Informatics, Department of Anesthesiology, University of California San Diego, 200 West Arbor Drive, San Diego, CA, 80203, USA
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Tsilingiris D, Kokkinos A. Advances in obesity pharmacotherapy; learning from metabolic surgery and beyond. Metabolism 2024; 151:155741. [PMID: 37995806 DOI: 10.1016/j.metabol.2023.155741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/05/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
Currently, metabolic surgery (MS) constitutes the most effective means for durable weight loss of clinically meaningful magnitude, type 2 diabetes remission and resolution of non-alcoholic steatohepatitis, as well as other obesity-related comorbidities. Accumulating evidence on the mechanisms through which MS exerts its actions has highlighted the altered secretion of hormonally active peptides of intestinal origin with biological actions crucial to energy metabolism as key drivers of MS clinical effects. The initial success of glucagon-like peptide-1 (GLP-1) receptor agonists regarding weight loss and metabolic amelioration have been followed by the development of unimolecular dual and triple polyagonists, additionally exploiting the effects of glucagon and/or glucose-dependent insulinotropic polypeptide (GIP) which achieves a magnitude of weight loss approximating that of common MS operations. Through the implementation of such therapies, the feasibility of a "medical bypass", namely the replication of the clinical effects of MS through non-surgical interventions may be foreseeable in the near future. Apart from weight loss, this approach ought to be put to the test also regarding other clinical outcomes, such as liver steatosis and steatohepatitis, cardiovascular disease, and overall prognosis, on which MS has a robustly demonstrated impact. Besides, a medical bypass as an alternative, salvage, or combination strategy to MS may promote precision medicine in obesity therapeutics.
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Affiliation(s)
- Dimitrios Tsilingiris
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Alexander Kokkinos
- 1st Department of Propaedeutic Internal Medicine, Athens University Medical School, Laiko Hospital, Athens, Greece.
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Casson C, Blatnik J, Majumder A, Holden S. Is weight trajectory a better marker of wound complication risk than BMI in hernia patients with obesity? Surg Endosc 2024; 38:1005-1012. [PMID: 38082008 DOI: 10.1007/s00464-023-10596-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 11/14/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Complex ventral hernias are frequently repaired via an open transversus abdominis release (TAR). Obesity, particularly a BMI > 40, is a strong predictor of wound morbidity following this procedure. We aimed to determine if preoperative weight loss may still be beneficial in patients with persistently elevated BMIs. METHODS A retrospective chart review of patients with obesity (BMI ≥ 30) who underwent open TAR at a tertiary academic medical center from January 2018 to December 2021 was completed. Demographics, medical history, operative details, and postoperative data were analyzed. Weight and BMI were recorded at three time points: > 6 months prior to initial surgical consultation, surgical consultation, and day of surgery. RESULTS In total, 182 patients with obesity underwent an open TAR. Twenty-seven patients (14.8%) underwent surgery with a BMI > 40; they did not have any significant differences in surgical site occurrences (SSO, 48.1% vs 32.9%, p = 0.13) or surgical site infections (SSI, 25.9% vs 23.2%, p = 0.76) compared to those with a BMI ≤ 40. The average timeframe analyzed for preoperative weight loss was 592 days. Patients who had at least a 3% weight loss (n = 49, 26.9%) had decreased rates of SSI compared to those who did not have this weight loss (12.2% vs 27.8%, p = 0.03), despite the groups having similar BMIs at the time of surgery (36.4 vs 36.0, p = 0.50). Patients who only had a 1% weight loss did not see a decrease in SSI rate compared to those who did not (20.6% vs 25.4%, p = 0.45). CONCLUSION Weight loss may be a better indicator of a patient's risk for wound morbidity following TAR than BMI alone, as weight loss of at least 3% resulted in fewer SSIs despite similar BMIs at time of surgery. Further research into optimal timing and amount of weight loss, as well as effects on long-term outcomes, is needed to confirm these findings.
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Affiliation(s)
- Cameron Casson
- Division of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, Saint Louis, MO, 63110, USA.
| | - Jeffrey Blatnik
- Division of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, Saint Louis, MO, 63110, USA
| | - Arnab Majumder
- Division of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, Saint Louis, MO, 63110, USA
| | - Sara Holden
- Division of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, Saint Louis, MO, 63110, USA
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Murphy E, Finucane FM. Addressing uncertainty about the role of structured lifestyle modification for metabolic surgery patients. Metabolism 2024; 151:155739. [PMID: 37984732 DOI: 10.1016/j.metabol.2023.155739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Abstract
There is good evidence that structured lifestyle modification programmes improve health in patients with metabolic and cardiovascular disorders, but there is no specific evidence that they improve outcomes in patients undergoing metabolic or obesity surgery. Despite expert consensus guidelines stating this fact, some healthcare systems still compel patients to participate in a structured lifestyle modification programme prior to metabolic or obesity surgery. There is a well-established need for individualised multidisciplinary dietetic and physical activity care for metabolic and obesity surgery patients, and the benefits of intentional weight loss prior to surgery are well proven, but these are distinct from potentially harmful requirements for patients to undertake compulsory structured lifestyle programmes of fixed duration, frequency and intensity, which may delay surgery and reinforce obesity stigma. A critical step in rejuvenating metabolic surgery is to reframe patient participation in structured lifestyle modification programmes as an opportunity for education and empowerment, not as an indicator of motivation or suitability for metabolic surgery. Large, well-designed and adequately powered clinical trials are needed to address uncertainties in the evidence base for these programmes. Given genuine equipoise, they will need to determine whether "surgery plus lifestyle" is superior to "surgery plus placebo". Moreover, they will need to determine the cost-effectiveness of these programmes and identify some of the factors giving rise to the substantial heterogeneity in responses to structured lifestyle modification.
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Affiliation(s)
- Enda Murphy
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Saolta Health Care Group, Galway, Ireland; HRB Clinical Research Facility, University of Galway and Saolta University Health Care Group, Ireland; Cúram, University of Galway, Ireland.
| | - Francis M Finucane
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Saolta Health Care Group, Galway, Ireland; HRB Clinical Research Facility, University of Galway and Saolta University Health Care Group, Ireland; Cúram, University of Galway, Ireland
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Kokkorakis M, Katsarou A, Katsiki N, Mantzoros CS. Milestones in the journey towards addressing obesity; Past trials and triumphs, recent breakthroughs, and an exciting future in the era of emerging effective medical therapies and integration of effective medical therapies with metabolic surgery. Metabolism 2023; 148:155689. [PMID: 37689110 DOI: 10.1016/j.metabol.2023.155689] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/11/2023]
Abstract
The 21st century is characterized by an increasing incidence and prevalence of obesity and the burden of its associated comorbidities, especially cardiometabolic diseases, which are reaching pandemic proportions. In the late '90s, the "black box" of adipose tissue and energy homeostasis was opened with the discovery of leptin, transforming the adipose tissue from an "inert fat-storage organ" to the largest human endocrine organ and creating the basis on which more intensified research efforts to elucidate the pathogenesis of obesity and develop novel treatments were based upon. Even though leptin was eventually not proven to be the "standalone magic bullet" for the treatment of common/polygenic obesity, it has been successful in the treatment of monogenic obesity syndromes. Additionally, it shifted the paradigm of treating obesity from a condition due to "lack of willpower" to a disease due to distinct underlying biological mechanisms for which specific pharmacotherapies would be needed in addition to lifestyle modification. Subsequently, the melanocortin pathway proved to be an equally valuable pathway for the pharmacotherapy of obesity. Melanocortin receptor agonists have recently been approved for treating certain types of syndromic obesity. Other molecules- such as incretins, implicated in energy and glucose homeostasis- are secreted by the gastrointestinal tract. Glucagon-like peptide 1 (GLP-1) is the most prominent one, with GLP-1 analogs approved for common/polygenic obesity. Unimolecular combinations with other incretins, e.g., GLP-1 with gastric inhibitory polypeptide and/or glucagon, are expected to be approved soon as more effective pharmacotherapies for obesity and its comorbidities. Unimolecular combinations with other compounds and small molecules activating the receptors of these molecules are currently under investigation as promising future pharmacotherapies. Moreover, metabolic and bariatric surgery has also demonstrated impressive results, especially in the case of morbid obesity. Consequently, this broadening therapeutic armamentarium calls for a well-thought-after and well-coordinated multidisciplinary approach, for instance, through cardiometabolic expertise centers, that would ideally address effectively and cost-effectively obesity and its comorbidities, providing tangible benefits to large segments of the population.
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Affiliation(s)
- Michail Kokkorakis
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Angeliki Katsarou
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Niki Katsiki
- Department of Nutritional Sciences and Dietetics, International Hellenic University, 57400 Thessaloniki, Greece
| | - Christos S Mantzoros
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; Section of Endocrinology, VA Boston Healthcare System, Harvard Medical School, Boston, MA 02115, USA.
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Henao Carrillo DC, Gómez AM, Muñoz OM, Rubio C, Rodríguez N, Ursida V, Forero AM, Pinzón F, Mikler R. Factors associated with different patterns of weight change after bariatric surgery: A longitudinal study. Obes Sci Pract 2023; 9:477-483. [PMID: 37810525 PMCID: PMC10551117 DOI: 10.1002/osp4.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/03/2023] [Accepted: 04/16/2023] [Indexed: 10/10/2023] Open
Abstract
Background The mean weight loss (WL) after successful bariatric surgery is approximately one third of the initial body weight, which is mainly achieved between the first 2 years of follow-up. However, 15%-35% of patients do not achieve a significant percentage of total WL (%TWL). Information on factors associated with a higher or lower WL after bariatric surgery is limited. This study aimed to assess the change in %TWL and describe the factors associated with greater or lesser WL over time. Methods This prospective longitudinal study included patients treated with laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. Baseline data were recorded before surgery. Follow-up was performed at 3 (n = 141), 6 (n = 208), 9 (n = 115), 12 (n = 216), 24 (n = 166), and 36 months (n = 99). Generalized estimating equation analysis was performed to assess the changes in %TWL over time and factors associated with different patterns of WL. Results In total, 231 patients were included (women, 82.2%; basal body mass index (BMI) 41.4 ± 5.1 kg/m2). The tendencies to increase %TWL (32 ± 6.5) were evident in the first year and stabilized thereafter. Sustained nutritionist follow-up (2.3%, p = 0.004), baseline BMI >40 kg/m2 (0.4%, p < 0.001), and WL ≥ 10 kg before surgery (0.3%, p = 0.001) were associated with a higher %TWL. Patients who performed physical activity >30 min/day after surgery reduced their %TWL by 0.6% (p = 0.002). Conclusions Modifiable factors such as nutritional monitoring and WL before surgery are associated with a significant increase in %TWL over time. Basal BMI was associated with a significant decrease in %TWL.
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Affiliation(s)
| | - Ana María Gómez
- Pontificia Universidad JaverianaBogotáColombia
- Endocrinology UnitHospital Universitario San IgnacioBogotáColombia
| | - Oscar M. Muñoz
- Pontificia Universidad JaverianaBogotáColombia
- Internal Medicine DepartmentHospital Universitario San IgnacioBogotáColombia
| | - Claudia Rubio
- Endocrinology UnitHospital Universitario San IgnacioBogotáColombia
- Surgery DepartmentHospital Universitario San IgnacioBogotáColombia
| | | | | | | | - Fabio Pinzón
- Nutrition DepartmentHospital Universitario San IgnacioBogotáColombia
| | - Rami Mikler
- Nutrition DepartmentHospital Universitario San IgnacioBogotáColombia
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Koutoukidis DA, Jebb SA, Foster C, Wheatstone P, Horne A, Hill TM, Taylor A, Realpe A, Achana F, Buczacki SJA. CARE: Protocol of a randomised trial evaluating the feasibility of preoperative intentional weight loss to support postoperative recovery in patients with excess weight and colorectal cancer. Colorectal Dis 2023; 25:1910-1920. [PMID: 37525408 DOI: 10.1111/codi.16687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 08/02/2023]
Abstract
AIM Excess weight increases the risk of morbidity following colorectal cancer surgery. Weight loss may improve morbidity, but it is uncertain whether patients can follow an intensive weight loss intervention while waiting for surgery and there are concerns about muscle mass loss. The aim of this trial is to assess the feasibility of intentional weight loss in this setting and determine progression to a definitive trial. METHODS CARE is a prospectively registered, multicentre, feasibility, parallel, randomised controlled trial with embedded evaluation and optimisation of the recruitment process. Participants with excess weight awaiting curative colorectal resection for cancer are randomised 1:1 to care as usual or a low-energy nutritionally-replete total diet replacement programme with weekly remote behavioural support by a dietitian. Progression criteria will be based on the recruitment, engagement, adherence, and retention rates. Data will be collected on the 30-day postoperative morbidity, the typical primary outcome of prehabilitation trials. Secondary outcomes will include, among others, length of hospital stay, health-related quality of life, and body composition. Qualitative interviews will be used to understand patients' experiences of and attitudes towards trial participation and intervention engagement and adherence. CONCLUSION CARE will evaluate the feasibility of intensive intentional weight loss as prehabilitation before colorectal cancer surgery. The results will determine the planning of a definitive trial.
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Affiliation(s)
- Dimitrios A Koutoukidis
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Claire Foster
- Centre for Psychosocial Research in Cancer: CentRIC+ in Health Sciences, University of Southampton, Southampton, UK
| | | | - Alison Horne
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - T Martyn Hill
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Amy Taylor
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
| | - Felix Achana
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon J A Buczacki
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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14
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Reed BL, Jackson DG, Lilly C, Abunnaja S, Tabone LE, Szoka NL. Preoperative Weight Loss as a Predictor of Short and Midterm Postoperative Weight Loss in Patients Undergoing Bariatric Surgery. Bariatr Surg Pract Patient Care 2023; 18:8-12. [PMID: 36950501 PMCID: PMC10027342 DOI: 10.1089/bari.2021.0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective To examine if preoperative weight loss correlates to postoperative weight loss 2 and 3 years after surgery. Methods A review was conducted of bariatric surgery patients who underwent either gastric bypass or sleeve gastrectomy during 2015-2018 and had 3-year follow-up data. Demographic and outcome data were collected. A best-fit regression model for weight loss was constructed. Results Eight hundred fifty-nine patients underwent surgery during the selected period, of which 199 patients (23%) were analyzed. Eighty-two percent of patients had gastric bypass and 82% were female. Preoperative percent excess weight loss (%EWL) was not significantly associated with 2- and 3-year postoperative %EWL (p = 0.18). Patients demonstrated significant weight regain at 3 years postoperatively versus 1 year (p < 0.01). Higher preoperative weight loss was associated with lower %EWL 3 years postoperatively versus 1 year (p = 0.04). Postoperative %EWL had a significant negative association with higher preoperative weight, diabetes, baseline use of a mobility device, and sleeve gastrectomy. Conclusions In a cohort of bariatric surgery patients, there was no statistically significant association between preoperative and midterm postoperative %EWL. Postoperative %EWL was negatively associated with several patient-specific factors and increasing time since operation.
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Affiliation(s)
- Benjamin L. Reed
- Division of Bariatric Surgery, Department of Surgery, WVU School of Medicine, Morgantown, West Virginia, USA
| | - David G. Jackson
- Division of Bariatric Surgery, Department of Surgery, WVU School of Medicine, Morgantown, West Virginia, USA
| | - Christa Lilly
- Department of Epidemiology and Biostatistics, WVU School of Public Health, Morgantown, West Virginia, USA
| | - Salim Abunnaja
- Division of Bariatric Surgery, Department of Surgery, WVU School of Medicine, Morgantown, West Virginia, USA
| | - Lawrence E. Tabone
- Division of Bariatric Surgery, Department of Surgery, WVU School of Medicine, Morgantown, West Virginia, USA
| | - Nova L. Szoka
- Division of Bariatric Surgery, Department of Surgery, WVU School of Medicine, Morgantown, West Virginia, USA
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Personality traits and preoperative lifestyle improvement are predictors of early weight loss after sleeve gastrectomy. Surg Today 2023:10.1007/s00595-023-02659-z. [PMID: 36792834 DOI: 10.1007/s00595-023-02659-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/18/2022] [Indexed: 02/17/2023]
Abstract
PURPOSE This study investigated the associations of personality traits and preoperative lifestyle improvements with early weight loss after sleeve gastrectomy. METHODS This was a single-center, retrospective study of 57 patients who underwent preoperative lifestyle intervention with a multidisciplinary team approach based on cognitive behavioral therapy before sleeve gastrectomy. All patients underwent preoperative psychological testing with the Neuroticism-Extraversion-Openness Five-Factor Inventory (NEO-FFI) and the Tokyo University Egogram New Version II (TEG II). We investigated the associations of psychological testing results and lifestyle improvements with percent total weight loss (%TWL) one year after surgery. RESULTS The median %TWL at 1 year was 38.2% for patients with an improved lifestyle and 26.9% for those without improvement (P = 0.0008). Although TEG II factors were not associated with %TWL at 1 year, higher NEO-FFI extraversion (E) scores were significantly associated with a better %TWL at 1 year. The median %TWL at 1 year was 35.2% for patients with higher E scores and 25.4% for those with lower E scores (P = 0.0247). Lifestyle improvement and the NEO-FFI E score significantly influenced %TWL at 1 year based on a logistic regression analysis. CONCLUSION The NEO-FFI E score and preoperative lifestyle improvement may be predictors of early weight loss after sleeve gastrectomy.
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Abbott S, Price C, Pournaras DJ, Coulman K. Variation and outcomes of liver-reducing dietary regimens before bariatric surgery: a national retrospective cohort study. Surg Obes Relat Dis 2023; 19:102-108. [PMID: 36464608 DOI: 10.1016/j.soard.2022.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 09/13/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Liver-reducing diets (LRDs) are mandated prior to bariatric surgery, but there are no guidelines on their implementation. OBJECTIVE To establish the variation and effectiveness of LRDs utilized in clinical practice. SETTING A nationwide, multicenter, retrospective cohort study. METHODS A total of 1699 adult patients across 14 bariatric centers in the United Kingdom were included. Multilevel logistic regression models were developed to examine factors predictive of 5% weight loss. RESULTS Most centers (n = 9) prescribed an 800- to 1000-kcal diet, but the duration and formulation of diet was variable. Overall, 30.6% (n = 510) of patients achieved 5% weight loss during the LRD. After adjustment for preoperative weight, women had reduced odds (odds ratio [OR], .65; 95% confidence interval [CI], .48-.88; P = .005), while increasing age (OR, 1.01; 95% CI, 1.00-1.02; P = .043) and having type 2 diabetes (OR, 1.49; 95% CI, 1.16-1.92; P = .002) increased odds of 5% weight loss. A normal consistency food LRD (OR, .64; 95% CI, .42-.98; P = .041) and energy prescription of >1200 kcals/d (OR, .33; 95% CI, .13-.83; P = .019) reduced odds, while an LRD with a duration of 3 weeks (OR, 2.28; 95% CI, 1.02-5.09; P = .044) or greater increased odds of 5% weight loss. CONCLUSIONS There is wide variation in how LRDs are delivered in clinical practice, highlighting the need for an evidence-based consensus. Our findings suggest the optimal LRD before bariatric surgery contains 800 to 1200 kcals/d over a duration of 3 to 4 weeks. Further research is required to determine the optimal formulation of LRD and whether women may require a lower-energy LRD than men.
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Affiliation(s)
- Sally Abbott
- Specialist Weight Management Service, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom; Research Centre for Intelligent Healthcare, Coventry University, Coventry, United Kingdom.
| | - Charlotte Price
- Sigma, Coventry University, Frederick Lanchester Library, Coventry, United Kingdom
| | - Dimitrios J Pournaras
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; Bristol Weight Management and Bariatric Service, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
| | - Karen Coulman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; Bristol Weight Management and Bariatric Service, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
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Despite regression of healthy lifestyle habits, weight loss after bariatric surgery is not affected during the COVID-19 pandemic. Surg Endosc 2023; 37:607-612. [PMID: 35697849 PMCID: PMC9191545 DOI: 10.1007/s00464-022-09356-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 05/16/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND The coronavirus pandemic has caused a worldwide health crisis. Bariatric patients require extensive pre- and post-operative follow-up, which may be less feasible during public health social distancing mandates. We assessed the impact of the pandemic on the behaviors and weight loss outcomes of our pre- and post-operative bariatric patients. METHODS A retrospective review of a prospectively maintained database identified patients who underwent either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at a single institution between March 2018 and May 2020. A cohort undergoing surgery within 12 months before the pandemic as well as a cohort undergoing a medically supervised diet prior to surgery was surveyed regarding pre- and post-COVID-19 lifestyle habits. Excess weight loss (EWL) outcomes from a group of pre-COVID surgical patients were compared to that of a group of post-COVID surgical patients. Primary outcome was whether the lockdown changed 1-year weight loss outcomes. Secondary outcome was whether patient lifestyle behaviors were changed during the pandemic. RESULTS There was no difference in 1-year EWL between pre- and post-COVID SG patients (51.7% versus 55.9%, p = 0.35), or between pre- and post-COVID RYGB patients (88.9% versus 80.4%, p = 0.42). Pre-stay-at-home order, 91.8% endorsed physical activity compared to 80.3% post-stay-at-home order (p = 0.0025). Mean physical activity decreased from 4.2 h/week to 2.7 h/week after the stay-at-home order (p < 0.0001). Additionally, 41.3% reported worsened dietary habits post-stay-at-home order. CONCLUSION The COVID-19 pandemic has greatly impacted the behaviors of bariatric surgery patients. Despite deterioration of lifestyle habits, 1-year weight loss outcomes after bariatric surgery remained the same before and after the instatement of social distancing measures. In the short term, the biological effect of metabolic procedures may mask the effects of suboptimal diet and physical activity, but more studies are necessary to better assess the impact of COVID-19 on outcomes after bariatric surgery.
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Barski K, Binda A, Jaworski P, Gonciarska A, Kudlicka E, Żurkowska J, Wawiernia K, Tałałaj M, Wąsowski M, Tarnowski W. Influence of preoperative weight loss on gastric wall thickness-analysis of laparoscopic sleeve gastrectomy histological material. Langenbecks Arch Surg 2022; 407:3315-3322. [PMID: 36074187 DOI: 10.1007/s00423-022-02668-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/26/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE The variables possibly enabling the prediction of gastric wall thickness during laparoscopic sleeve gastrectomy remain undetermined. The aim of the study was to identify preoperative factors affecting gastric wall thickness in patients undergoing laparoscopic sleeve gastrectomy. METHODS The measurements of the double-wall thickness of gastric specimen excised during sleeve gastrectomy were taken at three locations after 15 s of compression with an applied pressure of 8 g/mm2. Statistical calculations were used to determine the influence of preoperative weight loss and other perioperative parameters on gastric wall thickness. RESULTS The study involved one hundred patients (78 female; 22 male). The thickest tissue was observed at the antrum with the mean value 2.55 mm (range 1.77-4.0 mm), followed by the midbody, mean 2.13 mm (range 1.34-3.20 mm), and the fundus, mean 1.69 mm (range 0.99-2.69 mm). Positive relationships were found between gastric wall thickness and both preoperative weight loss and age in all three measured locations; p < 0.05. In a linear regression model, age and preoperative weight loss were found to be statistically significant and positive predictors of higher gastric wall thickness only at the antrum. Male patients were observed to have thicker gastric wall at all three locations as compared to female patients. CONCLUSION Preoperative weight loss should be considered an important factor influencing gastric wall thickness. Age and gender can also be helpful in predicting the varying tissue thickness. Anatomical region is a key factor determining thickness of the stomach walls.
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Affiliation(s)
- Krzysztof Barski
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Artur Binda
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland.
| | - Paweł Jaworski
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Agnieszka Gonciarska
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Emilia Kudlicka
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Joanna Żurkowska
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Karolina Wawiernia
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Marek Tałałaj
- Geriatrics, Internal Medicine and Metabolic Bone Diseases Department, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Michał Wąsowski
- Geriatrics, Internal Medicine and Metabolic Bone Diseases Department, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
| | - Wiesław Tarnowski
- Department of General, Oncological and Digestive Tract Surgery, Centre of Postgraduate Medical Education, Orlowski Hospital, Czerniakowska 231, 00-416, Warsaw, Poland
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Romaen IFL, Jense MTF, Palm-Meinders IH, de Witte E, Fransen SAF, Greve JWM, Boerma EJG. Higher Preoperative Weight loss Is Associated with Greater Weight Loss up to 12 Months After Bariatric Surgery. Obes Surg 2022; 32:2860-2868. [PMID: 35788954 DOI: 10.1007/s11695-022-06176-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Prior research suggested presurgical weight loss is associated with greater total weight loss, resulting in a more effective bariatric intervention. We aimed to assess whether preoperative weight loss is a predictor for total weight loss, and which patient factors are associated with successful weight loss. METHODS All patients (N = 773) that underwent primary bariatric surgery between June 2017 and August 2019 were included in this single-center retrospective study. Outcome measures were preoperative weight loss (%preopWL) and total weight loss (%TWL) up to 1 year postoperatively. Patients were divided into 4 groups based on quartiles of %preopWL. RESULTS Total weight loss after 1, 6, and 12 months for the upper quartile was 16.9%, 33.4%, and 37.8%, and for the lower quartile 11.8%, 28.9%, and 35.2%, respectively (p < 0.001). Seven hundred fourteen patients (92.4%) were available for the 1-year follow-up. Preoperative weight loss was not associated with the incidence of complications. Independent factors predicting increased %preopWL were mandated preoperative weight loss program (MWP) (p < 0.001), older age (p = 0.005), weight measurement in the week before surgery (p = 0.031), and non-diabetic status (p = 0.010). Predictors for superior %TWL were MWP (p = 0.014), younger age (p = 0.001), non-diabetic status (p = 0.005), female gender (p = 0.001), higher Body Mass Index (p = 0.006), and banded gastric bypass (p = 0.001). CONCLUSION Higher preoperative weight loss is associated with persisting greater weight loss up to at least 12 months post-surgery. In order to optimize preoperative weight loss, we recommend extra preoperative support to younger and diabetic patients. We advise nutritional counseling and additional weight measurement in the week before surgery.
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Affiliation(s)
- Ine F L Romaen
- Surgical Department, Zuyderland Medical Center, 6419 PC, Heerlen/Sittard, the Netherlands
| | - Marijn T F Jense
- Surgical Department, Zuyderland Medical Center, 6419 PC, Heerlen/Sittard, the Netherlands
| | | | - Evelien de Witte
- Surgical Department, Zuyderland Medical Center, 6419 PC, Heerlen/Sittard, the Netherlands
- Dutch Obesity Clinic South, 6419 XZ, Heerlen, the Netherlands
| | - Sofie A F Fransen
- Surgical Department, Zuyderland Medical Center, 6419 PC, Heerlen/Sittard, the Netherlands
- Dutch Obesity Clinic South, 6419 XZ, Heerlen, the Netherlands
| | - Jan Willem M Greve
- Surgical Department, Zuyderland Medical Center, 6419 PC, Heerlen/Sittard, the Netherlands
- Dutch Obesity Clinic South, 6419 XZ, Heerlen, the Netherlands
- Research School, NUTRIM University of Maastricht, 6229 ER, Maastricht, the Netherlands
| | - Evert-Jan G Boerma
- Surgical Department, Zuyderland Medical Center, 6419 PC, Heerlen/Sittard, the Netherlands.
- Dutch Obesity Clinic South, 6419 XZ, Heerlen, the Netherlands.
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Vosburg RW, Chaar ME, Djouzi SE, Docimo S, Choi D, LaMasters T, Srivastava G, Shukla AP, Oviedo RJ, Fitch A, Azagury DE. Literature review on anti-obesity medication use for metabolic and bariatric surgery patients from the ASMBS clinical issues committee. Surg Obes Relat Dis 2022; 18:1109-1119. [DOI: 10.1016/j.soard.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/06/2022] [Indexed: 11/16/2022]
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Sarno G, Calabrese P, Frias-Toral E, Ceriani F, Fuchs-Tarlovsky V, Spagnuolo M, Cucalón G, Córdova LÁ, Schiavo L, Pilone V. The relationship between preoperative weight loss and intra and post-bariatric surgery complications: an appraisal of the current preoperative nutritional strategies. Crit Rev Food Sci Nutr 2022; 63:10230-10238. [PMID: 35546051 DOI: 10.1080/10408398.2022.2074963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Preoperative weight loss before a bariatric surgery reduces long-term complications, but there is no solid evidence for short-term or perioperative complications. This review highlights recent evidence on dietary protocols and the possible correlation between weight loss and surgical complications. Updated evidence was searched in PubMedDirect with the terms "preoperative very low-calorie diet or very-low-calorie ketogenic diet or low-fat diet or intermittent fasting or Mediterranean diet and bariatric surgery or bariatric surgery complications." The main characteristics of each diet, achievements related to weight loss, liver reduction, peri and postoperative outcomes, surgical complications, tolerance, and adherence to the diet are presented from the selected studies. There are few reports about the Mediterranean diet as a strategy to reach these goals. The VLCKD has been associated with better body weight reduction and lesser postoperative complications risk. However, the results in animal models are still controversial. When comparing VLCD with an LCD, there is no apparent superiority between one against the other one. However, LCD has shown better tolerance and adherence than VLCD. There is still a need for more controlled studies to define the best preoperative dietary treatment for weight loss before bariatric surgery since there are controversial positions regarding this issue.
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Affiliation(s)
- Gerardo Sarno
- Scuola Medica Salernitana, "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Salerno, Italy
| | - Pietro Calabrese
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggid'Aragona, Salerno, Italy
| | - Evelyn Frias-Toral
- School of Medicine, Universidad Católica Santiago de Guayaquil, Guayaquil, Ecuador
| | - Florencia Ceriani
- Nutrition School, Universidad de la Republica (UdelaR), Montevideo, Uruguay
| | | | - Maria Spagnuolo
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggid'Aragona, Salerno, Italy
| | - Gabriela Cucalón
- Escuela Superior Politécnica del Litoral, ESPOL, Lifescience Faculty, ESPOL Polytechnic University, Guayaquil, Ecuador
| | - Ludwig Álvarez Córdova
- Facultad de Ciencias Médicas, Carrera de Nutrición y Dietética, Universidad Católica De Santiago de Guayaquil, Guayaquil, Ecuador
| | - Luigi Schiavo
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggid'Aragona, Salerno, Italy
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana," University of Salerno, Salerno, Italy
| | - Vincenzo Pilone
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggid'Aragona, Salerno, Italy
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana," University of Salerno, Salerno, Italy
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Singhal R, Omar I, Madhok B, Ludwig C, Tahrani AA, Mahawar K. Effect of BMI on safety of bariatric surgery during the COVID-19 pandemic, procedure choice, and safety protocols - An analysis from the GENEVA Study. Obes Res Clin Pract 2022; 16:249-253. [PMID: 35718696 PMCID: PMC9174153 DOI: 10.1016/j.orcp.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 06/04/2022] [Indexed: 11/17/2022]
Abstract
Background It has been suggested that patients with a Body Mass Index (BMI) of > 60 kg/m2 should be offered expedited Bariatric Surgery (BS) during the Coronavirus Disease-2019 (COVID-19) pandemic. The main objective of this study was to assess the safety of this approach. Methods We conducted a global study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into three groups according to their preoperative BMI - Group I (BMI<50 kg/m2), Group II (BMI 50–60 kg/m2), and Group III (BMI>60 kg/m2). The effect of preoperative BMI on 30-day morbidity and mortality, procedure choice, COVID-19 specific safety protocols, and comorbidities was assessed. Results This study included 7084 patients (5197;73.4 % females). The mean preoperative weight and BMI were 119.49 ± 24.4 Kgs and 43.03 ± 6.9 Kg/m2, respectively. Group I included 6024 (85 %) patients, whereas Groups II and III included 905 (13 %) and 155 (2 %) patients, respectively. The 30-day mortality rate was higher in Group III (p = 0.001). The complication rate and COVID-19 infection were not different. Comorbidities were significantly more likely in Group III (p = <0.001). A significantly higher proportion of patients in group III received Sleeve Gastrectomy or One Anastomosis Gastric Bypass compared to other groups. Patients with a BMI of > 70 kg/m2 had a 30-day mortality of 7.7 % (2/26). None of these patients underwent a Roux-en-Y Gastric Bypass. Conclusion The 30-day mortality rate was significantly higher in patients with BMI > 60 kg/m2. There was, however, no significant difference in complications rates in different BMI groups, probably due to differences in procedure selection.
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Affiliation(s)
- Rishi Singhal
- Upper GI unit, University Hospital Birmingham NHS Foundation Trust, UK.
| | - Islam Omar
- General Surgery Department, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Brijesh Madhok
- Upper GI unit, University Hospital of Derby and Burton NHS Foundation Trust, UK
| | - Christian Ludwig
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Kamal Mahawar
- Bariatric Unit, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
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23
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Abstract
The Enhanced Recovery After Surgery Society published guidelines for bariatric surgery reviewing the evidence and providing specific care recommendations. These guidelines emphasize preoperative nutrition, multimodal analgesia, postoperative nausea and vomiting prophylaxis, anesthetic technique, nutrition, and mobilization. Several studies have since evaluated these pathways, showing them to be safe and effective at decreasing hospital length of stay and postoperative nausea and vomiting. This article emphasizes anesthetic management in the perioperative period and outlines future directions, including the application of Enhanced Recovery After Surgery principles in patients with extreme obesity, diabetes, and metabolic disease and standardization of the pathways to decrease heterogeneity.
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Affiliation(s)
- Christa L Riley
- Fellow, Surgical Critical Care, Department of Anesthesiology and Critical Care, Penn Medicine, 6 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA; Anesthesiologist & Intensivist, Department of Anesthesiology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.
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Nutritional Management in Bariatric Surgery Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212049. [PMID: 34831805 PMCID: PMC8618972 DOI: 10.3390/ijerph182212049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 02/08/2023]
Abstract
The obesity epidemic, mainly due to lifestyle changes in recent decades, leads to serious comorbidities that reduce life expectancy. This situation is affecting the health policies of many nations around the world. Traditional measures such as diet, physical activity, and drugs are often not enough to achieve weight loss goals and to maintain the results over time. Bariatric surgery (BS) includes various techniques, which favor rapid and sustained weight loss. BS is a useful and, in most cases, the best treatment in severe and complicated obesity. In addition, it has a greater benefit/risk ratio than non-surgical traditional therapies. BS can allow the obese patient to lose weight quickly compared with traditional lifestyle changes, and with a greater probability of maintaining the results. Moreover, BS promotes improvements in metabolic parameters, even diabetes remission, and in the quality of life. These changes can lead to an increase of life expectancy by over 6 years on average. The nutrition of people before and after BS must be the subject of indications from a trained staff, and patients must be followed in the subsequent years to reduce the risk of malnutrition and the associated problems. In particular, it is still debated whether it is necessary to lose weight prior to surgery, a procedure that can facilitate the surgeon's work reducing the surgical risk, but at the same time, lengthens preparation times increasing the risks associated with concomitant pathologies. Furthermore, preventing nutritional deficiencies prior to the intervention can improve the results and reduce short- and long-term mortality.
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25
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Efficacy of Telephone Health Coaching Integration with Standard Multidisciplinary Care for Adults with Obesity Attending a Weight Management Service: A Pilot Study. Nutrients 2021; 13:nu13114078. [PMID: 34836331 PMCID: PMC8625904 DOI: 10.3390/nu13114078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 12/23/2022] Open
Abstract
Australia has one of the highest prevalences of obesity in the developed world with recognised gaps in patient access to obesity services. This non-randomised before and after study investigated the health benefits and patient acceptability of integrating the Get Healthy Service, a state-funded telephone-delivered coaching service in Australia, as an adjunct to multidisciplinary care for adults attending a public obesity service. Forty-one participants received multidisciplinary care alone while 39 participants were subsequently allocated to receive adjunctive treatment with the Get Healthy Service. Weight, body mass index, glycosylated haemoglobin, measurement of hepatic steatosis and liver enzymes were collected at baseline and 6 months. Participant evaluation was obtained post intervention. Statistically significant reductions from baseline were achieved for both control and intervention with respect to weight (−6.7 ± 2.2 kg, p = 0.01; −12.6 ± 3.2, p = 0.002), body mass index (−2.3 ± 0.8, p = 0.01; −4.8 ± 1.2 kg/m2, p = 0.002) and glycosylated haemoglobin (−0.2 ± 0.2%, p = 0.2 (NS); −0.7 ± 0.2%, p = 0.02), respectively. There were no significant differences in steatosis or liver enzymes or in outcomes between control and intervention cohorts. A high level of patient acceptability was reported. Integrating telephone-delivered coaching provided non-inferior care and high levels of patient satisfaction. Telephone coaching aligned with the principles of an obesity service should be trialled to improve patient access to obesity interventions.
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Gasoyan H, Soans RS, Ibrahim JK, Aaronson WE, Sarwer DB. Association between insurance-mandated precertification criteria and inpatient healthcare utilization during 1 year after bariatric surgery. Surg Obes Relat Dis 2021; 18:271-280. [PMID: 34753674 DOI: 10.1016/j.soard.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/06/2021] [Accepted: 10/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Insurance-mandated precertification requirements are barriers to bariatric surgery. The value of their prescription, based on insurance type rather that the clinical necessity, is unclear. OBJECTIVES To determine whether there is an association between insurance-mandated precertification criteria for bariatric surgery and short-term inpatient healthcare utilization. SETTING Pennsylvania Health Care Cost Containment Council's inpatient care databases for the years 2016-2017. METHODS The study included 2717 adults who underwent bariatric surgery in Southeastern Pennsylvania in 2016. Postoperative length of stay and rehospitalizations for these individuals were followed using clinical and claims data during the first year after bariatric surgery. RESULTS The requirements for 3- to 6-month preoperative medical weight management, as well as pulmonology and cardiology examinations, were not associated with the patient length of stay, number of all-cause rehospitalizations, or number of all-cause rehospitalization days after adjusting for patient age, sex, race, ethnicity, the Elixhauser comorbidity score, type of the surgery, facility where the surgery was performed, primary payer type, and the estimated median household income. Among commercially insured individuals (n = 1499), the mean number of all-cause rehospitalizations during the study period was lower in patients with no medical weight management requirement by a factor of .57 (lower by 43.1%; 95% confidence interval, .35-.94, P = .03) and higher in patients with no requirement for preoperative cardiology and pulmonology evaluations by a factor of 2.09 (95% confidence interval 1.09-4.02, P = .03). CONCLUSION The findings suggest that the precertification requirement for preoperative medical weight management is not associated with a reduction in inpatient healthcare utilization in the first postoperative year.
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Affiliation(s)
- Hamlet Gasoyan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, Pennsylvania.
| | - Rohit S Soans
- Bariatric Surgery Program, Temple University Hospital, Philadelphia, Pennsylvania
| | - Jennifer K Ibrahim
- Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, Pennsylvania
| | - William E Aaronson
- Department of Health Services Administration and Policy, College of Public Health, Temple University, Philadelphia, Pennsylvania
| | - David B Sarwer
- Center for Obesity Research and Education, College of Public Health, Temple University, Philadelphia, Pennsylvania
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27
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Alimi Y, Azagury DE. Comment on: Preoperative weight loss is linked to improved mortality and leaks following elective bariatric surgery: an analysis of 548,597 patients from 2015 to 2018. Surg Obes Relat Dis 2021; 17:e59-e60. [PMID: 34548247 DOI: 10.1016/j.soard.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Yewande Alimi
- Stanford University School of Medicine, Stanford, California, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Dan E Azagury
- Section of Minimally Invasive & Bariatric Surgery, Stanford University School of Medicine, Stanford, California
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Eley VA, Thuzar M, Navarro S, Dodd BR, Zundert AAV. Obesity, metabolic syndrome, and inflammation: an update for anaesthetists caring for patients with obesity. Anaesth Crit Care Pain Med 2021; 40:100947. [PMID: 34534700 DOI: 10.1016/j.accpm.2021.100947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/11/2021] [Accepted: 03/20/2021] [Indexed: 11/25/2022]
Abstract
Our understanding of chronic inflammation in obesity is evolving. Suggested mechanisms include hypoxia of adipose tissue and a subsequent increase in circulating cytokines. It is now known that adipose tissue, far from being an inert tissue, produces and secretes multiple peptides that influence inflammation and metabolism, including substrates of the renin-angiotensin-aldosterone system (RAAS). RAAS blocking antihypertensive medication and cholesterol-lowering agents are now being evaluated for their metabolic and inflammation-modulating effects. Surgery also has pro-inflammatory effects, which may be exacerbated in patients with obesity. This narrative review will summarise the recent literature surrounding obesity, metabolic syndrome, inflammation, and interplay with the RAAS, with evidence-based recommendations for the optimisation of patients with obesity, prior to surgery and anaesthesia.
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Affiliation(s)
- Victoria A Eley
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, 4006 Queensland, Australia; Faculty of Medicine, The University of Queensland, St Lucia, 4067 Queensland, Australia.
| | - Moe Thuzar
- Faculty of Medicine, The University of Queensland, St Lucia, 4067 Queensland, Australia; Department of Endocrinology and Diabetes, Princess Alexandra Hospital, Ipswich Road Woolloongabba, 4102 Queensland, Australia; Endocrine Hypertension Research Centre, The University of Queensland Diamantina Institute, Ipswich Road Woolloongabba, 4102 Queensland, Australia
| | - Séverine Navarro
- Department of Immunology, QIMR Berghofer Medical Research Institute Herston Rd, Herston, 4006 Queensland, Australia; Woolworths Centre for Childhood Nutrition Research, Faculty of Health, School of Exercise and Nutrition Sciences, Queensland University of Technology, Kelvin Grove, 4059 Queensland, Australia
| | - Benjamin R Dodd
- Faculty of Medicine, The University of Queensland, St Lucia, 4067 Queensland, Australia; Department of Upper GI and Bariatric Surgery, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, 4006 Queensland, Australia
| | - André A Van Zundert
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, 4006 Queensland, Australia; Faculty of Medicine, The University of Queensland, St Lucia, 4067 Queensland, Australia
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29
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Benotti PN, Petrick AT, Still CD. Comment on: Preoperative weight loss: a value-added opportunity? Surg Obes Relat Dis 2021; 17:1853-1854. [PMID: 34426100 DOI: 10.1016/j.soard.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022]
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30
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Structured Lifestyle Modification Prior to Bariatric Surgery: How Much is Enough? Obes Surg 2021; 31:4585-4591. [PMID: 34297255 PMCID: PMC8458190 DOI: 10.1007/s11695-021-05573-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/22/2021] [Accepted: 06/30/2021] [Indexed: 01/06/2023]
Abstract
Many healthcare systems require patients to participate in a structured lifestyle modification programme prior to bariatric surgery, even though bariatric consensus guidelines do not recommend this. While there is good evidence that such programmes improve health in other conditions such as metabolic and cardiovascular diseases, there is no evidence that they improve outcomes after bariatric surgery. The distinction needs to be drawn between the well-established need for individualised multidisciplinary dietetic and physical activity care for bariatric surgical patients and the potential harms from mandating participation in compulsory structured lifestyle programmes of fixed duration, frequency and intensity, which may delay surgery, reinforce obesity stigma, or both. Large clinical trials might help to address some of the uncertainty and provide an evidence base for clinicians and policymakers.
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31
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Robertson AGN, Wiggins T, Robertson FP, Huppler L, Doleman B, Harrison EM, Hollyman M, Welbourn R. Perioperative mortality in bariatric surgery: meta-analysis. Br J Surg 2021; 108:892-897. [PMID: 34297806 DOI: 10.1093/bjs/znab245] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/02/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Bariatric surgery is an established treatment for severe obesity; however, fewer than 1 per cent of eligible patients undergo surgery. The perceived risk of surgery may contribute to the low uptake. The aim of this study was to determine perioperative mortality associated with bariatric surgery, comparing different operation types and data sources. METHODS A literature search of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was conducted to identify studies published between 1 January 2014 and 31 July 2020. Inclusion criteria were studies of at least 1000 patients reporting short-term mortality after bariatric surgery. Data were collected on RCTs. Meta-analysis was performed to establish overall mortality rates across different study types. The primary outcome measure was perioperative mortality. Different operation types were compared, along with study type, in subgroup analyses. The study was registered at PROSPERO (2019: CRD 42019131632). RESULTS Some 4356 articles were identified and 58 met the inclusion criteria. Data were available on over 3.6 million patients. There were 4707 deaths. Pooled analysis showed an overall mortality rate of 0.08 (95 per cent c.i. 0.06 to 0.10; 95 per cent prediction interval 0 to 0.21) per cent. In subgroup analysis, there was no statistically significant difference between overall, 30-day, 90-day or in-hospital mortality (P = 0.29). There was no significant difference in reported mortality for RCTs, large studies, national databases or registries (P = 0.60). The pooled mortality rates by procedure type in ascending order were: 0.03 per cent for gastric band, 0.05 per cent for sleeve gastrectomy, 0.09 per cent for one-anastomosis gastric bypass, 0.09 per cent for Roux-en-Y gastric bypass, and 0.41 per cent for duodenal switch (P < 0.001 between operations). CONCLUSION Bariatric surgery is safe, with low reported perioperative mortality rates.
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Affiliation(s)
| | - T Wiggins
- Heartlands Hospital, Birmingham, Birmingham, UK
| | | | | | - B Doleman
- University of Nottingham, Nottingham, UK
| | - E M Harrison
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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Mocanu V, Marcil G, Dang JT, Birch DW, Switzer NJ, Karmali S. Preoperative weight loss is linked to improved mortality and leaks following elective bariatric surgery: an analysis of 548,597 patients from 2015-2018. Surg Obes Relat Dis 2021; 17:1846-1853. [PMID: 34330621 DOI: 10.1016/j.soard.2021.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/30/2021] [Accepted: 06/29/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The effects of preoperative weight loss on bariatric surgery outcomes are still unclear, despite the practice being adopted by bariatric centers worldwide. Ongoing studies are needed for routine adoption of this practice given the multiple issues patients face with following difficult preoperative weight loss protocols. OBJECTIVES The aim of this study was to characterize the prevalence of preoperative weight loss and evaluate its impact on outcomes following elective bariatric surgery. SETTING This retrospective study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015-2018. METHODS All primary Roux-en-Y (RYGB) and sleeve gastrectomy (SG) procedures were included, whereas prior revisional surgeries and emergency surgeries were excluded. Cases were then divided into preoperative weight loss (PWL) and control cohorts. PWL was defined categorically if the highest 30-day preoperative weight was greater than the closest recorded weight before surgery. Primary outcomes included identifying the impact of PWL on postoperative complications. Multivariable logistic regression modelling was used to examine the influence of PWL on serious complications and mortality after adjusting for patient co-morbidities and procedure type. RESULTS A total of 548,597 patients were identified with the majority experiencing preoperative weight loss (n= 459,500; 83.8%). The PWL cohort was older (44.8 ± 12.0 versus 43.2 ± 11.9 yr), had a reduced body mass index (BMI) (45.0 ± 7.4 versus 46.1 ± 7.6 kg/m2), and was more likely to be male (20.3% versus 18.7%). Patients with preoperative weight loss also were more likely to have metabolic co-morbidities including medication and insulin-dependent diabetes (27.0% versus 23.2%), hypertension (HTN) (48.9% versus 44.7%), dyslipidemia (DLP ) (24.6% versus 21.0%), and sleep apnea (39.6% versus 32.3%). No clinically significant differences were observed for operative length between cohorts (85.3 ± 46.9 min PWL versus 83.9 ± 46.2 min control). The protective benefit was found to be most significant for patients experiencing greatest weight loss with those experiencing a >10% PWL showing 30% decreased odds of leak (OR .68%; 95% CI [confidence interval] .56-.84; P < .0001) and a 40% decrease in odds of mortality versus those with no PWL (OR .60; 95% CI .39-.92; P = .02). CONCLUSION Preoperative weight loss before bariatric surgery is common, occurring in >80% of elective cases. Our findings suggest that preoperative weight loss is associated with improved odds of 30-day mortality and leaks but no differences in bleeds or overall serious complications. Additional prospective trials are needed to further evaluate the role of routine PWL in addition to ongoing development of tolerable preoperative weight-loss protocols.
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Affiliation(s)
- Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Gabriel Marcil
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jerry T Dang
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel W Birch
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Noah J Switzer
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Shahzeer Karmali
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Aubrey C, Skeldon M, Chapelsky S, Giannakopoulos N, Ghosh S, Steed H, Pin S. Preoperative weight loss in women with obesity in gynaecologic oncology: A retrospective study. Clin Obes 2021; 11:e12445. [PMID: 33710796 DOI: 10.1111/cob.12445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 01/24/2023]
Abstract
To retrospectively review the efficacy of short term supervised medical weight loss for women with obesity, body mass index (BMI ≥40 kg/m2 ) in gynaecologic oncology, and the associated perioperative and pathologic outcomes. A retrospective study of a dedicated preoperative weight loss clinic for gynaecologic oncology patients from March to December 2019. Statistical analysis was performed with McNemar's test for correlated proportions, Pearson's correlation tests for continuous variables, and paired t-tests to compare means. Generalized estimating equations (GEE) were used to determine the factors associated with weight loss over time. A P-value of <.05 was used for statistical significance. Review of cases up-graded after surgery was performed by a gynaecologic pathologist. There were a total of 49 women included in the study. The most common referral reason was endometrioid carcinoma or hyperplasia of the endometrium (77.6%). Mean initial weight was 130.2 kg, and corresponding mean BMI 48.1 kg/m2 . Patients attended on average nine preoperative weight loss visits. A significant difference between initial weight and weight at surgery was demonstrated, from 129.6 to 118.0 kg (8.4% weight loss) (P < .0001). This difference persisted to their post-surgical visit, with an additional mean loss of 1.89 kg (9.4% weight loss) (P = .044). The majority (92.1%) of patients with endometrial pathology had surgical management, and of these 85.7% were minimally invasive. Preoperative weight loss is a feasible option in gynaecologic oncology patients. Greater understanding of clinical significance, follow-up, and ideal target population for this intervention is needed.
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Affiliation(s)
- Christa Aubrey
- Gynecologic Oncology Fellow, Tom Baker Cancer Centre, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Skeldon
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sarah Chapelsky
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nadia Giannakopoulos
- Department of Anatomic Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Research Scientist, Alberta Health Services-Cancer Control Alberta, Department of Medical Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Helen Steed
- Cross Cancer Institute, Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sophia Pin
- Cross Cancer Institute, Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Wiggins T, Pournaras DJ, Priestman E, Osborne A, Titcomb DR, Finlay I, Hopkins J, Hollyman M, Mason M, Noble H, Mahon D, Welbourn R. Effect of Preoperative Weight Loss and Baseline Comorbidity on Short-Term Complications and Reoperations After Laparoscopic Roux-en-Y Gastric Bypass in 2,067 Patients. Obes Surg 2021; 31:2444-2452. [PMID: 33768433 DOI: 10.1007/s11695-021-05331-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Decreasing popularity of Roux-en-Y gastric bypass (RYGB) in bariatric-metabolic surgery may be due to higher perceived peri-operative complications. There are few studies on whether preoperative weight loss can reduce complications or reoperations following RYGB. We investigated this using a standardised operative technique. MATERIALS AND METHODS Retrospective single-centre study of RYGB from 2004 to 2019 using a prospective database. Preoperative behavioural management included intentional weight loss. Maximum preoperative weight, weight on the day of operation, and Obesity-Surgery Mortality Risk Score (OS-MRS) class were recorded. Short-term outcomes (post-operative stay, 30-day complication and reoperation rates) were analysed. RESULTS In 2,067 RYGB patients (1,901 primary and 166 revisional), median preoperative total body weight loss (TWL) was 6.2% (IQR: 2.5-10.7%). The median age was 46 (interquartile range (IQR) 38-54) and 80.4% were female (n=1,661). For primary surgery, the median body mass index (BMI) was 47.6 kg/m2 (IQR: 43.1-53.3). Excluding the 100-procedure learning curve, the complication rate for primary cases was 4.4% and reoperation rate of 2.8% and one peri-operative mortality (0.06%). OS-MRS ≥2 (class B or C) predicted higher risk of complications (6.1%) compared to those with a score <2 (class A) (3.8%, p=0.021), but not reoperations. Five percent preoperative TWL did not decrease complications compared to <5% TWL. Patients with ≥10% TWL had greater baseline risk and had an increased risk of complications (6.6% vs 3.7%, p=0.017) and reoperations (4.5% vs 2.7%, p<0.001). CONCLUSIONS RYGB performed using a standardised technique has low overall risk. The influence of preoperative weight loss on outcomes was inconsistent.
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Affiliation(s)
- Tom Wiggins
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - Dimitri J Pournaras
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - Elena Priestman
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - Alan Osborne
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - Daniel R Titcomb
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - Ian Finlay
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - James Hopkins
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - Marianne Hollyman
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - Matthew Mason
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - Hamish Noble
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - David Mahon
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK
| | - Richard Welbourn
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, TA1 5DA, UK.
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Abstract
Obesity is increasing in prevalence in liver transplant candidates and recipients. The rise in liver transplantation for nonalcoholic steatohepatitis reflects this increase. Management of obesity in liver transplant candidates can be challenging due to the presence of decompensated cirrhosis and sarcopenia. Obesity may increase peritransplant morbidity but does not have an impact on long-term post-transplant survival. Bariatric surgery may be a feasible option in select patients before, during, or after liver transplantation. Use of weight loss drugs and/or endoscopic therapies for obesity management ultimately may play a role in liver transplant patients, but more research is needed to determine safety.
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Morales-Marroquin E, Xie L, Meneghini L, de la Cruz-Muñoz N, Almandoz JP, Mathew SM, Schneider BE, Messiah SE. Type 2 Diabetes and HbA1c Predict All-Cause Post-Metabolic and Bariatric Surgery Hospital Readmission. Obesity (Silver Spring) 2021; 29:71-78. [PMID: 33215855 PMCID: PMC9348604 DOI: 10.1002/oby.23044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/28/2020] [Accepted: 09/04/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The main goal of this analysis was to determine whether type 2 diabetes and hemoglobin A1c (HbA1c) predict all-cause 30-day hospital readmission after metabolic and bariatric surgery (MBS). It was hypothesized that a diagnosis of type 2 diabetes or high HbA1c values would predict all-cause hospital readmission rates post MBS. METHODS A retrospective analysis from the 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) cohort was completed (N = 744,776); 30,972 participants were readmitted during the 30 days post MBS. RESULTS Mean age of the MBSAQIP sample was 45.1 (11.5) years, and the majority were female (80.7%) and non-Hispanic White (59.4%). The all-cause hospital readmission rate was 4.2% and increased by 10% in those with uncontrolled type 2 diabetes (HbA1c > 7.5% [> 58 mmol/mol]); after adjustment, diabetes was not associated with increased readmission. Uncontrolled type 2 diabetes, type 2 diabetes, and prediabetes resulted in less weight loss 30 days post MBS. CONCLUSIONS These results based on a national MBS cohort showed that uncontrolled type 2 diabetes is associated with a greater likelihood of all-cause hospital readmission and reduced weight loss 30 days post MBS. Both type 2 diabetes and prediabetes were also associated with decreased weight loss 30 days post MBS. These findings highlight the need to classify and optimize glycemic control prior to MBS.
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Affiliation(s)
- Elisa Morales-Marroquin
- University of Texas Health Science Center, School of Public Health, Dallas, TX, USA
- Center for Pediatric Population Health, UTHealth School of Public Health and Children’s Health System of Texas, Dallas, TX, USA
| | - Luyu Xie
- University of Texas Health Science Center, School of Public Health, Dallas, TX, USA
- Center for Pediatric Population Health, UTHealth School of Public Health and Children’s Health System of Texas, Dallas, TX, USA
| | - Luigi Meneghini
- University of Texas Southwestern Medical Center, Department of Internal Medicine, and Parkland Health & Hospital System, Dallas, TX, USA
| | | | - Jaime P. Almandoz
- University of Texas Southwestern Medical Center, Department of Internal Medicine, and Parkland Health & Hospital System, Dallas, TX, USA
| | - Sunil M. Mathew
- University of Texas Health Science Center, School of Public Health, Dallas, TX, USA
- Center for Pediatric Population Health, UTHealth School of Public Health and Children’s Health System of Texas, Dallas, TX, USA
| | - Benjamin E. Schneider
- University of Texas Southwestern Medical Center Department of Surgery, Dallas, TX, USA
| | - Sarah E. Messiah
- University of Texas Health Science Center, School of Public Health, Dallas, TX, USA
- Center for Pediatric Population Health, UTHealth School of Public Health and Children’s Health System of Texas, Dallas, TX, USA
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Sari C, Seip RL, Umashanker D. Case Report: Off Label Utilization of Topiramate and Metformin in Patients With BMI ≥50 kg/m 2 Prior to Bariatric Surgery. Front Endocrinol (Lausanne) 2021; 12:588016. [PMID: 33716960 PMCID: PMC7947603 DOI: 10.3389/fendo.2021.588016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/18/2021] [Indexed: 11/13/2022] Open
Abstract
FDA approved anti-obesity medications may not be cost effective for patients struggling with pre-operative weight loss prior to bariatric surgery. Metformin, a biguanide, and Topiramate, a carbonic anhydrase inhibitor, both cost effective medications, have demonstrated weight loss when used for the treatment of type 2 diabetes or seizures, respectively. The aim of the three cases is to demonstrate the clinical utility of topiramate and metformin for preoperative weight loss in patients with a body mass index (BMI) ≥ 50 kg/m2 prior to bariatric surgery who are unable to follow the bariatric nutritional prescription due to a dysregulated appetite system Each patient was prescribed metformin and/or topiramate in an off-label manner in conjunction with lifestyle modifications and achieved >8% total body weight loss during the preoperative period.
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Affiliation(s)
- Cetin Sari
- Metabolic and Bariatric Surgery Center, Hartford Hospital, Hartford, CT, United States
| | - Richard L. Seip
- Metabolic and Bariatric Surgery Center, Hartford Hospital, Hartford, CT, United States
- Division of Research Data Management, Hartford Hospital, Hartford, CT, United States
| | - Devika Umashanker
- Metabolic and Bariatric Surgery Center, Hartford Hospital, Hartford, CT, United States
- Medical Weight Management Program, Hartford Hospital, Hartford, CT, United States
- *Correspondence: Devika Umashanker,
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Enhanced recovery after surgery (ERAS) in gynecology oncology. Eur J Surg Oncol 2020; 47:952-959. [PMID: 33139130 DOI: 10.1016/j.ejso.2020.10.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/11/2020] [Accepted: 10/26/2020] [Indexed: 12/18/2022] Open
Abstract
The Enhanced Recovery After Surgery (ERAS) is a pathway designed to achieve early recovery for patients undergoing major surgery. The ERAS pathway included three important components preoperative, intraoperative, postoperative program. Pre-habilitation and re-habilitation are of paramount importance to improve patients' care. The ERAS is based on evidence-based medicine. Accumulating evidence highlighted that adopting ERAS resulted in lower complication rate, and shorter length of hospital stay in comparison to standard protocols of care. The adoption of the ERAS resulted in a significant improvement of patients' outcomes and a reduction of the overall cost of care. In the present review, we summarized current evidence on ERAS, focusing on the steps useful for its adoption into clinical practice.
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Affiliation(s)
- Micaela M Esquivel
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Dan Azagury
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
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