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Mackenzie RM, Ali A, Bruce D, Bruce J, Ford I, Greenlaw N, Grieve E, Lean M, Lindsay RS, O'Donnell J, Sattar N, Stewart S, Logue J. Clinical outcomes and adverse events of bariatric surgery in adults with severe obesity in Scotland: the SCOTS observational cohort study. Health Technol Assess 2024; 28:1-115. [PMID: 38343107 PMCID: PMC11017628 DOI: 10.3310/unaw6331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Background Bariatric surgery is a common procedure worldwide for the treatment of severe obesity and associated comorbid conditions but there is a lack of evidence as to medium-term safety and effectiveness outcomes in a United Kingdom setting. Objective To establish the clinical outcomes and adverse events of different bariatric surgical procedures, their impact on quality of life and the effect on comorbidities. Design Prospective observational cohort study. Setting National Health Service secondary care and private practice in Scotland, United Kingdom. Participants Adults (age >16 years) undergoing their first bariatric surgery procedure. Main outcome measures Change in weight, hospital length of stay, readmission and reoperation rate, mortality, diabetes outcomes (HbA1c, medications), quality of life, anxiety, depression. Data sources Patient-reported outcome measures, hospital records, national electronic health records (Scottish Morbidity Record 01, Scottish Care Information Diabetes, National Records Scotland, Prescription Information System). Results Between December 2013 and February 2017, 548 eligible patients were approached and 445 participants were enrolled in the study. Of those, 335 had bariatric surgery and 1 withdrew from the study. Mean age was 46.0 (9.2) years, 74.7% were female and the median body mass index was 46.4 (42.4; 52.0) kg/m2. Weight was available for 128 participants at 3 years: mean change was -19.0% (±14.1) from the operation and -24.2% (±12.8) from the start of the preoperative weight-management programme. One hundred and thirty-nine (41.4%) participants were readmitted to hospital in the same or subsequent 35 months post surgery, 18 (5.4% of the operated cohort) had a reoperation or procedure considered to be related to bariatric surgery gastrointestinal complications or revisions. Fewer than five participants (<2%) died during follow-up. HbA1c was available for 93/182 and diabetes medications for 139/182 participants who had type 2 diabetes prior to surgery; HbA1c mean change was -5.72 (±16.71) (p = 0.001) mmol/mol and 65.5% required no diabetes medications (p < 0.001) at 3 years post surgery. Physical quality of life, available for 101/335 participants, improved in the 3 years post surgery, mean change in Rand 12-item Short Form Survey physical component score 8.32 (±8.95) (p < 0.001); however, there was no change in the prevalence of anxiety or depression. Limitations Due to low numbers of bariatric surgery procedures in Scotland, recruitment was stopped before achieving the intended 2000 participants and follow-up was reduced from 10 years to 3 years. Conclusions Bariatric surgery is a safe and effective treatment for obesity. Patients in Scotland, UK, appear to be older and have higher body mass than international comparators, which may be due to the small number of procedures performed. Future work Intervention studies are required to identify the optimal pre- and post surgery pathway to maximise safety and cost-effectiveness. Study registration This study is registered as ISRCTN47072588. Funding details This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 10/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 7. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Ruth M Mackenzie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Abdulmajid Ali
- University Hospital Ayr, NHS Ayrshire and Arran, Ayr, UK
| | | | - Julie Bruce
- Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Eleanor Grieve
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mike Lean
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Robert S Lindsay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Joanne O'Donnell
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sally Stewart
- Department of Nursing and Community Health, Glasgow Caledonian University, Glasgow, UK
| | - Jennifer Logue
- Lancaster Medical School, Lancaster University, Lancaster, UK
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Tabesh MR, Eghtesadi M, Abolhasani M, Maleklou F, Ejtehadi F, Alizadeh Z. Nutrition, Physical Activity, and Prescription of Supplements in Pre- and Post-bariatric Surgery Patients: An Updated Comprehensive Practical Guideline. Obes Surg 2023; 33:2557-2572. [PMID: 37389806 DOI: 10.1007/s11695-023-06703-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/18/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023]
Abstract
Only in the USA, 315 billion dollars are spent annually on the medical cost of obesity in adult patients. Till now, bariatric surgery is the most effective method for treating obesity and can play an essential role in reducing the direct and indirect costs of obesity treatment. Nonetheless, there are few comprehensive guidelines which include nutrition, physical activity, and supplements, before and after surgery. The purpose of the present narrative review is to provide an updated and comprehensive practical guideline to help multidisciplinary teams. The core keywords include nutrition, diet, physical activity, exercise, supplements, macronutrients, micronutrients, weight reduction, bariatric surgery, Roux-en-Y Gastric Bypass, Sleeve Gastrostomy, Laparoscopic Adjustable Gastric Banding, and Biliopancreatic diversion with duodenal switch which were searched in databases including PubMed/Medline, Cochrane, and some other sources such as Google Scholar. We answered questions in five important areas: (a) nutritional strategies before bariatric surgery, (b) nutrition after bariatric surgery, (c) physical activity before and after bariatric surgery, (d) weight regain after bariatric surgery, and (e) micronutrient assessments and recommendations before and after bariatric surgery. Some new items were added in this updated guideline including "weight regain" and "pregnancy after bariatric surgery." Other fields were updated based on new evidence and guidelines.
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Affiliation(s)
| | - Maryam Eghtesadi
- Sports and Exercise Medicine Department, Tehran University of Medical Sciences, No. 7, Ale-ahmad Highway, Tehran, 14395-578, Iran
| | - Maryam Abolhasani
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Faezeh Maleklou
- Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Ejtehadi
- Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Alizadeh
- Sports and Exercise Medicine Department, Tehran University of Medical Sciences, No. 7, Ale-ahmad Highway, Tehran, 14395-578, Iran.
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Nutritional Interventions for Patients with Severe Obesity Seeking Bariatric Surgery. Nutrients 2023; 15:nu15030515. [PMID: 36771222 PMCID: PMC9919116 DOI: 10.3390/nu15030515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/10/2023] [Indexed: 01/21/2023] Open
Abstract
Bariatric surgery (BS) is usually considered when other weight-loss treatments have failed, and remains an effective long-term treatment for severe obesity and its related medical complications [...].
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Bhattacharya S, Kalra S, Kapoor N, Singla R, Dutta D, Aggarwal S, Khandelwal D, Surana V, Dhingra A, Kantroo V, Chittawar S, Deka N, Bindal V, Dutta P. Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery. World J Diabetes 2021; 12:1587-1621. [PMID: 34754367 PMCID: PMC8554368 DOI: 10.4239/wjd.v12.i10.1587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/18/2021] [Accepted: 08/25/2021] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.
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Affiliation(s)
| | - Sanjay Kalra
- Endocrinology, Bharti Hospital, Karnal 132001, Haryana, India
| | - Nitin Kapoor
- Endocrinology, Christian Medical College, Vellore 632004, Tamil Nadu, India
| | - Rajiv Singla
- Endocrinology, Kalpavriksh Super Speciality Center, New Delhi 110075, India
| | - Deep Dutta
- Endocrinology, CEDAR Superspecialty Clinic, New Delhi 110075, India
| | - Sameer Aggarwal
- Endocrinology, Apex Plus Superspeciality Hospital, Rohtak 124001, Haryana, India
| | | | - Vineet Surana
- Endocrinology, Manipal Hospitals, New Delhi 110075, India
| | - Atul Dhingra
- Endocrinology, Gangaram Bansal Super Speciality Hospital, Sri Ganganagar 335001, Rajasthan, India
| | - Viny Kantroo
- Respiratory Medicine & Critical Care, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110076, India
| | - Sachin Chittawar
- Endocrinology, Gandhi Medical College, Bhopal 462001, Madhya Pardesh, India
| | - Nilakshi Deka
- Endocrinology, Apollo Hospitals, Guwahati 781005, Assam, India
| | - Vivek Bindal
- Minimal Access, Metabolic and Bariatric surgery, Max Superspeciality Hospital, Patparganj, New Delhi 110092, India
| | - Puja Dutta
- Nutrition, Max Superspeciality Hospital, Patparganj, New Delhi 110092, India
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Sridhar N, Hetzel E, Kindel TL, Gould JC, Higgins RM. The Impact of Hemoglobin A1c on Post-operative Outcomes in Bariatric Surgery Patients. J Surg Res 2021; 267:636-641. [PMID: 34273793 DOI: 10.1016/j.jss.2021.06.022] [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: 02/25/2021] [Revised: 05/13/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pre-operative hemoglobin (Hb) A1c levels ≥ 8% can lead to increased post-operative complications. In bariatric surgery patients, attaining a pre-operative HbA1c < 8% can be a challenge. The purpose of this study was to identify the association of pre-operative HbA1c on post-operative outcomes in bariatric surgery patients. MATERIAL AND METHODS A retrospective chart review was conducted on diabetic patients (HbA1c ≥ 6.5%) who underwent primary bariatric surgery at a single institution between the years 2013 and 2019. Patients were divided into two groups based on their pre-operative HbA1c levels of < 8% and ≥ 8%. Univariate analyses were performed to determine an association between pre-operative HbA1c levels and post-operative outcomes. RESULTS There were 351 primary diabetic bariatric surgery patients, 270 HbA1c <8%, and 81 HbA1c ≥ 8%. Procedure selection was significantly different between the HbA1c < 8% and HbA1c ≥ 8% group (49.3% sleeve, 50.4% bypass and 0.4% band versus 43.2% sleeve, 53.1% bypass and 3.7% band respectively, P < 0.04). There was no statistically significant difference in any 30-day post-operative outcome between the two groups. Post-operative HbA1c was significantly less in the HbA1c < 8% group at 3-6 month (6.0% ± 0.9 versus 7.4% ± 1.4, P <0.001) and 6-12 month (6.0% ± 1.1 versus 7.2% ± 1.4, P <0.001) follow-up. CONCLUSIONS This study demonstrated no difference in post-operative outcomes of primary bariatric surgery patients based on a HbA1c cut-off of 8%. This highlights that bariatric surgery can be considered and safely performed in patients with a pre-operative HbA1c ≥ 8%.
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Affiliation(s)
- Nithya Sridhar
- Division of Minimally Invasive and Gastrointestinal Surgery , Medical College of Wisconsin, Milwaukee, Wisconsin 53226
| | - Emily Hetzel
- Division of Minimally Invasive and Gastrointestinal Surgery , Medical College of Wisconsin, Milwaukee, Wisconsin 53226
| | - Tammy L Kindel
- Division of Minimally Invasive and Gastrointestinal Surgery , Medical College of Wisconsin, Milwaukee, Wisconsin 53226
| | - Jon C Gould
- Division of Minimally Invasive and Gastrointestinal Surgery , Medical College of Wisconsin, Milwaukee, Wisconsin 53226
| | - Rana M Higgins
- Division of Minimally Invasive and Gastrointestinal Surgery , Medical College of Wisconsin, Milwaukee, Wisconsin 53226.
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Sherf-Dagan S, Sinai T, Goldenshluger A, Globus I, Kessler Y, Schweiger C, Ben-Porat T. Nutritional Assessment and Preparation for Adult Bariatric Surgery Candidates: Clinical Practice. Adv Nutr 2021; 12:1020-1031. [PMID: 33040143 PMCID: PMC8262552 DOI: 10.1093/advances/nmaa121] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/25/2020] [Accepted: 09/03/2020] [Indexed: 12/13/2022] Open
Abstract
Bariatric surgery (BS) has proven to be highly efficacious in the treatment of obesity and its comorbidities. However, careful patient selection is critical for its success. Thus, patients should undergo medical, behavioral, and nutritional assessment by a multidisciplinary team. From the nutritional point of view, BS candidates should undergo nutritional assessment, preparation, and education by a registered dietitian in the preoperative period. Currently, detailed specified and comprehensive information on these topics is lacking. The present narrative review aimed to summarize the available literature concerning both the preoperative nutritional assessment components and the preoperative nutritional preparation and education components of patients planning to undergo BS. Current literature indicates that proper management before BS should include a comprehensive nutritional assessment, in which it is advisable to perform a clinical interview to assess patients' medical background, weight management history, eating patterns and pathologies, oral health, physical activity habits, nutritional status, supplementation usage, BS knowledge, surgery expectations and anthropometric measurements. Nutritional preparation and educational strategies should include an individualized preoperative weight-loss nutrition program, improvement of glycemic control, micronutrients deficiencies correction, eating and lifestyle habits adaptation, physical activity initiation, and strengthening knowledge on obesity and BS. At this stage, more well-designed intervention and long-term cohort studies are needed in order to formulate uniform evidence-based nutritional guidelines for patients who plan to undergo BS, including populations at higher nutritional risk. Moreover, postoperative outcomes of presurgical nutritional intervention programs should be studied.
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Affiliation(s)
- Shiri Sherf-Dagan
- Department of Nutritional Sciences, School of Health Sciences, Ariel University, Ariel, Israel
- Department of Nutrition, Assuta Medical Center, Tel Aviv, Israel
| | - Tali Sinai
- Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel
- School of Nutritional Sciences, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Ariela Goldenshluger
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, and Sylvan Adams Sports Institute, Tel-Aviv University, Tel Aviv, Israel
| | | | - Yafit Kessler
- Department of Nutritional Sciences, School of Health Sciences, Ariel University, Ariel, Israel
- Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel
| | - Chaya Schweiger
- Nutrition Service, Rabin Medical Center, Campus Beilinson, Petach Tiqva, Israel
| | - Tair Ben-Porat
- Department of Nutrition, Hadassah-Hebrew University Medical Center, Ein-Kerem Campus, Jerusalem, Israel
- Department of Human Metabolism and Nutrition, Braun School of Public Health, Hebrew University, Jerusalem, Israel
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7
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Frieder JS, Montorfano L, Gomez CO, Aleman R, Okida LF, Ferri F, Funes DR, Lo Menzo E, Szomstein S, Rosenthal RJ. Sleeve gastrectomy versus Roux-en-Y gastric bypass in patients Aged ≥65 years: a comparison of short-term outcomes. Surg Obes Relat Dis 2021; 17:1409-1415. [PMID: 34031010 DOI: 10.1016/j.soard.2021.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 03/23/2021] [Accepted: 07/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bariatric surgery in the elderly population has been reported as feasible and safe. Sleeve gastrectomy (SG) seems to have fewer complications than Roux-en-Y gastric bypass (RYGB) even in the 65 years of age population. We analyzed the difference in weight loss between SG and RYGB in patients age 65 years. OBJECTIVES To analyze and compare outcomes between SG and RYGB in patients 65 years of age and older. SETTING Academic hospital, United States. METHODS After internal review board approval, we retrospectively reviewed 2486 patients who underwent either SG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative body mass index (BMI), and co-morbidities were described. We identified all patients age ≥65 years and subsequently divided them into 2 groups based on type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were completed. Postoperative BMI was reviewed at 6, 12, and 24 months and percent excess BMI loss (%EBMIL, as defined by the ASMBS clinical committee) was calculated accordingly. The t test and χ2 analysis were performed for nominal and categorical variables, respectively. RESULTS From 2486 patients reviewed, 22.7% (n = 565) were aged ≥65 years. From these, 43.1% (n = 244) underwent SG and 56.8% (n = 321) underwent RYGB. White and female patients were predominant in both groups. Mean age was similar for both populations (SG: 71.1 ± 4.0, RYGB: 71.7 ± 4.5; P = .12). Pre-procedure mean BMI for both groups was close in value, but the difference was statistically significant (40.5 ± 5.5 for SG versus 43.7 ± 7.2 for RYGB; P < .0001). Postoperative follow-up rates were similar in both groups at 12 and 24 months (SG: 51.2% and 31.6%; RYGB: 48.3% and 34.3%; P = .49 and P = .5). The %EBMIL at 6, 12, and 24 months was higher for the RYGB group than the SG group (59.3 ± 27.9, 72.1 ± 29.5, 77.4 ± 26.1 versus 50.2 ± 21.9, 55.2 ± 25.6, 43.9 ± 32.2; P < .01, P < .01, and P < .01, respectively). Complication rates were significantly higher in RYGB versus SG (27.7% versus 9.4%; P < .01). We observed significantly higher anastomotic ulcer and stricture rates for RYGB versus SG (7.2% and 5.9 versus 0% and 0%; P < .01 and P < .01, respectively). RYGB had a higher rate for gastrointestinal obstruction requiring intervention (2.2% versus .4%; P = .07). A similar de novo gastroesophageal reflux disease rate was noted in both procedures (3.7% versus 3.7%; P = .98). No leaks were reported in either group. CONCLUSIONS Both SG and RYGB are effective weight loss procedures for patients aged ≥65 years. RYGB seems to have higher %EBMIL at 1 and 2 years; however, when compared with SG, complication rates appear to be almost 3 times higher.
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Affiliation(s)
- Joel S Frieder
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Lisandro Montorfano
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Camila Ortiz Gomez
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Rene Aleman
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Luis Felipe Okida
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Francisco Ferri
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - David Romero Funes
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Emanuele Lo Menzo
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Samuel Szomstein
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Raul J Rosenthal
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida.
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Mazzei M, Edwards MA. Poor glycemic control in bariatric patients: a reason to delay or a reason to proceed? Surg Obes Relat Dis 2020; 17:744-755. [PMID: 33423962 DOI: 10.1016/j.soard.2020.11.022] [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: 06/17/2020] [Revised: 10/23/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND More than 90% of patients with type 2 diabetes (T2D) have obesity, and over 85% of diabetic patients who undergo metabolic and bariatric surgery (MBS) will see improvement or resolution of diabetes. However, diabetes is a known risk factor for surgical complications. OBJECTIVES To determine whether poor preoperative glycemic control confers an increased perioperative risk after MBS. SETTING Academic Hospital. METHODS Retrospective review of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). From the 2017-2018 MBSAQIP databases, we identified patients with diabetes who underwent Roux-en-Y gastric bypass or gastric sleeve surgery. Unmatched and propensity-matched univariate analyses, as well as multivariate logistic regressions, were performed to compare 30-day postoperative outcomes and complication rates between patients with poor (glycated hemoglobin [HbA1C] > 7.0) and good (HbA1C ≤ 7.0) glycemic control. RESULTS Of 40,132 T2D patients, 19,094 (52.42%) had an HbA1C level ≤ 7.0. Patients with poor glycemic control had slightly higher rates of overall morbidity (6.53% versus 5.49%, respectively; relative risk = 1.188; P < .001). However, in a 1:1 matched analysis of 23,930 patients controlling for body mass index, surgery type, approach, and co-morbidities, the findings of poorer outcomes were largely mitigated. In a multivariate analysis, poor glycemic control was not associated with morbidity. CONCLUSIONS In T2D patients, poor glycemic control does not independently increase the risk of 30-day morbidity following MBS. Adverse outcomes in the setting of poor glycemic control appear to be largely mediated by associated co-morbidities. Performing MBS in the setting of suboptimal glycemic control may be justified, with the understanding that delaying or refusing surgery can contribute to worsening of diabetes-related co-morbidities that, in turn, may ultimately have a more deleterious effect on outcomes.
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Affiliation(s)
- Michael Mazzei
- Department of General Surgery, Temple University Hospital, Philadelphia, Pennsylvania
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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10
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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11
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Grieve E, Mackenzie RM, Munro J, O'Donnell J, Stewart S, Ali A, Bruce D, Trevor M, Logue J. Variations in bariatric surgical care pathways: a national costing study on the variability of services and impact on costs. BMC OBESITY 2018; 5:43. [PMID: 30607251 PMCID: PMC6307243 DOI: 10.1186/s40608-018-0223-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 12/17/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND We undertook a survey of all bariatric centres in Scotland in order to describe current pre- and post-operative care, to estimate their costs and explore differences in financial impact. METHODS A questionnaire was distributed to each health centre. Descriptive statistics were used to present average cost per patient along with 95% confidence intervals, and the range of costs. RESULTS Results show nearly a five-fold difference in costs per patient for pre-operative services (range £226 - £1071) and more than a three-fold difference for post-operative services (range £259 - £896). CONCLUSIONS There is a lack of evidence base and a clear requirement for the evaluation of bariatric surgical services to identify the care pathways pre- and post-surgery which lead to largest improvements in health outcomes and remain cost-effective.
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Affiliation(s)
- Eleanor Grieve
- 1Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QQ UK
| | - Ruth M Mackenzie
- 2Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8QQ UK
| | - Jane Munro
- 2Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8QQ UK
| | - Joanne O'Donnell
- 2Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8QQ UK
| | - Sally Stewart
- 2Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8QQ UK
| | - Abdulmajid Ali
- 3University Hospital Ayr, NHS Ayrshire and Arran, Ayr, KA6 6DX UK
| | - Duff Bruce
- 3University Hospital Ayr, NHS Ayrshire and Arran, Ayr, KA6 6DX UK
| | - Miranda Trevor
- 4Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QQ UK
| | - Jennifer Logue
- 5Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA UK
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