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Nimeri A. Paired Commentary for OBSU-D-24-00337R2 Similar Rates of Symptomatic Marginal Ulcers After One-Anastomosis-Gastric Bypass Compared to Roux-en-Y Gastric Bypass. Obes Surg 2024; 34:3115-3116. [PMID: 38910206 DOI: 10.1007/s11695-024-07369-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/08/2024] [Accepted: 06/14/2024] [Indexed: 06/25/2024]
Affiliation(s)
- Abdelrahman Nimeri
- Brigham & Women's Hospital, Bariatric Surgery, Harvard Medical School, Boston, MA, USA.
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Abu-Abeid A, Litmanovich A, Yuval JB, Tome J, Keidar A, Eldar SM. Marginal Ulcer Perforation after One Anastomosis Gastric Bypass: Surgical Treatment and Two-Year Outcomes. J Clin Med 2024; 13:3075. [PMID: 38892786 PMCID: PMC11172864 DOI: 10.3390/jcm13113075] [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: 04/10/2024] [Revised: 05/07/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Marginal ulcer (MU) perforation is a chronic complication after One-anastomosis Gastric Bypass (OAGB). This study's purpose was to analyze patients undergoing OAGB revision due to MU perforation and describe the two-year outcomes. Methods: A retrospective analysis of a database in a single-tertiary hospital. All patients undergoing surgical revision due to MU perforation were included. Results: During the study period, 22 patients underwent OAGB revision due to MU perforation. The rate of MU perforation was 0.98%. The median age was 48 years and there were 13 men (59%). The median time from OAGB to MU perforation was 19 months with a median total weight loss of 31.5%. Nine patients (41%) were smokers. Omental patch (±primary closure) was performed in 19 patients (86%) and three patients (14%) underwent conversion to Roux-en-Y gastric bypass (RYGB). At a median follow-up of 48 months, three patients (14%) had recurrent MU diagnosis, of which one had a recurrent MU perforation. Four patients (18%) underwent conversion to RYGB during follow-up. Conclusions: MU perforation is a chronic complication after OAGB. In this cohort, most patients were men and likely to be smokers. Omental patch was effective in most cases. Recurrent MU rates at two years follow-up were acceptable.
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Affiliation(s)
- Adam Abu-Abeid
- Division of General Surgery, Tel Aviv Sourasky Medical Center, Affiliated to Sackler Faculty of Medicine, Tel Aviv University, 6, Weizman St., Tel Aviv 6423906, Israel; (A.L.); (J.B.Y.); (J.T.); (A.K.); (S.M.E.)
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Sowers B, Reed BL, Szoka N, Tabone LE, Abunnaja S. Marginal Ulcers Following Roux-en-Y Gastric Bypass, Expect the Unexpected: a Video Case Series. Obes Surg 2024; 34:297-298. [PMID: 38010453 DOI: 10.1007/s11695-023-06946-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/29/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Briana Sowers
- Department of Surgery, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506, USA
| | - Benjamin L Reed
- Department of Surgery, Prisma Health, Greenville, SC, 29607, USA
| | - Nova Szoka
- Department of Surgery, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506, USA
| | - Lawrence E Tabone
- Department of Surgery, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506, USA
| | - Salim Abunnaja
- Department of Surgery, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506, USA.
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Zeller MH, Strong H, Reiter-Purtill J, Jenkins TM, Mitchell JE, Michalsky MP, Helmrath MA. Marijuana, e-cigarette, and tobacco product use in young adults who underwent pediatric bariatric surgery. Surg Obes Relat Dis 2023; 19:512-521. [PMID: 36567232 PMCID: PMC10461174 DOI: 10.1016/j.soard.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/16/2022] [Accepted: 11/14/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The postoperative course after pediatric metabolic and bariatric surgery (MBS) cuts across a developmental phase when substance-use behaviors emerge as significant public health concerns. OBJECTIVE We examined use of marijuana, conventional cigarettes, and alternate tobacco products/devices (e.g., e-cigarettes, hookah, smokeless, dissolvable) in young adults (YA) to 6 years postsurgery. SETTING Five academic medical centers. METHODS In a prospective observational cohort series, 139 surgical (Mage = 16.9, Mbody mass index [BMI] = 51.5, 80% female, 66% white) and 83 nonsurgical comparisons (Mage = 16.1, MBMI = 44.9, 82% female, 54% white) completed assessments at presurgery/baseline and postsurgery years 2, 4, and 6 (year 6 [2014-2018]: surgical n = 123 [89%], Mage = 23.0, MBMI = 39.8; nonsurgical n = 63 [76%], Mage = 22.4, MBMI = 53.6). Lifetime and current (past 30 days) use were reported. RESULTS Consistent with national YA trends (2014-2018), the most commonly used were (1) conventional cigarettes (30% surgical, 41% nonsurgical, nonsignificant [ns]); (2) marijuana (25% surgical, 27% nonsurgical, ns); and (3) e-cigarettes (12% surgical, 10% nonsurgical). A sizable minority (26% surgical, 18% nonsurgical) used one or more alternate tobacco product/device. Many YA reported persistent and/or heavy use (e.g., >50% marijuana at year 6 and year 2 or 4; ≈50% ≥.5 pack/d of cigarettes), suggesting more established (versus intermittent) health risk behaviors. For the surgical group at year 6, current tobacco product/device use was associated with lower BMI (P < .001) and greater percent weight loss (P = .002). CONCLUSIONS Pediatric MBS demonstrates promise in lowering risks for adult chronic disease, which may be diminished by age-typical health risk behaviors. Developmentally salient and holistic pediatric postoperative care guidelines are needed.
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Affiliation(s)
- Meg H Zeller
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Heather Strong
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer Reiter-Purtill
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Todd M Jenkins
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James E Mitchell
- Department of Psychiatry and Behavioral Science, University of North Dakota, Fargo, North Dakota
| | - Marc P Michalsky
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Michael A Helmrath
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Tiesenga F, Adorno LF, Udoeyop D, Dinh V, Ahmed S, Sharma A, Sharma K. Perforated Marginal Ulcer. Cureus 2023; 15:e38127. [PMID: 37252481 PMCID: PMC10212605 DOI: 10.7759/cureus.38127] [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] [Accepted: 04/25/2023] [Indexed: 05/31/2023] Open
Abstract
Marginal ulcers are a late complication of gastric bypass surgery. A marginal ulcer is a term for ulcers that develop at the margins of a gastrojejunostomy, primarily on the jejunal side. A perforated ulcer involves the entire thickness of an organ, creating an opening on both surfaces. We will present an intriguing case of a 59-year-old Caucasian female who arrived at the emergency department with diffused chest and abdominal pain that began in her left shoulder and went down to the right lower quadrant area. The patient was in visible pain with restlessness, and her abdomen was moderately distended. The computed tomography (CT) showed possible perforation in the gastric bypass surgery area, but the results were inconclusive. The patient had laparoscopic cholecystectomy ten days prior, and the pain began right after surgery. The patient underwent an open abdominal exploratory surgery, with the closure of the perforated marginal ulcer. The fact that the patient had undergone another surgery and had pain immediately afterward also obscured the diagnosis. This case shows the rare presentation of the patientäs diverse signs and symptoms and inconclusive reports that led to the open abdominal exploratory surgery that finally confirmed the diagnosis. This case highlights the importance of a thorough past medical history, including surgical history. The past surgical history led the team to zone in on the gastric bypass area, leading to an accurate differential diagnosis.
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Affiliation(s)
| | - Luis F Adorno
- Surgery, Windsor University School of Medicine, Community First Medical Center, Chicago, USA
| | | | - Victor Dinh
- Surgery, Windsor University School of Medicine, Chicago, USA
| | - Sarosh Ahmed
- Surgery, Windsor University School of Medicine, Chicago, USA
| | - Akash Sharma
- Surgery, Windsor University School of Medicine, Chicago, USA
| | - Karan Sharma
- Surgery, Windsor University School of Medicine, Chicago, USA
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Maroun J, Vahibe A, Shah M, Mundi MS, Acosta A, McKenzie TJ, Kellogg TA, Ghanem OM. Impact of Chronic Immunosuppression on Short-, Mid-, and Long-Term Bariatric Surgery Outcomes. Obes Surg 2023; 33:240-246. [PMID: 36469206 DOI: 10.1007/s11695-022-06372-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Bariatric surgical outcomes depend heavily on proper healing of gastrointestinal anatomy, metabolic alterations, and patient lifestyle modifications which are all negatively impacted by immunosuppression and underlying inflammatory diseases. There is a lack of literature exploring how patients with diseases requiring immunosuppression respond to bariatric surgical intervention in the long term. METHODS A retrospective analysis of chronically immunosuppressed patients who underwent primary bariatric surgeries at Mayo Clinic was conducted (2008-2020). Data collected included patient demographics, BMI, underlying disease, and immunosuppression regimen and complications at 3, 6, 12, 24, and 60 months. RESULTS We identified a total of 89 (RYGB = 49, SG = 34, BPD/DS = 6) patients on chronic immunosuppression who underwent bariatric surgery at our center. RYGB (N = 49), 38.2% had a SG (N = 34) and 6.7% had a BPD/DS (N = 6). Rheumatoid arthritis and renal transplantation were the most underlying condition at 20.22% each (N = 18). There were a total of 2 (2.25%) intraoperative complications. In the immediate post-operative period, there were 15 (16.5%) minor complications. In follow-up, 6.1% of RYGB patients experienced marginal ulcerations, while no gastrointestinal leaks occurred. The mean pre-surgical BMI was 48.29 kg/m2 (SD = 18.41). Percent total weight loss (%TWL) and BMI reduction were 30.89% and 14.83 kg/m2 (SD = 9.07) at 12 months and 29.48% and 14.43 kg/m2 (SD = 13.46) at 60 months, respectively. The mean follow-up time was 30.49 months. CONCLUSIONS Bariatric surgery remains safe and effective therapy for chronically immunosuppressed patients with excellent long-term outcomes for patients with moderate to severe obesity.
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Affiliation(s)
- Justin Maroun
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Ahmet Vahibe
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Meera Shah
- Department of Medicine, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Manpreet S Mundi
- Department of Medicine, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Andres Acosta
- Department of Medicine, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Todd A Kellogg
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA.
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Intraoperative Patterns of Gastric Microperfusion During Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2022; 32:4047-4056. [PMID: 36243899 DOI: 10.1007/s11695-022-06318-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: 05/20/2022] [Revised: 10/01/2022] [Accepted: 10/11/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Visible light spectroscopy (VLS) represents a sensitive, non-invasive method to quantify tissue oxygen levels and detect hypoxemia. The aim of this study was to assess the microperfusion patterns of the gastric pouch during laparoscopic Roux-en-Y gastric bypass (LRYGB) using the VLS technique. METHODS Twenty patients were enrolled. Tissue oxygenation (StO2%) measurements were performed at three different localizations of the gastric wall, prior and after the creation of the gastric pouch, and after the creation of the gastro-jejunostomy. RESULTS Prior to the creation of the gastric pouch, the lowest StO2% levels were observed at the level of the distal esophagus with a median StO2% of 43 (IQR 40.8-49.5). After the creation of the gastric pouch and after the creation of the gastro-jejunostomy, the lowest StO2% levels were recorded at the level of the His angle with median values of 29% (IQR 20-38.5) and 34.5% (IQR 19-39), respectively. The highest mean StO2 reduction was recorded at the level of the His angle after the creation of the gastric pouch, and it was 18.3% (SD ± 18.1%, p < 0.001). A reduction of StO2% was recorded at all localizations after the formation of the gastro-jejunostomy compared to the beginning of the operation, but the mean differences of the StO2% levels were statistically significant only at the resection line of the pouch and at the His angle (p = 0.044 and p < 0.001, respectively). CONCLUSION Gastric pouch demonstrates reduction of StO2% during LRYGB. VLS is a useful technique to assess microperfusion patterns of the stomach during LRYGB.
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Jen J, Phan H, Johnson B, Blyn C, Lavrich J, Mallem K, Pai PK, Krecioch P. Comparing weight loss outcomes after conversion to Roux-en-Y gastric bypass versus duodenal switch from sleeve gastrectomy in a community hospital. Surg Endosc 2022:10.1007/s00464-022-09654-4. [PMID: 36197520 PMCID: PMC9533973 DOI: 10.1007/s00464-022-09654-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/13/2022] [Indexed: 11/27/2022]
Abstract
Background Recidivism after initial sleeve gastrectomy (SG) remains common. Revisional surgery to convert SG to Roux-en-Y gastric bypass (RYGB) or duodenal switch (DS) for additional weight loss is increasing. This study aims to compare the outcomes after conversion of SG to RYGB or DS. Methods A retrospective single-institution review was conducted from 2015 to 2021, identifying 75 patients who underwent conversion from prior SG to either RYGB (40) or DS (35). Mean excess body weight loss (EBWL) at 3, 6, 12, and 24 months was assessed and compared. Secondary measures of length of stay (LOS), procedure length, and 30-day readmission rate were also reviewed. Results Percentage EBWL for RYGB vs DS was 24.0% vs 18.8% at 3 months (N = 36 vs 26; P < 0.0491), 34.8% vs 29.0% at 6 months (N = 29 vs 17; P < 0.2192), 43.0% vs 40.1% at 12 months (N = 28 vs 12; P < 0.6828), and 36.2% vs 41.7% at 24 months (N = 27 vs 7; P < 0.5553). Average LOS was 2.6 days ± 1.4 for RYGB and 2.8 days ± 1.3 for DS (P < 0.6032). Average procedure length was 134.4 min for RYGB and 189.8 min for DS (P < 0.0001). 30-day readmission rate was 27.5% (N = 11) for RYGB and 14.3% (N = 5) for DS (P < 0.1645). Significant weight loss was observed in both subgroups up to 12 months, with no significant weight loss between 12 and 24 months (RYGB N = 21, P < 0.2961; DS N = 5, P < 0.7233). Conclusion Both revisional RYGB and revisional DS procedures had significant and sustained weight loss in the first 12 months. There was no significant excess body weight loss difference between revisional RYGB and revisional DS patients at 6, 12, and 24 months, with only significant greater weight loss for RYGB patients at 3 months. Additionally, procedure length was significantly longer for DS compared to RYGB, with no significant differences in LOS and 30-day readmission rates. Graphical abstract ![]()
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Affiliation(s)
- Jeremy Jen
- Department of Surgery, Mercy Catholic Medical Center, 1500 Lansdowne Avenue, Darby, PA, 19123, USA.
| | - Hau Phan
- Department of Surgery, Mercy Catholic Medical Center, 1500 Lansdowne Avenue, Darby, PA, 19123, USA
| | - Brett Johnson
- Department of Surgery, Mercy Catholic Medical Center, 1500 Lansdowne Avenue, Darby, PA, 19123, USA
| | - Corliann Blyn
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Janet Lavrich
- University of New England College of Osteopathic Medicine, Biddeford, ME, USA
| | - Krishna Mallem
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Piotr Krecioch
- Department of Surgery, Mercy Catholic Medical Center, 1500 Lansdowne Avenue, Darby, PA, 19123, USA
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Increased incidence of marginal ulceration following conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: a multi-institutional experience. Surg Endosc 2022; 37:3974-3981. [PMID: 36002686 DOI: 10.1007/s00464-022-09430-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/29/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Marginal ulcer (MU) formation is a serious complication following Roux-en-Y Gastric Bypass (RYGB). Incidental data suggested a higher incidence of MU following conversion of Sleeve Gastrectomy to RYGB (S-RYGB). Herein, we evaluate the incidence of MU after primary versus secondary RYGB. METHODS After IRB approval, each institution's electronic medical record and MBSAQIP database were queried to retrospectively identify adult patients who underwent primary RYGB (P-RYGB), Gastric Banding to RYGB (B-RYGB), or S-RYGB between 2014 and 2019, with minimum 1 year follow-up. Patient demographics, operative data, and post-operative outcomes were compared. Numeric variables were compared via two-sample t test, Wilcoxon test or Kruskal Wallis rank sum test. Two-sample proportion test or Fisher's exact test was employed for categorical and binary variables. p < 0.05 marked statistical significance. RESULTS 748 patients underwent RYGB: P-RYGB n = 584 [78.1%]; B-RYGB n = 98 [13.1%]; S-RYGB n = 66 [8.8%]. Most patients were female (83.2%). Mean age was 45.7 years. Forty-six (n = 6.1%) patients developed MU, a median of 14 ± 32.2 months (range 0.5-82) post-operatively. Incidence of MU was significantly higher for patients undergoing S-RYGB (n = 9 [13.6%]), compared to P-RYGB (n = 34 [5.8%]) and B-RYGB (n = 3 [3.1%]) (p = 0.023). Median time (months) to MU was significantly shorter for patients who underwent S-RYGB (5 ± 6) compared to P-RYGB or B-RYGB (19 ± 37.5) (p = 0.035). Among those who developed MU, there was no significant difference in H. pylori status, NSAID, steroid, or tobacco use, irrespective of operation performed. CONCLUSION In this multi-institutional cohort, patients who underwent S-RYGB had a significantly higher incidence of MU than those with P-RYGB or B-RYGB. Further research is needed to elucidate its pathophysiology and prevention strategies.
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Portela RC, Sharma I, Vahibe A, Hassan O, Spaniolas K, Dayyeh BA, Clapp B, Ghanem OM. Aspirin Use as a Risk Factor for Marginal Ulceration in Roux-en-Y Gastric Bypass Patients: A Meta-Analysis of 24,770 Patients. Am Surg 2022:31348221103647. [PMID: 35586872 DOI: 10.1177/00031348221103647] [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: 11/15/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is a recognized, safe bariatric procedure with minimal complications. Marginal ulceration, however, remains a challenging problem with an incidence of 8-12%. While chronic NSAID use is an established risk factor for ulcer formation, aspirin use itself as a cause for marginal ulceration is still unclear. We aim to compare the rates of marginal ulceration in RYGB with and without aspirin use. METHODS PubMed, ScienceDirect, Cochrane, Web of Science, and Google Scholar were searched for articles between 2008 and 2021 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The risk of bias was assessed using Newcastle-Ottawa Scale. Meta-analysis was conducted using a fixed-effect model. RESULTS From 5324 studies screened, we included 3 studies. Two studies had a low risk of bias, and the other one presented a high risk of bias on the Newcastle-Ottawa Scale. We included 24,770 patients, 1911 with aspirin use and 22,859 without aspirin use. After the meta-analysis, patients who used aspirin had a significantly higher marginal ulceration rate than those who did not (OR = 1.33 [95% CI 1.08 to 1.63], P < .002; I2 = 39%). CONCLUSIONS Aspirin use is associated with increased rates of marginal ulceration after RYGB.
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Affiliation(s)
- Ray C Portela
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Ishna Sharma
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Ahmet Vahibe
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Omer Hassan
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | | | | | - Benjamin Clapp
- Department of Surgery, 37316Texas Tech HSC Paul Foster School of Medicine, El Paso, TX, USA
| | - Omar M Ghanem
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
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King WC, White GE, Belle SH, Yanovski SZ, Pomp A, Pories WJ, Wolfe BM, Ahmed B, Courcoulas AP. Changes in Smoking Behavior Before and After Gastric Bypass: A 7-year Study. Ann Surg 2022; 275:131-139. [PMID: 32084036 DOI: 10.1097/sla.0000000000003828] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate smoking history and change in smoking behavior, from 1 year before through 7 years after Roux-en-Y gastric bypass (RYGB) surgery, and to identify risk factors for post-surgery smoking. BACKGROUND Smoking behavior in the context of bariatric surgery is poorly described. METHODS Adults undergoing RYGB surgery entered a prospective cohort study between 2006 and 2009 and were followed up to 7 years until ≤2015. Participants (N = 1770; 80% female, median age 45 years, median body mass index 47 kg/m2) self-reported smoking history pre-surgery, and current smoking behavior annually. RESULTS Almost half of participants (45.2%) reported a pre-surgery history of smoking. Modeled prevalence of current smoking decreased in the year before surgery from 13.7% [95% confidence interval (CI) = 12.1-15.4] to 2.2% (95% CI = 1.5-2.9) at surgery, then increased to 9.6% (95% CI = 8.1-11.2) 1-year post-surgery and continued to increase to 14.0% (95% CI = 11.8-16.0) 7-years post-surgery. Among smokers, mean packs/day was 0.60 (95% CI = 0.44-0.77) at surgery, 0.70 (95% CI = 0.62-0.78) 1-year post-surgery and 0.77 (95% CI = 0.68-0.88) 7-years post-surgery. At 7-years, smoking was reported by 61.7% (95% CI = 51.9-70.8) of participants who smoked 1-year pre-surgery (n = 221), 12.3% (95% CI = 8.5-15.7) of participants who formerly smoked but quit >1 year pre-surgery (n = 507), and 3.8% (95% CI = 2.1-4.9) of participants who reported no smoking history (n = 887). Along with smoking history (ie, less time since smoked), younger age, household income <$25,000, being married or living as married, and illicit drug use were independently associated with increased risk of post-surgery smoking. CONCLUSION Although most adults who smoked 1-year before RYGB quit pre-surgery, smoking prevalence rebounded across 7-years, primarily due to relapse.
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Affiliation(s)
- Wendy C King
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gretchen E White
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven H Belle
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Susan Z Yanovski
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Alfons Pomp
- Department of Surgery, Weill Cornell Medical College, New York, New York
| | - Walter J Pories
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Bruce M Wolfe
- Department of Surgery, Oregon Health & Sciences University, Portland, Oregon
| | - Bestoun Ahmed
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anita P Courcoulas
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Zandomenico JG, Trevisol FS, Machado JA. Compliance with Enhanced Recovery After Surgery (ERAS) protocol recommendations for bariatric surgery in an obesity treatment center. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2021; 73:36-41. [PMID: 34963616 PMCID: PMC9801194 DOI: 10.1016/j.bjane.2021.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/19/2021] [Accepted: 10/02/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The higher risk of perioperative complications associated with obesity has made anesthesiologists increasingly concerned with the management of obese patients. Measures that improve bariatric surgery patient safety have become essential. The implementation of ERAS protocols in several surgical specialties has made it possible to achieve appropriate outcomes as to surgery safety. The aim of this study was to evaluate patient compliance with the recommendations of an ERAS protocol for Bariatric Surgery (ERABS) at a hospital specialized in obesity treatment. METHODS Cross-sectional study, using a medical record database, in a hospital certified as an International Center of Excellence in Bariatric and Metabolic Surgery. The definition of the variables to be assessed was based on the most recent ERABS proposed by Thorell et al. Results were analyzed using descriptive epidemiology. RESULTS The study evaluated all patients undergoing bariatric surgery in 2019. Mean compliance with the recommendations per participant was 42.8%, with a maximum of 55.5%, and was distributed as follows: 22.6% of compliance with preoperative recommendations, 60% to intraoperative recommendations, and 58.1% to postoperative recommendations. The anesthesiologist is the professional who provides most measures for the perioperative optimization of bariatric surgery patients. In our study we found that anesthesiologists complied with only 39.5% of ERABS recommendations. CONCLUSIONS Mean compliance with ERABS recommendations per participant was 42.8%. Considering that the study was carried out at a hospital certified as an international center of excellence, the need for introducing improvements in the care of patients to be submitted to bariatric surgery is evident.
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Montgomery JR, Waits SA, Dimick JB, Telem DA. Perioperative Risks of Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass Among Patients With Chronic Kidney Disease: A Review of the MBSAQIP Database. Ann Surg 2021; 274:e328-e335. [PMID: 31599806 PMCID: PMC8088121 DOI: 10.1097/sla.0000000000003627] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine whether patients with CKD experience higher rates of perioperative complications after RYGB compared to sleeve gastrectomy. SUMMARY OF BACKGROUND DATA For obese CKD patients who qualify for bariatric surgery, sleeve gastrectomy is often preferred to RYGB based on perceptions of prohibitively-high perioperative risks surrounding RYGB. However, some patients with CKD are not candidates for sleeve gastrectomy and the incremental increased-risk from RYGB has never been rigorously tested in this population. METHODS CKD patients who underwent RYGB or sleeve gastrectomy between 2015 and 2017 were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use File. RYGB patients were 1:1 propensity-score matched with sleeve gastrectomy patients based on preoperative factors that influence operative choice. Primary outcomes included 30-day readmissions, surgical complications, medical complications, and death. Secondary outcomes included the individual complications used to create the composite surgical/medical complications. Univariate logistic regression was used to compare outcomes. E-value statistic was used to test the strength of outcome point estimates against possible unmeasured confounding. RESULTS Demographics were similar between RYGB (n = 673) and sleeve gastrectomy (n = 673) cohorts. There were no statistically significant differences in primary outcomes. Among secondary outcomes, only acute kidney injury was statistically-significantly higher among RYGB patients (4.9% vs 2.7%, P = 0.035, E-value 1.27). CONCLUSIONS Among well-matched cohorts of RYGB and sleeve gastrectomy patients, incidence of primary outcomes were similar. Among secondary outcomes, only acute kidney injury was statistically-significantly higher among RYGB patients; however, the E-value for this difference was small and relatively weak confounder(s) could abrogate the statistical difference. The perception that RYGB has prohibitively-high perioperative risks among CKD patients is disputable and operative selection should be weighed on patient candidacy and anticipated long-term benefit.
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Affiliation(s)
- John R Montgomery
- University of Michigan, Department of General Surgery, Ann Arbor, Michigan
- University of Michigan, Center for Healthcare Outcomes & Policy, Ann Arbor, Michigan
| | - Seth A Waits
- University of Michigan, Department of General Surgery, Ann Arbor, Michigan
| | - Justin B Dimick
- University of Michigan, Department of General Surgery, Ann Arbor, Michigan
- University of Michigan, Center for Healthcare Outcomes & Policy, Ann Arbor, Michigan
| | - Dana A Telem
- University of Michigan, Department of General Surgery, Ann Arbor, Michigan
- University of Michigan, Center for Healthcare Outcomes & Policy, Ann Arbor, Michigan
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Kumbhari V, le Roux CW, Cohen RV. Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review. Obes Surg 2021; 31:4624-4633. [PMID: 34331187 DOI: 10.1007/s11695-021-05603-7] [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: 04/07/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.
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Affiliation(s)
- Vivek Kumbhari
- Department of Gastroenterology and Hepatology, The Johns Hopkins University, 1800 Orleans St, Suite 7125B, Baltimore, MD, USA. .,Department of Gastroenterology and Hepatology, Mayo Clinic, 1800 Orleans St, Suite 7125B, Florida, FL, USA.
| | - Carel W le Roux
- Diabetes Complications Research Centre, University College Dublin, Dublin, Ireland
| | - Ricardo V Cohen
- The Center for the Treatment of Obesity and Diabetes, Hospital Oswaldo Cruz, Sao Paulo, Brazil
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15
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Impact of smoking on weight loss outcomes after bariatric surgery: a literature review. Surg Endosc 2021; 35:5936-5952. [PMID: 34319440 DOI: 10.1007/s00464-021-08654-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The association between smoking and surgical complications after bariatric surgery has been well-established. However, given that this patient population is inherently weight-concerned, understanding the effects of tobacco use on postoperative weight loss is essential to guiding clinicians in counseling patients. We aimed to summarize the current literature examining the effects of preoperative and postoperative smoking, as well as changes in smoking status, on bariatric surgery weight loss outcomes. METHODS Ovid MEDLINE, PubMed, and SCOPUS databases were queried to identify relevant published studies. RESULTS Overall, 20 studies were included. Preoperative and postoperative smoking rates varied widely across studies, as did requirements for smoking cessation prior to bariatric surgery. Reported preoperative smoking prevalence ranged from 1 to 62%, and postoperative smoking prevalence ranged from 6 to 43%. The majority of studies which examined preoperative and/or postoperative smoking habits found no association between smoking habits and postoperative weight loss outcomes. A minority of studies found relatively small differences in postoperative weight loss between smokers and nonsmokers; these often became nonsignificant with longer follow-up. No studies found significant associations between changes in smoking status and weight loss outcomes. CONCLUSION While smoking has been associated with weight loss in the general population, most current evidence demonstrates that smoking habits are not associated with weight loss outcomes after bariatric surgery. However, due to the heterogeneity in study design and analysis, no definitive conclusions can be made, and more robust studies are needed to investigate any relationship between smoking and long-term weight loss outcomes. Given the established increased risk of surgical complications and mortality in smokers, smoking cessation should be encouraged.
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16
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Chow A, Neville A, Kolozsvari N. Smoking in bariatric surgery: a systematic review. Surg Endosc 2021; 35:3047-3066. [PMID: 32524412 DOI: 10.1007/s00464-020-07669-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The prevalence of smoking among patients undergoing bariatric surgery has been reported to be as high as 40%. The effect of smoking in the perioperative period has been extensively studied for various surgical procedures, but limited data are available for bariatric surgery. The objective of this study is to review the existing literature to assess: (1) the impact of smoking on postoperative morbidity and mortality after bariatric surgery, (2) the relationship between smoking and weight loss after bariatric surgery, and (3) the efficacy of smoking cessation in the perioperative period among bariatric surgery patients. METHODS A comprehensive search of electronic databases including MEDLINE, EMBASE and the Cochrane Library from 1946 to February 2020 was performed to identify relevant articles. Following an initial screen of 940 titles and abstracts, 540 full articles were reviewed. RESULTS Forty-eight studies met criteria for analysis: five structured interviews, three longitudinal studies, thirty-two retrospective studies and eight prospective studies. Smoking within 1 year prior to bariatric surgery was found to be an independent risk factor for increased 30-day mortality and major postoperative complications, particularly wound and pulmonary complications. Smoking was significantly associated with long-term complications including marginal ulceration and bone fracture. Smoking has little to no effect on weight loss following bariatric surgery, with studies reporting at most a 3% increased percentage excess weight loss. Rates of smoking recidivism are high with studies reporting that up to 17% of patients continue to smoke postoperatively. CONCLUSIONS Although current best practice guidelines recommend only a minimum of 6 weeks of abstinence from smoking prior to bariatric surgery, the findings of this review suggest that smoking within 1 year prior to bariatric surgery is associated with significant postoperative morbidity. More investigation is needed on strategies to improve smoking cessation compliance among bariatric surgery patients in the perioperative period.
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Affiliation(s)
- Alexandra Chow
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Hospital, Civic Campus, Loeb Research Building, Main Floor, 725 Parkdale Avenue, Office WM150B, Ottawa, ON, K1Y 4E9, Canada.
| | - Amy Neville
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
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17
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Cottam D, Cottam S, Surve A. Single-Anastomosis Duodenal Ileostomy with Sleeve Gastrectomy "Continued Innovation of the Duodenal Switch". Surg Clin North Am 2021; 101:189-198. [PMID: 33743963 DOI: 10.1016/j.suc.2020.12.010] [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] [Indexed: 12/12/2022]
Abstract
Single-anastomosis duodenal ileostomy with sleeve gastrectomy (SADI-S) is an important emerging procedure in bariatric surgery as an alternative to performing the Roux-en-Y gastric bypass (RYGB) or the Roux-en-Y duodenal switch. With this significant weight loss and low weight regain, SADI-S has low complication rates. SADI-S, because of its anatomic configuration, also does not increase ulcer risk in patients, with almost no ulcers observed. Because of the short common channel, malnutrition is a risk. Diabetes resolution is higher than with RYGB. Overall SADI-S is a safe and effective procedure for patients with higher body mass index and patients with diabetes.
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Affiliation(s)
- Daniel Cottam
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT 84102, USA.
| | - Samuel Cottam
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT 84102, USA
| | - Amit Surve
- Bariatric Medicine Institute, 1046 East 100 South, Salt Lake City, UT 84102, USA
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18
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Cheng Z, Qing R, Hao S, Ding Y, Yin H, Zha G, Chen X, Ji J, Wang B. Fabrication of ulcer-adhesive oral keratin hydrogel for gastric ulcer healing in a rat. Regen Biomater 2021; 8:rbab008. [PMID: 33738122 PMCID: PMC7955710 DOI: 10.1093/rb/rbab008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/09/2021] [Accepted: 01/17/2021] [Indexed: 12/28/2022] Open
Abstract
Hydrogel has been used for in suit gastric ulcer therapy by stopping bleeding, separating from ulcer from gastric fluids and providing extracellular matrix scaffold for tissue regeneration, however, this treatment guided with endoscopic catheter in most cases. Here, we developed an oral keratin hydrogel to accelerate the ulcer healing without endoscopic guidance, which can specially adhere to the ulcer because of the high-viscosity gel formation on the wound surface in vivo. Approximately 50% of the ulcer-adhesive keratin hydrogel can resident in ethanol-treated rat stomach within 12 h, while approximately 18% of them maintained in health rat stomach in the same amount of time. Furthermore, Keratin hydrogels accelerated the ethanol-induced gastric ulcer healing by stopping the bleeding, preventing the epithelium cells from gastric acid damage, suppressing inflammation and promoting re-epithelization. The oral administration of keratin hydrogel in gastric ulcer treatment can enhance the patient compliance and reduce the gastroscopy complications. Our research findings reveal a promising biomaterial-based approach for treating gastrointestinal ulcers.
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Affiliation(s)
- Zhongjun Cheng
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China.,School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China.,Bijie Institute of Traditional Chinese Medicine, Bijie City, Guizhou Province 551700, China
| | - Rui Qing
- Media Lab, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Shilei Hao
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China
| | - Yi Ding
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China
| | - Haimeng Yin
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - GuoDong Zha
- HEMOS (Chongqing) Bioscience Co., Ltd, Chongqing 402760, China
| | - Xiaoliang Chen
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China.,Department of Nuclear Medicine, Institution of Chongqing Cancer, Chongqing 400030, China
| | - Jingou Ji
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - Bochu Wang
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400030, China
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19
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Zeller MH, Kidwell KM, Reiter-Purtill J, Jenkins TM, Michalsky MP, Mitchell JE, Courcoulas AP, Inge TH. Cigarette Use and Adolescent Metabolic and Bariatric Surgery. Obesity (Silver Spring) 2021; 29:579-586. [PMID: 33528876 PMCID: PMC8023426 DOI: 10.1002/oby.23084] [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: 09/09/2020] [Revised: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study aimed to track conventional cigarette smoking behaviors and associated correlates in adolescents with severe obesity who did or did not undergo metabolic and bariatric surgery to 4 years after surgery/baseline. METHODS Utilizing a prospective controlled design, surgical (n = 153; mean BMI = 52) and nonsurgical (n = 70; mean BMI = 47) groups that completed assessments before surgery/at baseline and at Years 2 and 4 post surgery (Year 4: n = 117 surgical [mean BMI = 38]; n = 56 nonsurgical [mean BMI = 48]) were compared. Separate logistic regression models tested correlates of Year 4 current smoking. RESULTS More than half of participants (surgical: 55%; nonsurgical: 60%) had ever smoked a cigarette, with current smoking increasing with time. Groups did not differ in Year 4 current smoking (surgical: 23%; nonsurgical: 33%), with ≈ 50% meeting criteria for "heavy" smoking (≥ half pack/day) and ≈ 40% smoking their first cigarette before ninth grade. Factors associated with higher odds of Year 4 current smoking included dysregulation (P < 0.001), internalizing symptoms (P = 0.01), alcohol use (P = 0.04), caregiver smoking (P < 0.001), friend smoking (P = 0.001), and perceiving low harm (P = 0.02), plus greater percent weight loss (P = 0.03) in the surgical group. CONCLUSIONS Smoking is a clinical health challenge for adolescents and young adults with severe obesity, including those who have undergone metabolic and bariatric surgery. Upstream identification, monitoring, and intervention to prevent smoking uptake and escalation in youth with obesity across settings should be prioritized.
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Affiliation(s)
- Meg H Zeller
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Katherine M Kidwell
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer Reiter-Purtill
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Todd M Jenkins
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Marc P Michalsky
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - James E Mitchell
- Department of Psychiatry and Behavioral Science, University of North Dakota, Fargo, North Dakota, USA
| | - Anita P Courcoulas
- Division of Minimally Invasive General and Bariatric Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Thomas H Inge
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
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20
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Wolvers PJD, Ayubi O, Bruin SC, Hutten BA, Brandjes DPM, Meesters EW, Gerdes VEA. Smoking Behaviour and Beliefs About Smoking Cessation After Bariatric Surgery. Obes Surg 2021; 31:239-249. [PMID: 32803711 PMCID: PMC7808968 DOI: 10.1007/s11695-020-04907-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 08/01/2020] [Accepted: 08/06/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Currently, bariatric surgery is the most effective intervention for treating morbid obesity and its complications. Smoking cessation is likely to improve smoking-related comorbidities and decrease postoperative complications. This study evaluated the smoking behaviour and thoughts about smoking cessation of patients more than 18 months after bariatric surgery. MATERIALS AND METHODS A cross-sectional study was performed in patients who underwent bariatric surgery from July 2012 to December 2013. A questionnaire was used to evaluate smoking status, thoughts about the health benefits of cessation and characteristics of previous quit attempts in current and former smokers. Finally, actual bariatric surgery outcomes were evaluated in current, former and never smokers. RESULTS Six hundred nine patients (response rate 52.0%) were included. Of them, 101 (16.6%) patients were current smokers, 239 (39.2%) former smokers and 269 (44.2%) patients were lifetime never smokers. Compared with former smokers, current smokers were less aware of the beneficial effects of smoking cessation on their general health; 66.4% of the former smokers thought smoking cessation would be much better for general health, compared with 20.6% of current smokers. Total weight loss was 2.8% higher in current smokers compared with former smokers. Actual long-term bariatric surgery outcomes were not significantly different between the groups. CONCLUSION Despite advice to quit smoking and temporary quitting before surgery, a considerable group of bariatric surgery patients continues smoking after surgery. These patients were less aware of the beneficial effects of smoking cessation. This study emphasizes the need for better strategies to increase the number of successful cessations.
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Affiliation(s)
- Paula J. D. Wolvers
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Oranos Ayubi
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Sjoerd C. Bruin
- Department of Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM Hoofddorp, Netherlands
| | - Barbara A. Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Dees P. M. Brandjes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Eelco W. Meesters
- Department of Internal Medicine, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM Hoofddorp, Netherlands
| | - Victor E. A. Gerdes
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
- Department of Internal Medicine, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM Hoofddorp, Netherlands
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21
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Athanasiadis DI, Christodoulides A, Monfared S, Hilgendorf W, Embry M, Stefanidis D. High Rates of Nicotine Use Relapse and Ulcer Development Following Roux-en-Y Gastric Bypass. Obes Surg 2020; 31:640-645. [PMID: 32959330 DOI: 10.1007/s11695-020-04978-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/05/2020] [Accepted: 09/11/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Given that smoking is known to contribute to gastrojejunal anastomotic (GJA) ulcers, cessation is recommended prior to laparoscopic Roux-en-Y gastric bypass (LRYGB). However, smoking relapse rates and the exact ulcer risk remain unknown. This study aimed to define smoking relapse, risk of GJA ulceration, and complications after LRYGB. MATERIALS AND METHODS We performed a retrospective cohort study of patients who underwent primary LRYGB during 2011-2015. Initially, three patient categories were identified: lifetime non-smokers, patients who were smoking during the initial visit at the bariatric clinic or within the prior year (recent smokers), and patients who had ceased smoking more than a year prior to their initial clinic visit (former smokers). Smoking relapse, GJA ulcer occurrences, reinterventions, and reoperations were recorded and compared. RESULTS A total of 766 patients were included in the analysis. After surgery, 53 (64.6%) recent smokers had resumed smoking. Out of these relapsed smokers, 51% developed GJA ulcers compared with 14.8% in non-relapsed recent smokers, 16.1% in former smokers, and 6% in lifetime nonsmokers (p < 0.001). Furthermore, relapsed smokers required more frequently endoscopic reinterventions (60.4%) compared with non-relapsed smokers (20.8%, p < 0.001), former smokers (20.7%, p < 0.001), and lifetime non-smokers (15.4%, p < 0.001). Additionally, relapsed smokers required a reoperation (18.9%) more often than non-relapsed recent smokers (5.7%, p < 0.001) and lifetime non-smokers (1.3%, p < 0.001). CONCLUSION Smokers relapse frequently after LRYGB, and the majority experience GJA complications. They should be counseled about this risk preoperatively and directed towards less ulcerogenic procedures when possible. Alternatively, longer periods of preoperative smoking abstinence might be needed.
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Affiliation(s)
- Dimitrios I Athanasiadis
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 130, Indianapolis, IN, 46202, USA
| | | | - Sara Monfared
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 130, Indianapolis, IN, 46202, USA
| | | | - Marisa Embry
- Department of Surgery, Indiana University Health, Indianapolis, IN, USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 130, Indianapolis, IN, 46202, USA. .,Department of Surgery, Indiana University Health, Indianapolis, IN, USA.
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Self-Reported Smoking Compared to Serum Cotinine in Bariatric Surgery Patients: Smoking Is Underreported Before the Operation. Obes Surg 2020; 30:23-37. [PMID: 31512159 DOI: 10.1007/s11695-019-04128-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Smoking has been associated with postoperative complications and mortality in bariatric surgery. The evidence for smoking is based on self-report and medical charts, which can lead to misclassification and miscalculation of the associations. Determination of cotinine can objectively define nicotine exposure. We determined the accuracy of self-reported smoking compared to cotinine measurement in three phases of the bariatric surgery trajectory. METHODS Patients in the phase of screening (screening), on the day of surgery (surgery), and more than 18 months after surgery (follow-up) were consecutively selected. Self-reported smoking was registered and serum cotinine was measured. We evaluated the accuracy of self-reported smoking compared to cotinine, and the level of agreement between self-report and cotinine for each phase. RESULTS In total, 715 patients were included. In the screening, surgery, and follow-up group, 25.6%, 18.0%, and 15.5%, respectively, was smoking based on cotinine. The sensitivity of self-reported smoking was 72.5%, 31.0%, and 93.5% in the screening, surgery, and follow-up group, respectively (p < 0.001). The specificity of self-report was > 95% in all groups (p < 0.02). The level of agreement between self-report and cotinine was 0.778, 0.414, and 0.855 for the screening, surgery, and follow-up group, respectively. CONCLUSIONS Underreporting of smoking occurs before bariatric surgery, mainly on the day of surgery. Future studies on effects of smoking and smoking cessation in bariatric surgery should include methods taking into account the issue of underreporting.
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23
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Effects of smoking on bariatric surgery postoperative weight loss and patient satisfaction. Surg Endosc 2020; 35:3584-3591. [PMID: 32700150 DOI: 10.1007/s00464-020-07827-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND While general population studies have demonstrated a relationship between cigarette smoking and weight loss, this association is not well established among the bariatric patient population. Given that bariatric patients are inherently weight-concerned, understanding the effects of smoking on postoperative weight loss is essential. We examined the association of preoperative smoking, postoperative smoking and changes in smoking status with weight loss after bariatric surgery. In addition, we examined the association of changes in smoking status with subjective indices of patient satisfaction while controlling for weight loss. METHODS Retrospective chart review of patients who underwent Sleeve Gastrectomy or Roux-en-Y Gastric Bypass for weight loss at a single institution between August 2000 and November 2017. Additional follow up was obtained by telephone survey. Statistical analysis utilized multivariate logistical regressions. RESULTS Our study included 512 patients. Majority were female (n = 390, 76.2%) and underwent laparoscopic Roux-en-Y gastric bypass (n = 362, 70.7%). Average age was 46.8 years and average follow up was 6.99 years. Preoperative, postoperative and changes in smoking status were not significantly associated with weight loss. Former smokers were significantly more likely to report postoperative satisfaction with self-overall OR 10.62 (p < 0.01), satisfaction with postoperative outcomes OR 4.18 (p = 0.02), and improvement in quality of life OR 4.05 (p = 0.04) compared to continued smokers independent of weight loss. No difference in rates of satisfaction were found between former smokers and never smokers. Smoking cessation and weight loss were independently predictive of positive responses to these satisfaction indices. CONCLUSIONS We found no association between preoperative smoking, postoperative smoking or changes in smoking status with postoperative weight loss. Smoking cessation was associated with patient satisfaction and improvement in quality of life compared to continued smokers. Smoking cessation and postoperative weight loss were independently predictive of increased patient satisfaction.
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Bekhali Z, Sundbom M. Low Risk for Marginal Ulcers in Duodenal Switch and Gastric Bypass in a Well-Defined Cohort of 472 Patients. Obes Surg 2020; 30:4422-4427. [PMID: 32638248 PMCID: PMC7524689 DOI: 10.1007/s11695-020-04822-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE Marginal ulcer (MU) is well-known complication in bariatric surgery. Several studies are available in Roux-en-Y gastric bypass (RYGBP), while data on the incidence in duodenal switch (DS) is limited. We aimed to compare the incidence of MU between DS and RYGBP in a well-defined cohort and to identify associative factors. METHODS A cohort of 732 patients with BMI ≥ 48 who had undergone primary DS or RYGBP during 2008-2018 received a questionnaire concerning ulcers, PPI therapy, and smoking habits; hereafter, patient charts were reviewed. Incidence rates (IRs) for MU were calculated in our survey and on previous registered data in the national quality register for bariatric surgery (SOReg). A multivariate regression analysis was performed to identify predictive risk factors for MU. RESULTS After a mean follow-up of 6.1 years, 472 (64%) patients responded (47 ± 11 years old, 65% women and 42% DS). Of 41 MUs identified, 23 were endoscopically verified. Gastrointestinal bleeding, abdominal pain, and dysphagia were the most common symptoms. IR for MU was 1.4% (DS 1.3% and RYGBP 1.5%) per patient-year, compared with 0.9% according to SOReg-data. Persisting PPI treatment was seen in about three quarter of former MU patients (OR 11.2 [3.6-34.7], p < 0.001), but no other associative factors were found. CONCLUSION The overall risk for MU was low, about 1% per patient-year, without difference between DS and RYGBP. Ongoing PPI treatment was frequent in many former MU patients. This study on MU after DS provides reassuring results for future bariatric surgery candidates.
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Affiliation(s)
- Zakaria Bekhali
- Department of Surgical Sciences, Uppsala University, SE-751 85, Uppsala, Sweden. .,Department of Surgery, Gävle Hospital, Kirurgmottagningen, Gävle sjukhus, SE-801 88, Gävle, Sweden.
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, SE-751 85, Uppsala, Sweden
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25
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Canadian consensus statement: enhanced recovery after surgery in bariatric surgery. Surg Endosc 2019; 34:1366-1375. [PMID: 31209605 DOI: 10.1007/s00464-019-06911-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/11/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND In Canada, bariatric surgery continues to remain the most effective treatment for severe obesity and its comorbidities. As the number of bariatric surgeries continues to grow, the need for consensus guidelines for optimal perioperative care is imperative. In colorectal surgery, enhanced recovery after surgery (ERAS) protocols were created for this purpose. The objective of this review is to develop evidence-based ERAS guidelines for bariatric surgery. METHODS A literature search of the MEDLINE database was performed using ERAS-specific search terms. Recently published articles with a focus on randomized controlled trials, systematic reviews, and meta-analyses were included. Quality of evidence and recommendations were evaluated using the GRADE assessment system. RESULTS Canadian bariatric surgeons from six provinces and ten bariatric centers performed a review of the evidence surrounding ERAS in bariatric surgery and created consensus guidelines for 14 essential ERAS elements. Our main recommendations were (1) to encourage participation in a presurgical weight loss program; (2) to abstain from tobacco and excessive alcohol; (3) low-calorie liquid diet for at least 2 weeks prior to surgery; (4) to avoid preanesthetic anxiolytics and long-acting opioids; (5) unfractionated or low-molecular-weight heparin prior to surgery; (6) antibiotic prophylaxis with cefazolin ± metronidazole; (7) reduced opioids during surgery; (8) surgeon preference regarding intraoperative leak testing; (9) nasogastric intubation needed only for Veress access; (10) to avoid abdominal drains and urinary catheters; (11) to prevent ileus by discontinuing intravenous fluids early; (12) postoperative analgesia with acetaminophen, short-term NSAIDS, and minimal opioids; (13) to resume full fluid diet on first postoperative day; (14) early telephone follow-up with full clinic follow-up at 3-4 weeks. CONCLUSIONS The purpose of addressing these ERAS elements is to develop guidelines that can be implemented and practiced clinically. ERAS is an excellent model that improves surgical efficiency and acts as a common perioperative pathway. In the interim, this multimodal bariatric perioperative guideline serves as a common consensus point for Canadian bariatric surgeons.
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Evaluation of the rate of marginal ulcer formation after bariatric surgery using the MBSAQIP database. Surg Endosc 2018; 33:1890-1897. [PMID: 30251139 DOI: 10.1007/s00464-018-6468-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/20/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Marginal ulcer (MU) formation is a known problem after gastric bypass. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database contains data from all US and Canadian Centers of Excellence including complication rates. We hypothesized that the short-term rate of ulceration is low. METHODS We queried the MBSAQIP database for the year 2015. We searched patients with primary gastric bypass who developed MU. We then compared preoperative, operative, and postoperative characteristics with patients who did not develop MU. RESULTS The incidence of MU in the entire cohort of GB patients was 155 of 44,379 (0.35%, 95% CI 0.297%, 0.409%). Among the 155 patients with an ulcer, 88 (57%) patients had only one procedure, 69 had an intervention (therapeutic or diagnostic endoscopy), 16 had readmission, and 3 had reoperation. 65 patients (42%) had two procedures with the majority having both readmissions and endoscopy (n = 59); and two patients (1%) had three procedures. Ulcer formation was most common in the intervention group (11.4%). The occurrence of ulcer formation was associated with unplanned ICU admissions (6.45%), transfusions (5.16%), postoperative UTI (3.87%), sepsis (1.94%), and myocardial infarction (0.65%). Death occurred in 76 patients with no related cases to MUs. The risk of ulcer was associated with increased BMI (OR 1.02, p = 0.01), presence of percutaneous transluminal cardiac catheterization (PTC) (2.17, p = 0.038), histories of DVT (1.72, p = 0.085), and pulmonary embolism (2.84, p = 0.002). CONCLUSIONS In a nationally reported database, symptomatic MUs rarely occur in the first month. The large majority are diagnosed and treated endoscopically with minimal need for surgical intervention. The risk of anastomotic ulcer was increased with increased BMI, need for PTC, and history of DVT/PE.
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