Rhabdomyolysis in bariatric surgery: a systematic review

Obesity at term: What to consider? How to deliver?

Obesity presents significant challenges during pregnancy, increasing the risk of complications and adverse outcomes for both mother and baby. With the rising prevalence of obesity among pregnant women, questions arise regarding optimal management, including timing of delivery and choice of delivery mode. Labour induction in obese women may require a combination of mechanical and pharmacological methods due to increased risk of failed induction. Caesarean section in obese women presents unique challenges, requiring comprehensive perioperative planning and specialized care to optimize outcomes. However, specific guidelines tailored to obese patients undergoing caesarean sections are lacking. Postpartum care should include vigilant monitoring for complications. Addressing obesity in pregnancy necessitates a multidisciplinary approach and specialized care to ensure the best outcomes.

Developing In Vitro Models to Define the Role of Direct Mitochondrial Toxicity in Frequently Reported Drug-Induced Rhabdomyolysis

The United States Food and Drug Administration Adverse Event Reporting System (FAERS) logged 27,140 rhabdomyolysis cases from 2004 to 31 March 2020. We used FAERS to identify 14 drugs frequently reported in 6583 rhabdomyolysis cases and to investigate whether mitochondrial toxicity is a common pathway of drug-induced rhabdomyolysis by these drugs. Preliminary screening for mitochondrial toxicity was performed using the acute metabolic switch assay, which is adapted here for use in murine L6 cells. Fenofibrate, risperidone, pregabalin, propofol, and simvastatin lactone drugs were identified as mitotoxic and underwent further investigation, using real-time respirometry (Seahorse Technology) to provide more detail on the mechanism of mitochondrial-induced toxicity. To confirm the human relevance of the findings, fenofibrate and risperidone were evaluated in primary human skeletal muscle-derived cells (HSKMDC), using the acute metabolic switch assay and real-time respirometry, which confirmed this designation, although the toxic effects on the mitochondria were more pronounced in HSKMDC. Overall, these studies demonstrate that the L6 model of acute modification may find utility as an initial, cost-effective screen for identifying potential myotoxicants with relevance to humans and, importantly, that drug-induced mitochondrial dysfunction may be a common mechanism shared by some drugs that induce myotoxicity.

Prevalence of Rhabdomyolysis Following Bariatric Surgery and its Associated Risk Factors: a Meta-Analysis

PURPOSE

This study aimed to evaluate the prevalence of rhabdomyolysis (RML) following bariatric surgery and potential associated factors.

MATERIALS AND METHODS

We systematically searched PubMed, Embase, and CENTRAL for relevant trials from database inception through August 2022. Articles were eligible for inclusion if they reported the prevalence of RML after bariatric surgery and provided at least one of the following outcome indicators: preoperative mean BMI/mean operative time for the included population.

RESULTS

Sixteen studies with a total of 1540 patients were analyzed. The mean preoperative age distribution of the included patients was centered between 32.9 and 47.0 years, and the mean preoperative BMI ranged from 42.3 to 60.0 kg/m². The operative time varied between 126.7 and 403.3 min. The overall pooled crude prevalence of post-bariatric surgery RML was 19.4%. Subgroup analyses showed the pooled prevalence of RML was 8.1% for operative duration > 120 and ≤ 180 min, 32.8% for > 180 and ≤ 240 min, and 47.4% for > 240 min. Meta-regression revealed that operation time was an independent risk factor for developing RML. Besides, BMI > 50 kg/m² and open Roux-en-Y gastric bypass (RYGB) indicated a higher risk of RML.

CONCLUSION

Post-bariatric surgery RML prevalence occurred more frequently with the extension of the operation time. For bariatric subjects with surgery time > 180 min, open RYGB, or BMI > 50 kg/m², CKP could be routinely measured early to verify the presence of RML and to actively prevent its fatal complications.

Rhabdomyolysis following Nuss Procedure: A Prospective Study in Children

INTRODUCTION

 Postoperative rhabdomyolysis (RML) has been documented after several surgical procedures in adults. Musculoskeletal remodeling after Nuss procedure for pectus excavatum (PE) could cause RML. We evaluated the incidence of RML after Nuss procedure in children.

METHODS

 This study was a prospective study from 2018 to 2021. We enrolled all otherwise healthy patients who underwent PE correction with only one bar. Studied variables included demographic and clinical data, duration of surgery, complications, and length of hospitalization. The patients included underwent serial measurements of serum creatine kinase (CK), troponin I, N terminal pro B-type natriuretic peptide (NT-proBNP), serum creatinine, urea, and glomerular filtration rate at 6 and 48 hours postoperatively, and hospital discharge.

RESULTS

 Forty-six patients met criteria (40 males/6 females), with a mean age of 15.1 ± 1.4 years. Mean duration of surgery was 74 ± 28 minutes, and length of hospitalization was 4.6 ± 1.6 days. RML was diagnosed in 30.4% of patients at 6 hours, 91.3% at 48 hours, and 21.7% at hospital discharge. Mean preoperative CK value was 181.1 ± 141.6 IU/L, and postoperative values were 863.3 ± 302.6 IU/L at 6 hours, 1,675.2 ± 561 IU/L at 48 hours, and 850 ± 683.7 IU/L at hospital discharge, with statistically significant differences (p = 0.001). High-sensitivity troponin I and NT-proBNP levels increased significantly during the postoperative time (p = 0.001). Renal function remained stable (p = 0.55).

CONCLUSION

 Nuss technique produces RML without kidney injury in healthy patients. This knowledge should be considered for patients at increased risk of developing acute kidney injury and other complications.

Efficacy of the opened legs position for protecting against postoperative rhabdomyolysis after robot-assisted radical prostatectomy: A propensity score-matched analysis of perioperative outcomes

OBJECTIVES

The aim of the present study was to clarify the relationships of intraoperative surgical position with the incidence of postoperative rhabdomyolysis and with postoperative renal function to safely perform robot-assisted radical prostatectomy.

METHODS

The participants in the present study were 276 consecutive patients who underwent robot-assisted radical prostatectomy at our institutions between 2013 and 2020; 130 cases were performed in the opened legs position and 146 cases in the lithotomy position with a steep 23°-25° head-down position. Rhabdomyolysis was defined as creatine kinase values greater than 1000 IU/L. Propensity score matching including age, body mass index, the presence of comorbidities, preoperative creatine kinase, preoperative estimated glomerular filtration rate, and prostate-specific antigen was performed, resulting in a matched cohort of 146 patients (opened legs position group n = 73; lithotomy position group n = 73).

RESULTS

After propensity score matching, creatine kinase values on the first day after surgery were significantly lower in the opened legs position group than in the lithotomy position group (opened legs position group: lithotomy position group = 246.9 ± 114.9 IU/L: 558.2 ± 114.9 IU/L, P = 0.034). There were significantly fewer patients diagnosed with postoperative rhabdomyolysis in the opened legs position group (opened legs position group: lithotomy position group = 0% (0/73): 9.6% (7/73), P < 0.001). In addition, fluid replacement volume was significantly less in the opened legs position group (opened legs position group: lithotomy position group = 5747 ± 180 mL: 6349 ± 0176 mL, P = 0.018).

CONCLUSIONS

To prevent rhabdomyolysis after surgery, robot-assisted radical prostatectomy should be performed in the opened legs position.

Fatal rhabdomyolysis and disseminated intravascular coagulation after total knee arthroplasty under spinal anesthesia: A case report

BACKGROUND

Rhabdomyolysis develops as a result of skeletal muscle cell collapse from leakage of the intracellular contents into circulation. In severe cases, it can be associated with acute kidney injury and disseminated intravascular coagulation, leading to life threatening outcomes. Rhabdomyolysis can occur in the perioperative period from various etiologies but is rarely induced by tourniquet use during orthopedic surgery.

CASE SUMMARY

A 77-year-old male underwent right total knee arthroplasty using a tourniquet under spinal anesthesia. About 24 h after surgery, he was found in a drowsy mental state and manifested features of severe rhabdomyolysis, including fever, hypotension, oliguria, high creatine kinase, myoglobinuria, and disseminated intravascular coagulation. Despite supportive care, cardiac arrest developed abruptly, and the patient was not able to be resuscitated.

CONCLUSION

Severe rhabdomyolysis and disseminated intravascular coagulation can develop from surgical tourniquet, requiring prompt, aggressive treatments to save the patient.

The first survey addressing patients with BMI over 50: a survey of 789 bariatric surgeons

Background

Bariatric surgery in patients with BMI over 50 kg/m² is a challenging task. The aim of this study was to address main issues regarding perioperative management of these patients by using a worldwide survey.

Methods

An online 48-item questionnaire-based survey on perioperative management of patients with a BMI superior to 50 kg/m² was ideated by 15 bariatric surgeons from 9 different countries. The questionnaire was emailed to all members of the International Federation of Surgery for Obesity (IFSO). Responses were collected and analyzed by the authors.

Results

789 bariatric surgeons from 73 countries participated in the survey. Most surgeons (89.9%) believed that metabolic/bariatric surgery (MBS) on patients with BMI over 50 kg/m² should only be performed by expert bariatric surgeons. Half of the participants (55.3%) believed that weight loss must be encouraged before surgery and 42.6% of surgeons recommended an excess weight loss of at least 10%. However, only 3.6% of surgeons recommended the insertion of an Intragastric Balloon as bridge therapy before surgery. Sleeve Gastrectomy (SG) was considered the best choice for patients younger than 18 or older than 65 years old. SG and One Anastomosis Gastric Bypass were the most common procedures for individuals between 18 and 65 years. Half of the surgeons believed that a 2-stage approach should be offered to patients with BMI > 50 kg/m², with SG being the first step. Postoperative thromboprophylaxis was recommended for 2 and 4 weeks by 37.8% and 37.7% of participants, respectively.

Conclusion

This survey demonstrated worldwide variations in bariatric surgery practice regarding patients with a BMI superior to 50 kg/m². Careful analysis of these results is useful for identifying several areas for future research and consensus building.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08979-w.

Preoperative preparation and premedication of bariatric surgical patient

The prevalence of obesity has tripled worldwide over the past four decades. The United States has the highest rates of obesity, with 88% of the population being overweight and 36% obese. The UK has the sixth highest prevalence of obesity. The problem of obesity is not isolated to the developed world and has increasingly become an issue in the developing world as well. Obesity carries an increased risk of many serious diseases and health conditions, including type 2 diabetes, heart disease, stroke, sleep apnea, and certain cancers. Our ability to take care of this population safely throughout the perioperative period begins with a thorough and in-depth preoperative assessment and meticulous preparation. The preoperative assessment begins with being able to identify patients who suffer from obesity by using diagnostic criteria and, furthermore, being able to identify patients whose obesity is causing pathologic and physiologic changes. A detailed and thorough anesthesia assessment should be performed, and the anesthesia plan individualized and tailored to the specific patient's risk factors and comorbidities. The important components of the preoperative anesthesia assessment and patient preparation in the patient suffering from obesity include history and physical examination, airway assessment, medical comorbidities evaluation, functional status determination, risk assessment, preoperative testing, current weight loss medication, and review of any prior weight loss surgeries and their implications on the upcoming anesthetic. The preoperative evaluation of this population should occur with sufficient time before the planned operation to allow for modifications of the preoperative management without needing to delay surgery as the perioperative management of patients suffering from obesity presents significant practical and organizational challenges.

Postoperative Rhabdomyolysis in the Bilateral Shoulder Areas After Cardiac Surgery

Rhabdomyolysis (RML) is a disease that results from the death of muscle fibers and the release of intracellular contents into the bloodstream as a result of traumatic or non-traumatic muscle injury. Postoperative RML is a rare complication that may result from improper patient positioning, extended surgery time, or unique patient risk factors. We describe a case of a 43-year-old obese male who presented with postoperative bilateral shoulder RML after undergoing cardiothoracic surgery for aortic valve disease. To our knowledge, after a thorough review of the literature using PubMed, Medline, and Google Scholar, no previous studies have reported positioning injuries specific to obese cardiac surgical patients and their relation to RML.

Characteristics of pediatric rhabdomyolysis and the associated risk factors for acute kidney injury: a retrospective multicenter study in Korea

Background

The clinical features of pediatric rhabdomyolysis differ from those of the adults with rhabdomyolysis; however, multicenter studies are lacking. This study aimed to investigate the characteristics of pediatric rhabdomyolysis and reveal the risk factors for acute kidney injury (AKI) in such cases.

Methods

This retrospective study analyzed the medical records of children and adolescents diagnosed with rhabdomyolysis at 23 hospitals in South Korea between January 2007 and December 2016.

Results

Among 880 patients, those aged 3 to 5 years old composed the largest subgroup (19.4%), and all age subgroups were predominantly male. The incidence of AKI was 11.3%. Neurological disorders (53.6%) and infection (39.0%) were the most common underlying disorder and cause of rhabdomyolysis, respectively. The median age at diagnosis in the AKI subgroup was older than that in the non-AKI subgroup (12.2 years vs. 8.0 years). There were no significant differences in body mass index, myalgia, dark-colored urine, or the number of causal factors between the two AKI-status subgroups. The multivariate logistic regression model indicated that the following factors were independently associated with AKI: multiorgan failure, presence of an underlying disorder, strong positive urine occult blood, increased aspartate aminotransferase and uric acid levels, and reduced calcium levels.

Conclusions

Our study revealed characteristic clinical and laboratory features of rhabdomyolysis in a Korean pediatric population and highlighted the risk factors for AKI in these cases. Our findings will contribute to a greater understanding of pediatric rhabdomyolysis and may enable early intervention against rhabdomyolysis-induced AKI.

Micronutrients deficiences in patients after bariatric surgery

Bariatric surgery is an effective option for managing obesity and has gained general acceptance among patients in recent years. Generally, despite the high caloric intake, a bad nutritional habit of obese people results in the deficiency of several vitamins, minerals, and trace elements essential for body metabolism and normal physiological processes. Additionally, the current bariatric surgical approaches such as sleeve gastrectomy (SG), Roux-en-Y-gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), and jejunoileal bypass (JIB) can cause or exacerbate these deficiencies. Based on several reports, it appears that the various bariatric surgical procedures affect nutrient absorption differently. Being purely restrictive, LAGB and SG affect the absorption of iron, selenium, and vitamin B₁₂, while RYGB, JIB, and biliopancreatic diversion have a more profound impact on the absorption of essential vitamins, minerals, and trace elements. Nutritional deficiencies in vitamins, minerals, and trace elements may follow bariatric surgery and are associated with clinical manifestations and diseases, including anemia, ataxia, hair loss, and Wernicke encephalopathy. The present review summarizes some of the major vitamin and micronutrient deficiencies associated with bariatric surgery, particularly those presented post-surgically. To avoid any adverse consequences of vitamin and trace element deficiency, proper monitoring and tests are recommended at any stage, from pre- to post-surgery (periodical check-up), followed by specific and individual nutritional supplementation treatments and a proper healthy diet.

Intraoperative Monitoring of the Obese Patient Undergoing Surgery: A Narrative Review

With the increasing prevalence of obesity in the population, anaesthetists must confidently manage both the pathophysiological and technical challenges presented in bariatric and non-bariatric surgery. The intraoperative period represents an important opportunity to optimise and mitigate risk. However, there is little formal guidance on what intraoperative monitoring techniques should be used in this population. This narrative review collates the existing evidence for intraoperative monitoring devices in the obese patients. Although a number of non-invasive blood pressure monitors have been tested, an invasive arterial line remains the most reliable monitor if accurate, continuous monitoring is required. Goal-directed fluid therapy is recommended by clinical practice guidelines, but the methods tested to assess this had guarded applicability to the obese population. Transcutaneous carbon dioxide (CO₂) monitoring may offer additional benefit to standard capnography in this population. Individually titrated positive end expiratory pressure (PEEP) and recruitment manoeuvres improved intraoperative mechanics but yielded no benefit in the immediate postoperative period. Depth of anaesthesia monitoring appears to be beneficial in the perioperative period regarding recovery times and complications. Objective confirmation of reversal of neuromuscular blockade continues to be a central tenet of anaesthesia practice, particularly relevant to this group who have been characterised as an "at risk" extubation group. Where deep neuromuscular blockade is used, continuous neuromuscular blockade is suggested. Both obesity and the intraoperative context represent somewhat unstable search terms, as the clinical implications of the obesity phenotype are not uniform, and the type and urgency of surgery have significant impact on the intraoperative setting. This renders the generation of summary conclusions around what intraoperative monitoring techniques are suitable in this population highly challenging.

Bariatric surgery related proximal myopathy: A partially reversible complication

Deficiency neuropathies and rhabdomyolysis have previously been reported after bariatric surgery (BS) but never myopathies. We report cases of five patients with morbid obesity who developed within 2 to 4 months of a BS, proximal myopathy following significant and rapid weight loss worsened by postoperative gastrointestinal complications. Muscle weakness concerned lower limbs in particular in quadriceps and less frequently in upper limbs and diaphragm, sometimes mimicked a Guillain-Barré syndrome. Muscle biopsy performed in 1 patient, revealed selective atrophy of type 2 fibers. Weakness slowly decreased with refeeding with vitamins supplementation. We enlarge here the clinical pattern of post-BS complications.

A "crush" course on rhabdomyolysis: risk stratification and clinical management update for the perioperative clinician

Rhabdomyolysis, the release of myoglobin and other cellular breakdown products from necrotic muscle tissue, is seen in patients with crush injuries, drug overdose, malignant hyperthermia, muscular dystrophy, and with increasing frequency in obese patients undergoing routine procedures. For the perioperative clinician, managing the resultant shock, hyperkalemia, acidosis, and myoglobinuric acute kidney injury can present a significant challenge. Prompt recognition, hydration, and correction of metabolic disturbances may reduce or eliminate the need for long-term renal replacement therapy. This article reviews the pathophysiology and discusses key issues in the perioperative diagnosis, risk stratification, and management of rhabdomyolysis.

Effect of Bariatric Surgery on Serum Enzyme Status in Obese Patients

BACKGROUND

Scarce data exists about serum enzyme in bariatric patients. We attempted to evaluate serum enzyme status in patients receiving Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) and to identify related predictors.

METHODS

We retrospectively reviewed the patients receiving RYGB and SG in our center from January 2013 to January 2018. Anthropometric data and serum enzyme data were collected preoperatively and 6 and 12 months postoperatively.

RESULTS

Five hundred patients (201 RYGB, 299 SG) were included. Serum enzyme abnormalities were common preoperatively, with 50.8% for elevated alanine aminotransferase (ALT), 33.0% for elevated aspartate aminotransferase (AST), 36.6% for elevated γ-glutamyltranspeptidase (γ-GT), 17.6% for elevated creatine kinase (CK), 15.2% for elevated lactic dehydrogenase (LDH), 9.0% for elevated adenosine deaminase (ADA), 6.2% for elevated hydroxybutyrate dehydrogenase (HBDH), and 8.4% for decreased superoxide dismutase (SOD). After RYGB and SG, the prevalence of serum ALT, AST, γ-GT, LDH, and HBDH abnormalities reduced. The levels of ALT, AST, γ-GT, ADA, cholinesterase (CHE), LDH, CK, and HBDH reduced significantly, while amylase and SOD levels increased. Age and preoperative γ-GT level were independent predictors of ALT, AST, γ-GT, and LDH change 1 year postoperatively. Preoperative ALT, AST, ALP, LDH, and HBDH levels could predict postoperative change, respectively. Gender and surgical procedure could predict postoperative ALP change.

CONCLUSION

Serum enzyme abnormalities are common in bariatric surgery candidates, with reduced prevalence of abnormalities postoperatively. RYGB and SG are related with reduced ALT, AST, γ-GT, ADA, CHE, LDH, CK, and HBDH levels, as well as increased amylase and SOD levels.

Black Race and Body Mass Index Are Risk Factors for Rhabdomyolysis and Acute Kidney Injury in Trauma

Purpose: Obesity has been shown in a single-center study to be a risk factor for rhabdomyolysis. More recently, sickle cell trait, known to be more prevalent in blacks, has been shown to be a risk factor for rhabdomyolysis. We hypothesized that in trauma patients, black race and a higher body mass index (BMI) are associated with risk for rhabdomyolysis and acute kidney injury (AKI). Materials and Methods: The National Trauma Data Bank (NTDB) was queried (2013-2015) to identify patients age ≥18 years and grouped by BMI: normal (18.5-24.99 kg/m2), underweight (16.5-18.49 kg/m2), overweight (25-29.99 kg/m2), obese (30-34.99 kg/m2), severely obese (35-39.99 kg/m2), and morbidly obese (≥40 kg/m2). A multivariable logistic regression model was used to assess whether a higher BMI or black race was associated with rhabdomyolysis or AKI. Results: After adjusting for covariates, severe obesity (odds ratio (OR) = 1.42, confidence interval (CI) = 1.01-1.99, p < .001), morbid obesity (OR = 1.46, CI = 1.04-2.06, p < .001), and black race (OR = 1.52, CI = 1.24-1.88, p < .001) were associated with higher risk for rhabdomyolysis. Patients that were overweight (OR = 1.17, CI = 1.11-1.24, p < .001), obese (OR = 1.32, CI = 1.24-1.41, p < .001), severely obese (OR = 1.72, CI = 1.59-1.86, p < .001), morbidly obese (OR = 1.77, CI = 1.64-1.92, p < .001), or black (OR = 1.31, CI = 1.24-1.38, p < .001) were associated with higher risk for AKI. Conclusions: Black race was associated with an increased risk of rhabdomyolysis as well as AKI in trauma. BMI ≥25 kg/m2 was associated with increased risk for AKI with the morbidly obese having the highest risk. BMI ≥35 kg/m2 was found to be associated with increased risk of rhabdomyolysis. Future studies should investigate the role for routine screening of these high-risk populations and other potential associated factors such as adherence to weight-based fluid resuscitation.

Perioperative care of the obese patient

Background

Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.

Methods

A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.

Results and conclusion

Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.

Predictors of surgical site skin infection and clinical outcome at caesarean section in the very severely obese: A retrospective cohort study

INTRODUCTION

The optimal surgical approach for caesarean section is uncertain in women with very severe obesity (body mass index (BMI) >40kg/m2). We aimed to assess maternal and surgical predictors of surgical site skin infection (SSSI) in very severely obese women and to undertake an exploratory evaluation of clinical outcomes in women with a supra-panniculus transverse compared to an infra-panniculus transverse skin incision.

MATERIAL AND METHODS

Using a retrospective cohort design, case-records were reviewed of very severely obese women with a singleton pregnancy delivered by caesarean between August 2011 and December 2015 (n = 453) in two maternity hospitals in Scotland. Logistic regression analysis was used to determine predictors for SSSI. Outcomes were compared between women who had a supra-panniculus transverse compared to infra-panniculus transverse skin incision.

RESULTS

Lower maternal age was predictive of SSSI, with current smoking status and longer wound open times being marginally significant. Maternal BMI, suture method and material demonstrated univariate associations with SSSI but were not independent predictors. Women with a supra-panniculus transverse skin incision were older (32.9 (4.4), vs. 30.6 (5.7), p = 0.002), had higher BMI (49.2 (7.1), vs. 43.3 (3.3), p<0.001), shorter gestation at delivery (days) (267.7 (14.9), vs. 274.8 (14.5), p<0.001) and higher prevalence of gestational diabetes mellitus (42.6% vs. 21.9%, p = 0.002). SSSI rates did not differ between supra-panniculus transverse (13/47; 27.7%) and infra-panniculus transverse (90/406; 22.2%; p = 0.395) skin incisions.

CONCLUSION

SSSI rates are high in very severely obese women following caesarean section, regardless of location of skin incision.

Duodenal switch in revisional bariatric surgery: conclusions from an expert consensus panel

BACKGROUND

Duodenal switch (BPD/DS) is gaining popularity as a secondary procedure for inadequate weight loss after an initial operation.

OBJECTIVES

We aimed to generate expert consensus points on the appropriate use of BPD/DS in the revisional bariatric surgical setting.

SETTING

Data were gathered at an international conference with attendees from a variety of different institutions and settings.

METHODS

Sixteen lines of questioning regarding revisional BPD/DS were presented to an expert panel of 29 bariatric surgeons. Current available literature was reviewed extensively for each topic and proposed to the panel before polling. Responses were collected and topics defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement).

RESULTS

Consensus was present in 10 of 16 lines of questioning, with several key points most prominent.

CONCLUSIONS

As a second-stage procedure, BPD/DS is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%). In a patient with weight regain and reflux and/or enlarged fundus after SG, Roux-en-Y gastric bypass is preferable and BPD/DS should be avoided (90%). BPD/DS should not be used prophylactically in patients with a history of jejunoileal bypass who are otherwise doing well (80.8%). Applicability of BPD/DS is limited by technical difficulty; 86.2% of experts would routinely recommend or consider the procedure if it were more technically feasible after failed bypass. No consensus was found on approaches to revision of BPD/DS for protein malnutrition.

Long-Term Outcomes of Laparoscopic Sleeve Gastrectomy-a Single-Center, Retrospective Study

Introduction

Sleeve gastrectomy (LSG) is one of the most popular bariatric procedures. We present our long-term results regarding weight loss, comorbidities, and gastric reflux disease.

Material and Methods

We identified patients who underwent LSG in our institution between 2006 and 2009. We revised the data, and the patients with outdated contact details were tracked with the national health insurance database and social media (facebook). Each of the identified patients was asked to complete an online or telephone survey covering, among others, their weight and comorbidities. On that basis, we calculated the percent total weight loss (%TWL) and percent excess weight loss (%EWL), along with changes in body mass index (ΔBMI). Satisfactory weight loss was set at >50% EWL (for BMI = 25 kg/m²). We evaluated type 2 diabetes (T2DM) and arterial hypertension (AHT) based on the pharmacological therapy. GERD presence was evaluated by the typical symptoms and/or proton pump inhibitor (PPI) therapy.

Results

One hundred twenty-seven patients underwent LSG between 2006 and 2009. One hundred twenty patients were qualified for this study. Follow-up data was available for 100 participants (47 female, 53 male). Median follow-up period reached 8.0 years (from 7.1 to 10.7). Median BMI upon qualification for LSG was 51.6 kg/m². Sixteen percent of patients required revisional surgery over the years (RS group), mainly because of insufficient weight loss (14 Roux-Y gastric bypass—LRYGB; one mini gastric bypass, one gastric banding). For the LSG (LSG group n = 84), the mean %EWL was 51.1% (±22.3), median %TWL was 23.5% (IQR 17.7–33.3%), and median ΔBMI was 12.1 kg/m² (IQR 8.2–17.2). Fifty percent (n = 42) of patients achieved the satisfactory %EWL of 50%. For RS group, the mean %EWL was 57.8% (±18.2%) and median %TWL reached 33% (IQR 27.7–37.9%). Sixty-two percent (n = 10) achieved the satisfactory weight loss. Fifty-nine percent of patients reported improvement in AHT therapy, 58% in T2DM. After LSG, 60% (n = 60) of patients reported recurring GERD symptoms and 44% were treated with proton pomp inhibitors (PPI). In 93% of these cases, GERD has developed de novo.

Conclusions

Isolated LSG provides fairly good effects in a long-term follow-up with mean %EWL at 51.1%. Sixteen percent of patients require additional surgery due to insufficient weight loss. More than half of the subjects observe improvement in AHT and T2DM. Over half of the patients complain of GERD symptoms, which in most of the cases is a de novo complaint.

Long-term effects of bariatric surgery on acute kidney injury: a propensity-matched cohort in the UK Clinical Practice Research Datalink

OBJECTIVE

Bariatric surgery is an effective method of weight reduction and has been associated with acute kidney injury (AKI) as a perioperative event. However, the long-term effects of the weight reduction after surgery on AKI are unknown. The objective of this study is to quantify the association of bariatric surgery with later risk of AKI.

DESIGN

This study uses a propensity score-matched cohort of patients from the UK Clinical Practice Research Datalink database with and without bariatric surgery to compare rates of AKI episodes derived from linkage to the Hospital Episode Statistics.

SETTING

England, UK.

PARTICIPANTS

We included 2643 patients with bariatric surgery and 2595 patients without.

RESULTS

Results were compatible with an increased risk of AKI in the first 30 days following surgery compared with patients without surgery, but AKI incidence was substantially decreased in patients with bariatric surgery during long-term follow-up (rate ratio 0.37, 95% CI 0.23 to 0.61) even after accounting for chronic kidney disease status at baseline. Over the whole period of follow-up, bariatric surgery had a net protective effect on risk of AKI (rate ratio 0.45, 95% CI 0.28 to 0.72).

CONCLUSIONS

Bariatric surgery was associated with protective effects on AKI incidence during long-term follow-up. While the risk of AKI may be increased within the first 30 days, the net effect seen was beneficial.

Age is not associated with increased surgical complications in patients after laparoscopic sleeve gastrectomy

INTRODUCTION

Age is considered as a risk factor in bariatric surgery. The observation was made on the basis of results from studies where patients underwent different type of surgery, but laparoscopic sleeve gastrectomy (LSG) was not among them. It is necessary to reevaluate the association of age with adverse events in the group of patients after LSG.

AIM

To investigate the association of age with surgery-related adverse events in patients after LSG.

MATERIAL AND METHODS

Retrospective analysis of medical data was performed. The study involved 345 patients who underwent LSG in our institution between January 2013 and December 2014. The patients were subdivided by age into four groups according to quartiles. In 30-day follow-up adverse events were evaluated. We considered the presence of the following events as the endpoint of our study: death, medical events and surgical events.

RESULTS

In general, we observed adverse events in 36 (10.4%) patients. The mortality rate in our study was 0.59%. Nineteen events were surgical and 18 medical. In 1 patient a surgical event was associated with a medical event. Bleeding was the most common surgical event and was observed in 17 (4.9%) cases. Age was not associated with surgical events (OR = 1.032, 95% CI: 0.991-1.075, p = 0.33) or medical events (OR = 0.997, 95% CI: 0.956-1.039, p = 0.89).

CONCLUSIONS

The LSG is a safe bariatric procedure with low mortality. Bleeding is the most frequent surgical complication. Our findings suggest that age is not associated with increased risk of surgical or medical adverse events after LSG.

A Nomogram Based on Clinical Factors to Predict the Serum Myoglobin Levels Following Bariatric Surgery

BACKGROUND

Increased serum myoglobin levels following bariatric surgery can predict rhabdomyolysis, a severe postoperative complication, which can induce acute kidney injury (AKI). The aim of this study is to evaluate clinical factors to predict increased postoperative serum myoglobin levels following bariatric surgery.

MATERIALS AND METHODS

Serum myoglobin levels were studied in 281obese patients undergoing bariatric surgery in the University Hospital Leipzig, Germany between May 2012 and June 2015. A linear regression model using stepwise model selection and hence a nomogram for postoperative serum myoglobin levels after bariatric surgery with statistically significant covariates were derived and verified using bootstrap sampling.

RESULTS

Increased serum myoglobin levels were detected firstly 4 h directly after bariatric surgery (median 124 ng/ml, range 25-22,064 ng/ml). On multivariable analysis, age, body mass index (BMI), presence of Diabetes Mellitus (DM) type II, duration of bariatric surgery, and preoperative serum myoglobin levels were significant predictors for increased serum myoglobin levels postoperatively. Furthermore, the patients were classified according to bariatric surgery duration and BMI into groups. Patients with BMI ≥ 60 kg/m² and operating time (OP-Time) ≥ 160 min demonstrated the highest postoperative serum myoglobin levels (32% with values ≥ 3000 ng/ml) and had significantly higher postoperative morbidity including rhabdomyolysis, AKI, and compartment syndrome.

CONCLUSION

We provide a clinical nomogram for prediction of serum myoglobin levels following bariatric surgery, which may improve clinicians' abilities to stratify bariatric patients in risk of developing rhabdomyolysis during the postoperative course, but requires further validation.

Perioperative Care of the Obese Cardiac Surgical Patient

Morbid obesity is associated with impairment of cardiovascular, pulmonary, gastrointestinal, and renal physiology with significant perioperative consequences and has been linked with higher morbidity and mortality after cardiac surgery. Cardiac surgery patients have a higher incidence of difficult airway and difficult laryngoscopy than general surgery patients do, and obesity is associated with difficult mask ventilation and direct laryngoscopy. Positioning injuries occur more frequently because obese patients are at greater risk of pressure injury, such as rhabdomyolysis and compartment syndrome. Despite the association between obesity and several chronic disease states, the effects of obesity on perioperative outcomes are conflicting. Studies examining outcomes of overweight and obese patients in cardiac surgery have reported varying results. An "obesity paradox" has been described, in which the mortality for overweight and obese patients is lower compared with patients of normal weight. This review describes the physiologic abnormalities and clinical implications of obesity in cardiac surgery and summarizes recommendations for anesthesiologists to optimize perioperative care of the obese cardiac surgical patient.

[Quality indicators for metabolic and bariatric surgery in Germany : Evidence-based development of an indicator panel for the quality of results, indications and structure]

An expert committee was appointed by the German Society for General and Visceral Surgery to develop a panel of appropriate quality indicators to collate the quality of results, indications and structure in metabolic and bariatric surgery. This entailed assimilating the available evidence (systematic literature search), results from the national registry of the society (StuDoQ|MBE) and specific socioeconomic aspects (e. g. severely limited access to metabolic and bariatric surgery in Germany). These quality parameters were to be incorporated into the national guidelines and the rules of procedure for certification in the future. The committee concluded that mortality, MTL30 and severe complications needing intervention (Clavien-Dindo ≥ 3b) are suitable indicators to measure surgical outcome quality due to their relevance, scientific soundness and practicability. As a systematic follow-up is mandatory after bariatric surgery, a minimum follow-up quota is now required using reported quality of life data as an indicator of process quality. As intestinal bypass procedures have been shown to be superior in the treatment of type 2 diabetes, these procedures should be offered to eligible patients and also be performed. The proposed threshold values based on the results of the available literature and StuDoQ registry are to be considered as preliminary and need to be validated and adjusted if necessary in the future. The StuDoQ|MBE is considered a valuable tool to gather this information and also represents the appropriate infrastructure for the collation of relevant risk adjustors.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

During the last two decades, an increasing number of bariatric surgical procedures have been performed worldwide. There is no consensus regarding optimal perioperative care in bariatric surgery. This review aims to present such a consensus and to provide graded recommendations for elements in an evidence-based "enhanced" perioperative protocol.

METHODS

The English-language literature between January 1966 and January 2015 was searched, with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded. After critical appraisal of these studies, the group of authors reached a consensus recommendation.

RESULTS

Although for some elements, recommendations are extrapolated from non-bariatric settings (mainly colorectal), most recommendations are based on good-quality trials or meta-analyses of good-quality trials.

CONCLUSIONS

A comprehensive evidence-based consensus was reached and is presented in this review by the enhanced recovery after surgery (ERAS) Society. The guidelines were endorsed by the International Association for Surgical Metabolism and Nutrition (IASMEN) and based on the evidence available in the literature for each of the elements of the multimodal perioperative care pathway for patients undergoing bariatric surgery.

Comparative Outcomes and Perioperative Complications of Robotic Vs Open Cystoplasty and Complex Reconstructions

OBJECTIVE

To compare perioperative and surgical outcomes in a 2-center, 2-surgeon open vs robotic augmentation ileocystoplasty.

MATERIALS AND METHODS

We reviewed patients undergoing augmentation ileocystoplasty open vs robotically between 2008 and 2014 at 2 centers. We compared the groups' preoperative characteristics, perioperative outcomes, complications, and interim functional outcomes.

RESULTS

The cohort consisted of 17 and 15 patients with median follow-up of 45 and 46 months, in open and robotic groups, respectively. Median operative time (incision to closure) was longer in the robotic cohort (265 minutes vs 623 minutes, P < .001). Median length of stay (7 days vs 6 days, P = .335), time to diet (4 days vs 4 days, P = .125), and mean intravenous morphine equivalents/kg (1.23 mg/kg vs 0.56 mg/kg, P = .091) were comparable between groups for open and robotic, respectively. There were 4/17 (23.5%) of the open cohort who had an epidural for an average of 93 hours. All patients had stable or improved hydronephrosis postoperatively. Major reoperations, such as for bowel obstruction, were required in 2/17 (11.7%) in the open group and none in the robotic cohort. Minor stomal complications requiring skin-level revision or endoscopic procedure occurred in 4/17 (23.5%) in the robotic cohort and 2 (11.7%) in the open group.

CONCLUSION

We reveal equivalent rates of complications, length of stay, and blood loss for augmentation cystoplasty among appropriately matched controls. Prolonged operative times of the robotic cohort did not lead to additional morbidity for patients. Further steps to reduce morbidity and additional investigations should be undertaken prior to widespread adoption of the intracorporeal technique in experienced robotic centers.

Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice

Background

Rhabdomyolysis is a clinical syndrome that comprises destruction of skeletal muscle with outflow of intracellular muscle content into the bloodstream. There is a great heterogeneity in the literature regarding definition, epidemiology, and treatment. The aim of this systematic literature review was to summarize the current state of knowledge regarding the epidemiologic data, definition, and management of rhabdomyolysis.

Methods

A systematic search was conducted using the keywords “rhabdomyolysis” and “crush syndrome” covering all articles from January 2006 to December 2015 in three databases (MEDLINE, SCOPUS, and ScienceDirect). The search was divided into two steps: first, all articles that included data regarding definition, pathophysiology, and diagnosis were identified, excluding only case reports; then articles of original research with humans that reported epidemiological data (e.g., risk factors, common etiologies, and mortality) or treatment of rhabdomyolysis were identified. Information was summarized and organized based on these topics.

Results

The search generated 5632 articles. After screening titles and abstracts, 164 articles were retrieved and read: 56 articles met the final inclusion criteria; 23 were reviews (narrative or systematic); 16 were original articles containing epidemiological data; and six contained treatment specifications for patients with rhabdomyolysis.

Conclusion

Most studies defined rhabdomyolysis based on creatine kinase values five times above the upper limit of normal. Etiologies differ among the adult and pediatric populations and no randomized controlled trials have been done to compare intravenous fluid therapy alone versus intravenous fluid therapy with bicarbonate and/or mannitol.

Rhabdomyolysis After Major Urologic Surgery: Epidemiology, Risk Factors, and Outcomes

OBJECTIVE

To study the epidemiology, risk factors, and outcomes of rhabdomyolysis (RM) after major urologic surgery.

MATERIALS AND METHODS

The National Inpatient Sample (2003-2011) was used to identify patients who underwent radical prostatectomy, radical or partial nephrectomy, or radical cystectomy. Demographics included age, sex, race, and comorbidities. Factors examined included bleeding, hospital teaching status, minimally invasive technique, and development of RM. Multivariate logistic regression was used to identify independent risk factors of RM. Outcomes of mortality, acute kidney injury (AKI), length of stay, and charges in patients with RM were compared with those of controls.

RESULTS

A weighted population of 1,016,074 patients was identified with 870 (0.1%) developing RM, which was significantly more likely for radical or partial nephrectomy and radical cystectomy patients compared with radical prostatectomy patients. On multivariate analysis, independent risk factors for RM included younger age, male sex, diabetes, chronic kidney disease, obesity, and bleeding. Race, minimally invasive technique, and teaching status were not associated with RM when controlling for other factors. Patients with RM experienced increases in mortality, AKI, length of stay, and hospital charges.

CONCLUSION

Rhabdomyolysis is a rare complication after urologic surgery. Risk factors include male sex, younger age, diabetes, chronic kidney disease, obesity, and perioperative bleeding. Patients who develop RM have a higher risk of AKI, mortality, prolonged hospital stay, and increased charges.

The Contemporary Incidence and Sequelae of Rhabdomyolysis Following Extirpative Renal Surgery: A Population Based Analysis

PURPOSE

We evaluate the contemporary incidence and consequences of postoperative rhabdomyolysis after extirpative renal surgery.

MATERIALS AND METHODS

We conducted a population based, retrospective cohort study of patients who underwent extirpative renal surgery with a diagnosis of a renal mass or renal cell carcinoma in the United States between 2004 and 2013. Regression analysis was performed to evaluate 90-day mortality (Clavien grade V), nonfatal major complications (Clavien grade III-IV), hospital readmission rates, direct costs and length of stay.

RESULTS

The final weighted cohort included 310,880 open, 174,283 laparoscopic and 69,880 robotic extirpative renal surgery cases during the 10-year study period, with 745 (0.001%) experiencing postoperative rhabdomyolysis. The presence of postoperative rhabdomyolysis led to a significantly higher incidence of 90-day nonfatal major complications (34.7% vs 7.3%, p <0.05) and higher 90-day mortality (4.4% vs 1.02%, p <0.05). Length of stay was twice as long for patients with postoperative rhabdomyolysis (incidence risk ratio 1.83, 95% CI 1.56-2.15, p <0.001). The robotic approach was associated with a higher likelihood of postoperative rhabdomyolysis (vs laparoscopic approach, OR 2.43, p <0.05). Adjusted 90-day median direct hospital costs were USD 7,515 higher for patients with postoperative rhabdomyolysis (p <0.001). Our model revealed that the combination of obesity and prolonged surgery (more than 5 hours) was associated with a higher likelihood of postoperative rhabdomyolysis developing.

CONCLUSIONS

Our study confirms that postoperative rhabdomyolysis is an uncommon complication among patients undergoing extirpative renal surgery, but has a potentially detrimental impact on surgical morbidity, mortality and costs. Male gender, comorbidities, obesity, prolonged surgery (more than 5 hours) and a robotic approach appear to place patients at higher risk for postoperative rhabdomyolysis.

The Changing Face of Malignant Hyperthermia: Less Fulminant, More Insidious

Modern anaesthetic techniques have resulted in the clinical presentation of malignant hyperthermia to be more often indolent and/or insidious than truly fulminant, as previously known in the anaesthetic community. We present four recently referred cases to illustrate this point: one late-onset case, two patients with slowly progressive hypercapnia as the sole sign and a fourth patient with postoperative myalgias and elevated creatine kinase. We also discuss the reasons for the shift in typical clinical presentation. The more insidious character of malignant hyperthermia is most likely due to the lower triggering potency of modern volatile anaesthetics, the mitigating effects of several intravenous drugs (neuromuscular blocking agents, alpha 2 adrenergic receptor agonists, beta-adrenergic blockade) or techniques (neuraxial anaesthesia) and the routine use of end-tidal CO2 monitoring leading to the early withdrawal of triggering drugs. Awareness among anaesthetists of this change in presentation is important since the clinical diagnosis is often more doubtful and, if corroborative evidence is not sought, the diagnosis may be delayed or missed altogether.

Critical Care Management of Bariatric Surgery Complications

Obesity remains a major medical disease that often requires surgical intervention in morbidly obese patients. Surgical procedures have evolved and are performed routinely in most major medical centers. Outcomes are often dependent on patient characteristics, type of procedure, and preoperative planning. Risk stratification often depends on screening and optimizing known comorbidities often encountered in this patient population. A thorough understanding of the physiologic changes seen in obese patient and the commonly performed operations will allow the physician to perform optimal treatment strategies.

Rhabdomyolysis in Obese Trauma Patients

Patients sustaining traumatic injuries are at risk for development of rhabdomyolysis. The effect of obesity on this risk is unknown. This study attempted to characterize the role of obesity in the development of rhabdomyolysis after trauma. This was a retrospective review of all trauma patients with creatine kinase (CK) levels admitted to the surgical intensive care unit (SICU) at a Level I trauma center from February 2011 until July 2013. Patients were divided based on their body mass index (BMI): overweight/obese group with BMI 25 kg/m2 or greater and nonoverweight/obese group with BMI less than 25 kg/m2. Primary outcome was CK greater than 10,000 U/L. During the 30-month study period, 198 trauma patients with available CK levels were admitted to the SICU. The majority (27.8%) of patients were involved in a motor vehicle collision. There were 96 patients (48.4%) with BMI 25 kg/m2 or greater and 102 (51.5%) with BMI less than 25 kg/m2. There was no difference in creatinine levels between the two groups (1.5 ± 1.2 mg/dL vs 1.5 ± 1.4 mg/dL, P = 0.83). BMI 25 kg/m2 or greater was independently associated with the development of CK greater than 10,000 U/L (14.6 vs 4.9%; adjusted odds ratio, 3.03; P = 0.04). Patients with BMI 25 kg/m2 or greater are at a significantly higher risk for rhabdomyolysis after trauma. Aggressive CK level monitoring to prevent rhabdomyolysis in this population is strongly encouraged.

[Management of complications in bariatric surgery]

Bariatric surgery is known to be the most effective and long-lasting treatment for morbid obesity and associated comorbidities. These comorbidities together with cardiopulmonary decompensation make morbidly obese patients a high risk group for operative interventions. Early detection of postoperative complications is a challenging task in these patients and requires accurate and timely interpretation of any alarm signals. Symptoms, such as tachycardia and abdominal pain are highly suspicious. The same applies to elevated inflammatory parameters and fever. Early diagnostic laparoscopy is mandatory once cardiopulmonary complications have been excluded. Moreover, it has a higher sensitivity and specificity than other radiological modalities and is a minimally invasive procedure with a highly satisfactory outcome.