Increased adverse outcomes after laparoscopic sleeve gastrectomy in older super-obese patients: analysis of American College of Surgeons National Surgical Quality Improvement Program Database

Update on antithrombotic therapy and body mass: a clinical consensus statement of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and the European Society of Cardiology Working Group on Thrombosis

Obesity and underweight are a growing health problem worldwide and a challenge for clinicians concerning antithrombotic therapy, due to the associated risks of thrombosis and/or bleeding. This clinical consensus statement updates a previous one published in 2018, by reviewing the most recent evidence on antithrombotic drugs based on body size categories according to the World Health Organization classification. The document focuses mostly on individuals at the extremes of body weight, i.e. underweight and moderate-to-morbid obesity, who require antithrombotic drugs, according to current guidelines, for the treatment or prevention of cardiovascular diseases or venous thromboembolism. Managing antithrombotic therapy or thromboprophylaxis in these individuals is challenging, due to profound changes in body composition, metabolism and organ function, and altered drug pharmacokinetics and pharmacodynamics, as well as weak or no evidence from clinical trials. The document also includes artificial intelligence simulations derived from in silico pharmacokinetic/pharmacodynamic models, which can mimic the pharmacokinetic changes and help identify optimal regimens of antithrombotic drugs for severely underweight or severely obese individuals. Further, bariatric surgery in morbidly obese subjects is frequently performed worldwide. Bariatric surgery causes specific and additional changes in metabolism and gastrointestinal anatomy, depending on the type of the procedure, which can also impact the pharmacokinetics of antithrombotic drugs and their management. Based on existing literature, the document provides consensus statements on optimizing antithrombotic drug management for underweight and all classes of obese patients, while highlighting the current gaps in knowledge in these complex clinical settings, which require personalized medicine and precision pharmacology.

Cumulative Incidence of Venous Thromboembolic Events In-Hospital, and at 1, 3, 6, and 12 Months After Metabolic and Bariatric Surgery: Systematic Review of 87 Studies and Meta-analysis of 2,731,797 Patients

Systematic review/meta-analysis of cumulative incidences of venous thromboembolic events (VTE) after metabolic and bariatric surgery (MBS). Electronic databases were searched for original studies. Proportional meta-analysis assessed cumulative VTE incidences. (PROSPERO ID:CRD42020184529). A total of 3066 records, and 87 studies were included (N patients = 4,991,683). Pooled in-hospital VTE of mainly laparoscopic studies = 0.15% (95% CI = 0.13-0.18%); pooled cumulative incidence increased to 0.50% (95% CI = 0.33-0.70%); 0.51% (95% CI = 0.38-0.65%); 0.72% (95% CI = 0.13-1.52%); 0.78% (95% CI = 0-3.49%) at 30 days and 3, 6, and 12 months, respectively. Studies using predominantly open approach exhibited higher incidence than laparoscopic studies. Within the first month, 60% of VTE occurred after discharge. North American and earlier studies had higher incidence than non-North American and more recent studies. This study is the first to generate detailed estimates of the incidence and patterns of VTE after MBS over time. The incidence of VTE after MBS is low. Improved estimates and time variations of VTE require longer-term designs, non-aggregated reporting of characteristics, and must consider many factors and the use of data registries. Extended surveillance of VTE after MBS is required.

Prediction of thirty-day morbidity and mortality after duodenal switch using an artificial neural network

BACKGROUND

Understanding factors that increase risk of both mortality and specific measures of morbidity after duodenal switch (DS) is important in deciding to offer this weight loss operation. Artificial neural networks (ANN) are computational deep learning approaches that model complex interactions among input factors to optimally predict an outcome. Here, a comprehensive national database is examined for patient factors associated with poor outcomes, while comparing the performance of multivariate logistic regression and ANN models in predicting these outcomes.

METHODS

2907 DS patients from the 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were assessed for patient factors associated with the previously validated composite endpoint of 30-day postoperative reintervention, reoperation, readmission, or mortality using bivariate analysis. Variables associated (P ≤ 0.05) with the endpoint were imputed in a multivariate logistic regression model and a three-node ANN with 20% holdback for validation. Goodness-of-fit was assessed using area under receiver operating curves (AUROC).

RESULTS

There were 229 DS patients with the composite endpoint (7.9%), and 12 mortalities (0.4%). Associated patient factors on bivariate analysis included advanced age, non-white race, cardiac history, hypertension requiring 3 + medications (HTN), previous foregut/obesity surgery, obstructive sleep apnea (OSA), and higher creatinine (P ≤ 0.05). Upon multivariate analysis, independently associated factors were non-white race (odds ratio 1.40; P = 0.075), HTN (1.55; P = 0.038), previous foregut/bariatric surgery (1.43; P = 0.041), and OSA (1.46; P = 0.018). The nominal logistic regression multivariate analysis (n = 2330; R² = 0.02, P < 0.001) and ANN (R² = 0.06; n = 1863 [training set], n = 467 [validation]) models generated AUROCs of 0.619, 0.656 (training set) and 0.685 (validation set), respectively.

CONCLUSION

Readily obtainable patient factors were identified that confer increased risk of the 30-day composite endpoint after DS. Moreover, use of an ANN to model these factors may optimize prediction of this outcome. This information provides useful guidance to bariatricians and surgical candidates alike.

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.

The Role of Preoperative Anemia in Predicting Short-Term Morbidity and Mortality After Roux-en-Y Gastric Bypass

BACKGROUND

Preoperative anemia has been suggested as a contraindication to gastric bypass. Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement database, this study sought to determine the role of preoperative hematocrit on 30-day morbidity and mortality after laparoscopic Roux-en-Y gastric bypass for weight loss.

METHODS

A cohort of 31 981 patients was reviewed for factors associated with a composite primary end point including 30-day reoperation, readmission, reintervention, or mortality, including degree of anemia. Analyzed separately by gender, factors significant on bivariate analysis were included in nominal logistic multivariate analysis to assess for independent significance of the hematocrit level as a risk factor for the primary end point.

RESULTS

Upon multivariate analysis, the hematocrit level was significantly associated with the 30-day end point in the male cohort (P = .05), specifically, severe anemia (hematocrit <35%) conferred an increased risk relative to a normal hematocrit (odds ratio 1.5, P = .03). There was no association of hematocrit with the 30-day end point in the female cohort.

CONCLUSION

Bariatricians should carefully consider the appropriateness of a gastric bypass over a less anemogenic procedure such as sleeve gastrectomy in patients, particularly men with preoperative anemia.

Perioperative outcomes of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in super-obese and super-super-obese patients: a national database analysis

BACKGROUND

Evidence remains contradictory for perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients undergoing bariatric surgery.

OBJECTIVE

To identify national 30-day morbidity and mortality of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

METHODS

All LSG and LRYGB patients from 2015 through 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were grouped based on body mass index (BMI) as follows: morbidly obese (MO; BMI 35.0-49.9 kg/m²), SO (BMI 50.0-59.9 kg/m²), and SSO (BMI ≥60.0 kg/m²). Complications and mortality within 30 days were compared between BMI groups using Pearson X² or Fischer's exact tests. Multivariate logistic regression was used to adjust for demographic characteristics and co-morbidities, and adjusted odds ratio (AOR) was reported for each outcome.

RESULTS

Of 356,621 patients, 71.6% had LSG and 28.4% LRYGB. A total of 272,195 patients were in the MO group, 65,565 in the SO group, and 18,861 in the SSO group. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for SO (AOR = 1.20, 95% confidence interval [CI] 1.13-1.28 for LSG; AOR = 1.08, 95% CI 1.01-1.15 for LRYGB) and SSO (AOR = 1.44, 95% CI 1.31-1.58 for LSG; AOR = 1.31, 95% CI 1.19-1.45 for LRYGB) compared with the MO group. Mortality was also significantly higher for SO (AOR = 1.65, 95% CI 1.10-2.48 for LSG; AOR = 1.85, 95% CI 1.23-2.80 for LRYGB) and SSO (AOR = 3.30, 95% CI 1.98-5.48 for LSG; AOR = 3.32, 95% CI 1.93-5.73 for LRYGB) compared with the MO group.

CONCLUSIONS

SO and SSO patients are at increased risk of 30-day morbidity and mortality compared with MO patients. Despite this elevated perioperative risk, the overall risk of these procedures remains low and acceptable especially as bariatric surgery is the durable treatment option for obesity.