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Maroun J, Vahibe A, Shah M, Mundi MS, Acosta A, McKenzie TJ, Kellogg TA, Ghanem OM. Impact of Chronic Immunosuppression on Short-, Mid-, and Long-Term Bariatric Surgery Outcomes. Obes Surg 2023; 33:240-246. [PMID: 36469206 DOI: 10.1007/s11695-022-06372-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Bariatric surgical outcomes depend heavily on proper healing of gastrointestinal anatomy, metabolic alterations, and patient lifestyle modifications which are all negatively impacted by immunosuppression and underlying inflammatory diseases. There is a lack of literature exploring how patients with diseases requiring immunosuppression respond to bariatric surgical intervention in the long term. METHODS A retrospective analysis of chronically immunosuppressed patients who underwent primary bariatric surgeries at Mayo Clinic was conducted (2008-2020). Data collected included patient demographics, BMI, underlying disease, and immunosuppression regimen and complications at 3, 6, 12, 24, and 60 months. RESULTS We identified a total of 89 (RYGB = 49, SG = 34, BPD/DS = 6) patients on chronic immunosuppression who underwent bariatric surgery at our center. RYGB (N = 49), 38.2% had a SG (N = 34) and 6.7% had a BPD/DS (N = 6). Rheumatoid arthritis and renal transplantation were the most underlying condition at 20.22% each (N = 18). There were a total of 2 (2.25%) intraoperative complications. In the immediate post-operative period, there were 15 (16.5%) minor complications. In follow-up, 6.1% of RYGB patients experienced marginal ulcerations, while no gastrointestinal leaks occurred. The mean pre-surgical BMI was 48.29 kg/m2 (SD = 18.41). Percent total weight loss (%TWL) and BMI reduction were 30.89% and 14.83 kg/m2 (SD = 9.07) at 12 months and 29.48% and 14.43 kg/m2 (SD = 13.46) at 60 months, respectively. The mean follow-up time was 30.49 months. CONCLUSIONS Bariatric surgery remains safe and effective therapy for chronically immunosuppressed patients with excellent long-term outcomes for patients with moderate to severe obesity.
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Affiliation(s)
- Justin Maroun
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Ahmet Vahibe
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Meera Shah
- Department of Medicine, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Manpreet S Mundi
- Department of Medicine, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Andres Acosta
- Department of Medicine, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Todd A Kellogg
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA.
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Performing laparoscopic sleeve gastrectomy in an obese patient with systemic lupus erythematosus undergoing long-term steroid therapy: a case report. Surg Case Rep 2019; 5:161. [PMID: 31664579 PMCID: PMC6820622 DOI: 10.1186/s40792-019-0735-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE), an autoimmune disease characterized by systemic inflammatory lesions, is often associated with obesity. Obesity aggravates symptoms of SLE; however, these symptoms can be improved by weight loss through diet therapy and bariatric surgery. However, there are only a few reports regarding the effectiveness of bariatric surgery in obese patients with SLE. Herein, we discuss the laparoscopic sleeve gastrectomy (LSG) performed in an obese patient with SLE while undergoing long-term steroid therapy. CASE PRESENTATION A 36-year-old female, suffering from SLE for 10 years with effects on the central nervous system, developed diabetes mellitus (DM) triggered by the steroid therapy for SLE. The patient was undergoing steroid therapy (6 mg/day) for SLE since a long time. For DM management, her HbA1c level was maintained at 7.4%. She was 158 cm tall and 91.6 kg in weight. Her body mass index was 36.7. She could not work and depended on welfare services. To improve her obesity and DM, physicians suggested that she should undergo bariatric surgery in our hospital. Eventually, she underwent LSG, which lasted for 185 min, with minimal blood loss and without complications. Her blood glucose level stabilized immediately after the surgery; hence, her antidiabetic medication was discontinued. She was discharged 8 days after surgery, and her weight decreased steadily. In the first year after surgery, her weight was 54.4 kg, and she had lost approximately 37 kg from her initial weight. Her steroid requirement had also reduced to 4 mg/day. Through weight loss, she could begin to work and became a part of society again. CONCLUSION LSG was safely performed in an obese patient with SLE undergoing long-term steroid therapy. We noted substantial weight loss, improved DM condition, and reduced requirement of SLE therapy after surgery. Hence, surgical risks must be carefully examined before patients undergo bariatric surgery.
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Guan H, Luo X, Chang X, Su M, Li Z, Li P, Wang X, Shi Y. Identification of the Chemical Constituents of an Anti-Arthritic Chinese Medicine Wen Luo Yin by Liquid Chromatography Coupled with Mass Spectrometry. Molecules 2019; 24:E233. [PMID: 30634574 PMCID: PMC6359360 DOI: 10.3390/molecules24020233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/03/2019] [Accepted: 01/08/2019] [Indexed: 11/16/2022] Open
Abstract
Wen Luo Yin (WLY), a well-known traditional Chinese medicine formulation, has been used as a complementary therapy for the treatment of rheumatoid arthritis in clinical settings. However, the chemical constituents of WLY remain unclear. In this study, a high-performance liquid chromatography coupled with tandem mass spectrometry method was established to separate and comprehensively identify the chemical constituents of WLY. The analytes were eluted with a mobile phase of acetonitrile and 0.1% aqueous acetic acid. Mass detection was performed in both positive and negative ion mode. The MS/MS fragmentation pathways were proposed for the identification of the components. A total of 42 compounds including sesquiterpenes, alkaloids, biflavonoids, polyacetylenes, phenylpropanoids and acetylenic phenols were identified unambiguously or tentatively according to their retention times and mass behavior with those of authentic standards or literature data. The identification and structural elucidation of chemical constituents may provide important information for quality control and pharmacological research of WLY.
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Affiliation(s)
- Huanyu Guan
- Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100193, China.
- School of Pharmaceutical Sciences, Guizhou Medical University, Guiyang 550004, China.
| | - Xiaomei Luo
- Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100193, China.
| | - Xiaoyan Chang
- Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100193, China.
| | - Meifeng Su
- Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100193, China.
| | - Zhuangzhuang Li
- Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100193, China.
| | - Pengfei Li
- Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100193, China.
| | - Xiaoming Wang
- Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100193, China.
| | - Yue Shi
- Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100193, China.
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Bariatric Surgery in Immunocompromised Patients: Outcomes from One Year Follow-up. Obes Surg 2018; 28:2811-2814. [PMID: 29679335 DOI: 10.1007/s11695-018-3251-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Recent Research evidences from across the world indicate the usefulness of bariatric surgery in improving the immunological co-morbidities in patients with morbid obesity. AIM The aim of the study was to evaluate the outcome from bariatric surgery in patients presenting with diabetes mellitus and or morbid obesity with immunological co-morbidities. METHODS It was a retrospective cross-sectional study. Study included patients with morbid obesity with immunological co-morbidities, and additional co- morbidity of type 2 diabetes mellitus in about one third of the cases, who had undergone bariatric surgery during the period 2014-2016 at our center. Patient demographics, preoperative data, and follow-up data were collected and analyzed. Patients were followed for assessing the outcome in terms of BMI and dependency on medications to evaluate the effectiveness of the procedure. RESULTS The study included 23 patients (52% female and 48% male). Bariatric surgery was effective in all the patients (except one) in weight reduction. Significant reduction in weight and BMI was observed (p < 0.05). The recent follow-up of these patients showed that the mean BMI of the study group decreased significantly, 34.4% patients had attained normal BMI ≤ 25 kg/m2. Three-month follow-up indicated that 55.56% were not dependent on medications. At 1-year follow-up, 94.4% patients were without any dependency on immunosuppressive medications. Complications included a reversal of surgery and a case of mortality. CONCLUSION The results of our study have shown that immune-compromised patients can undergo bariatric surgery with good weight loss results and improvement in co-morbidities.
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Andalib A, Aminian A, Khorgami Z, Jamal MH, Augustin T, Schauer PR, Brethauer SA. Early Postoperative Outcomes of Primary Bariatric Surgery in Patients on Chronic Steroid or Immunosuppressive Therapy. Obes Surg 2017; 26:1479-86. [PMID: 26647068 DOI: 10.1007/s11695-015-1923-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous research suggests that patients on chronic steroids may be at an increased risk of postoperative morbidity after major surgery. We aimed to evaluate the prognostic impact of chronic use of steroid or immunosuppression on 30-day morbidity and mortality rates after primary bariatric surgery. METHODS From American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent primary bariatric surgery between 2005 and 2013. Logistic regression was used to determine the prognostic impact of chronic use of steroid or immunosuppression on the 30-day postoperative outcomes. RESULTS One thousand two hundred seventy seven steroid/immunosuppressant-dependent (SD) and 112,892 non-dependent (ND) patients were analyzed. SD patients had a higher baseline risk profile compared to ND patients. Thirty-day mortality rates for SD and ND patients were 0.55 and 0.11 %, respectively (P < 0.001) which corresponds to an adjusted odds ration (OR) of 6.85 (95 % confidence interval (CI) 1.95-24.12). SD patients had a higher 30-day major morbidity compared to ND patients (5.01 versus 2.54 %; P < 0.001, respectively). After adjustment, this translated into an OR of 2.21 (95 % CI 1.29-3.79). Among SD patients, there was no significant difference in 30-day major morbidity after gastric bypass compared to sleeve gastrectomy (OR = 0.36; 95 % CI 0.08-1.66). CONCLUSIONS Chronic and active use of steroid or immunosuppressant medications is a strong predictor of 30-day postoperative morbidity and mortality following primary bariatric surgery. Among the steroid/immunosuppressant users, complication rates were similar for gastric bypass and sleeve gastrectomy patients. Further studies are needed to help guide the management or discontinuation of such medications in the perioperative period.
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Affiliation(s)
- Amin Andalib
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zhamak Khorgami
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammad H Jamal
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Toms Augustin
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Philip R Schauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stacy A Brethauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA.
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Patient Selection and Surgical Management of High-Risk Patients with Morbid Obesity. Surg Clin North Am 2016; 96:743-62. [DOI: 10.1016/j.suc.2016.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Comment on: "Trends in Bariatric Surgery in Spain in the Twenty-First Century: Baseline Results and 1-Month Follow Up of the RICIBA, a National Registry" by Lecube A, et al. Obes Surg 2016; 26:1596-8. [PMID: 27103029 DOI: 10.1007/s11695-016-2191-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Laparoscopic Sleeve Gastrectomy in a Morbidly Obese Patient with Myasthenia Gravis: A Review of the Management. Case Rep Med 2015; 2015:593586. [PMID: 26294914 PMCID: PMC4532903 DOI: 10.1155/2015/593586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/16/2015] [Indexed: 11/29/2022] Open
Abstract
Myasthenia gravis, a disorder of neuromuscular transmission, presents a unique challenge to the perioperative anesthetic management of morbidly obese patients. This report describes the case of a 27-year-old morbidly obese woman with a past medical history significant for myasthenia gravis and fatty liver disease undergoing bariatric surgery. Anesthesia was induced with intravenous agents and maintained with an inhalational and balanced intravenous technique. The nondepolarizing neuromuscular blocker Cisatracurium was chosen so that no reversal agents were given. Neostigmine was not used to antagonize the effects of Cisatracurium. The goal of this approach was to reduce the risk of complications such as postoperative mechanical ventilation. The anesthetic and surgical techniques used resulted in an uneventful hospital course. Therefore, we can minimize perioperative risks and complications by adjusting the anesthetic plan based on the patient's physiology and comorbidities as well as the pharmacology of the drugs.
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Laparoscopic placement of adjustable gastric band in patients with autoimmune disease or chronic steroid use. Obes Surg 2015; 24:584-7. [PMID: 24272886 DOI: 10.1007/s11695-013-1122-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Past medical or family history of autoimmune diseases and patient chronic steroid use are label contraindications for laparoscopic placement of adjustable gastric band (LAGB). We reviewed our experience with placement of LAGB in patients with autoimmune disease or chronic steroid use. METHODS This was a retrospective review of our prospective bariatric database. All patients who underwent LAGB and had a diagnosis of autoimmune disease or chronic steroid use with at least 1-year follow-up data were included in the study. Data on demographics, weight loss, and complications were collected. RESULTS Sixteen patients with autoimmune diseases or chronic steroid use underwent LAGB. Diseases included were lupus (n = 6), sarcoidosis (n = 4), renal transplant (n = 2), rheumatoid arthritis (n = 1), ulcerative colitis (n = 1), Grave's disease (n = 1), and celiac disease (n = 1). No patients developed infectious complications. One patient required port replacement due to malfunction, and one patient underwent a conversion to gastric bypass due to failure of weight loss. The average preoperative body mass index was 46.8 kg/m(2) with an average weight of 292.0 lbs. Average excess weight loss was 39.8 % (range, 7.4 to 95.5 %) at a median follow-up of 54 months. CONCLUSIONS Our review indicates that LAGB in patients with autoimmune diseases or chronic steroid use is safe, with no infectious complications and only one explant. Some of these autoimmune conditions may improve following significant weight loss, but larger studies are required to further substantiate these findings.
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Borg MCM. Comment on: Preoperative glucocorticoid use and risk of postoperative bleeding and infection after gastric bypass surgery for the treatment of obesity. Surg Obes Relat Dis 2015; 11:1218-9. [PMID: 25843398 DOI: 10.1016/j.soard.2015.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
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Corcelles R, Daigle CR, Talamas HR, Batayyah E, Brethauer SA, Schauer PR. Bariatric surgery outcomes in patients with systemic lupus erythematosus. Surg Obes Relat Dis 2014; 11:684-8. [PMID: 26093769 DOI: 10.1016/j.soard.2014.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/01/2014] [Accepted: 10/06/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Obesity is common among systemic lupus erythematosus (SLE) patients. An increased perioperative risk after major surgery in SLE has been reported. The aim of this study was to describe postoperative outcomes among SLE patients undergoing bariatric surgery. METHODS Charts were reviewed to identify patients with an active diagnosis of SLE before bariatric surgery. Demographic variables, perioperative data, and SLE-related parameters were extracted. RESULTS Thirty-one morbidly obese patients who underwent bariatric surgery between 2005 and 2013 had a SLE diagnosis. Twenty-three patients had laparoscopic Roux-en-Y gastric bypass (RYGBP), 3 underwent laparoscopic revisional surgery for failed bariatric procedure, 3 had laparoscopic sleeve gastrectomy and 1 underwent laparoscopic adjustable gastric banding. Mean age, body mass index, and excess weight (kg) at baseline were 52.8±9.4 years, 44.3±9 kg/m(2), and 52.5±25.7 kg, respectively. Of these 31 patients, 24 (77.4%) were taking immunosuppressive medications at the time of surgery. Early major postoperative complications occurred in 4 patients (12.9%), with 3 requiring reoperation (9.6%). Multivariate analysis identified immunosuppressive therapy to be significantly associated with postoperative complications (P = .05). At a mean follow-up of 3 years, 13 patients (42%) showed reduction in the number of immunosuppressive medications and 6 (19.3%) were off steroids completely. After bariatric surgery, mean body mass index decreased to 34.2±8.2 kg/m(2) (P<.005) and excess weight loss was 51.2%± 33.4%. CONCLUSION Results suggest that weight loss after bariatric surgery is associated with decreased SLE immunosuppression medication requirements; however, the risks are higher. Bariatric surgery in this patient population should be approached with caution.
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Affiliation(s)
- Ricard Corcelles
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Gastrointestinal Surgery, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | | | - Esam Batayyah
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stacy A Brethauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Philip R Schauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
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