Dehydration risk factors and impact after bariatric surgery: an analysis using a national database

Gastric Bypass vs Diet and Cardiovascular Risk Factors: A Nonrandomized Controlled Trial

Importance

Roux-en-Y gastric bypass (RYGB) is associated with reduced cardiovascular (CV) risk factors, morbidity, and mortality. Whether these effects are specifically induced by the surgical procedure or the weight loss is unclear.

Objective

To compare 6-week changes in CV risk factors in patients with obesity undergoing matching caloric restriction and weight loss by RYGB or a very low-energy diet (VLED).

Design, Setting, and Participants

This nonrandomized controlled study (Impact of Body Weight, Low Calorie Diet, and Gastric Bypass on Drug Bioavailability, Cardiovascular Risk Factors, and Metabolic Biomarkers [COCKTAIL]) was conducted at a tertiary care obesity center in Norway. Participants were individuals with severe obesity preparing for RYGB or a VLED. Recruitment began February 26, 2015; the first patient visit was on March 18, 2015, and the last patient visit (9-week follow-up) was on August 9, 2017. Data were analyzed from April 30, 2021, through June 29, 2023.

Interventions

VLED alone for 6 weeks or VLED for 6 weeks after RYGB; both interventions were preceded by 3-week LED.

Main Outcomes and Measures

Between-group comparisons of 6-week changes in CV risk factors.

Results

Among 78 patients included in the analyses, the mean (SD) age was 47.5 (9.7) years; 51 (65%) were women, and 27 (35%) were men. Except for a slightly higher mean (SD) body mass index of 44.5 (6.2) in the RYGB group (n = 41) vs 41.9 (5.4) in the VLED group (n = 37), baseline demographic and clinical characteristics were similar between groups. Major atherogenic blood lipids (low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein B, lipoprotein[a]) were reduced after RYGB in comparison with VLED despite a similar fat mass loss. Mean between-group differences were -17.7 mg/dL (95% CI, -27.9 to -7.5), -17.4 mg/dL (95% CI, -29.8 to -5.0) mg/dL, -9.94 mg/dL (95% CI, -15.75 to -4.14), and geometric mean ratio was 0.55 U/L (95% CI, 0.42 to 0.72), respectively. Changes in glycemic control and blood pressure were similar between groups.

Conclusions and Relevance

This study found that clinically meaningful reductions in major atherogenic blood lipids were demonstrated after RYGB, indicating that RYGB may reduce CV risk independent of weight loss.

Trial Registration

ClinicalTrials.gov Identifier: NCT02386917.

Association of prior bariatric surgery with outcomes following emergency general surgery

BACKGROUND

Despite the favorable outcomes and safety profile associated with metabolic and bariatric surgery (MBS), complications may occur postoperatively, necessitating emergency general surgery (EGS) intervention.

OBJECTIVES

To evaluate the association of outcomes in patients with prior MBS following EGS interventions.

SETTING

Academic, University-affiliated; USA.

METHODS

All adults undergoing nonelective EGS operations were identified using the 2016 to 2020 Nationwide Readmission Database. Patients with a history of MBS were subsequently categorized as Bariatric, with the remainder of patients as NonBariatric. The primary outcome of interest was in-hospital mortality, while perioperative complications, length of stay (LOS), hospitalization costs, non-home discharge, and 30-day readmission were secondarily assessed. Multivariable regression models were developed to evaluate the association of history of MBS with outcomes of interest.

RESULTS

Of an estimated 632,375 hospitalizations for EGS operations, 29,112 (4.6%) had a history of MBS. Compared to Nonbariatric, Bariatric were younger, more frequently female and more commonly had severe obesity. Following risk adjustment, Bariatric had significantly lower odds of in-hospital mortality (AOR .83, 95%CI .71-.98). Compared to others, Bariatric had reduced LOS by .5 days (95%CI .4-.7) and hospitalization costs by $1600 (95%CI $900-2100). Patients with prior MBS had reduced odds of nonhome discharge (AOR .89, 95%CI .85-.93) and increased likelihood of 30-day readmissions (AOR 2.32, 95%CI 1.93--2.79) following EGS.

CONCLUSIONS

Prior MBS is associated with decreased mortality and perioperative complications as well as reduced resource utilization in select EGS procedures. Our findings suggest that patients with a history of MBS can be managed effectively by acute surgical interventions.

Efficacy of Bowel Regimen in Decreasing Postoperative Constipation in Bariatric Surgery Patients

PURPOSE

Postoperative constipation after bariatric surgery is a common complaint, decreasing patient quality of life. No literature exists examining the efficacy of a preoperative bowel regimen in reducing postoperative constipation in this cohort. This study aims explore the efficacy of a well-established bowel regimen, polyethylene glycol (PEG), in reducing constipation frequency and severity after bariatric surgery.

METHODS

This was a retrospective study of adult patients undergoing primary and revisional bariatric procedures. The use of PEG bowel prep for bariatric patients was introduced as an institutional quality improvement measure. Patients during the first 3 months after PEG implementation were surveyed for postoperative constipation. For the year after implementation, patients were followed for 30-day emergency room visits or hospitalization secondary to constipation. This cohort was compared to historical controls from the previous year. Student t-tests were used for statistical analysis.

RESULTS

During the 3-month exploratory phase, 28/49 (57.14%) patients fully completed the bowel regimen. In total, 0/56 (0%) patients reported preoperative constipation, and 5/28 (17.9%) patients reported constipation at the 3-week follow-up. In the 1 year post-implementation cohort, 2/234 (0.85%) patients had constipation-related occurrences at 30-day follow-up, compared to 8/219 patients (3.65%) in the historical cohort (p = 0.04).

CONCLUSIONS

The implementation of a PEG-based bowel regimen did not eliminate self-reported constipation. However, there were significant differences in rates of constipation-related ED visits and hospital readmissions, suggesting that the bowel regimen decreases rates of severe constipation. Finally, patient compliance was limited. Future work should aim towards increasing compliance.

The changes on salivary flow rates, buffering capacity and chromogranin A levels in adults after bariatric surgery

OBJECTIVES

This study aimed to investigate changes in salivary flow rates, buffering capacity, and salivary chromogranin A (CHGA) levels in adults undergoing bariatric surgery (BS) compared with a non-obese control group.

MATERIALS AND METHODS

Salivary analyses were performed on 62 participants aged over 50 years, stratified into two groups matched for age and gender-individuals who had undergone bariatric surgery (BS) (n = 31) and a corresponding healthy control group (n = 31). Before saliva collection, participants completed a comprehensive 11-point visual numerical rating scale (NRS 0-10) xerostomia questionnaire, assessing subjective perceptions of two key aspects: dryness of the oral mucosa and resultant impact on oral functional ability. Three distinct saliva measurements were obtained: unstimulated whole saliva (UWS), stimulated whole saliva (SWS), and unstimulated upper labial saliva (ULS). The buffering capacity of unstimulated saliva was assessed using pH indicator strips, and concentrations of salivary Chromogranin A (CHGA) were quantified in stimulated saliva via enzyme-linked immunosorbent assay (ELISA).

RESULTS

After BS, more than 40% of BS group patients reported xerostomia, with 16.1% experiencing only mild symptoms without significant functional impact (p = 0.009). The prevalence of xerostomia and tongue dryness was higher in the BS group compared to the control group (p = 0.028 and p = 0.025, respectively). The comparative analysis unveiled no statistically significant differences in flow rates of unstimulated upper labial saliva (ULS), unstimulated whole saliva (UWS), and stimulated whole saliva (SWS) between the control group and patients who underwent bariatric surgery. However, in patients undergone BS with xerostomia, both ULS and UWS flow rates were significantly lower than in controls with xerostomia (p = 0.014 and p = 0.007, respectively). The buffering capacity was significantly lower in patients undergone BS than in controls (p = 0.009). No differences were found between groups regarding CHGA concentration and output values, nevertheless, higher values of CHGA concentrations were significantly correlated to lower flow rates.

CONCLUSION

According to the results, this study suggests that individuals undergoing BS may exhibit altered salivary buffering capacity and reduced unstimulated salivary flows in the presence of xerostomia. Additionally, the findings suggest that elevated concentration of salivary CHGA might be associated, in part, with salivary gland hypofunction.

CLINICAL RELEVANCE

The clinical significance of this study lies in highlighting the changes in salivary functions after BS. The identified salivary alterations might be attributed to adverse effects of BS such as vomiting, gastroesophageal reflux, and dehydration. Understanding these changes is crucial for healthcare professionals involved in the care of post-BS patients, as it sheds light on potential oral health challenges that may arise as a consequence of the surgical intervention. Monitoring and managing these salivary alterations can contribute to comprehensive patient care and enhance the overall postoperative experience for individuals undergoing BS.

The Association of Preoperative Food Insecurity With Early Postoperative Outcomes After Bariatric Surgery

INTRODUCTION

To assess the rate of food insecurity in patients undergoing bariatric surgery. To compare the rates of 30-d postoperative complications based on food security status.

METHODS

Patients undergoing primary Roux-en-Y gastric bypass or sleeve gastrectomy between 7/2020 - 3/2022 were screened for food insecurity via telephone using questions from the Accountable Health Communities Health-Related Social Needs Screening Tool. Screens were matched to patient data and 30-d outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

RESULTS

In total, 213 (59%) of the 359 bariatric surgery patients were screened with 81 (38%) screening positive for food insecurity. Evaluation of preoperative variables based on food security status showed comparable age, body mass index, and comorbidity status. Food insecure patients were found to have an increased length of stay following surgery compared to food secure patients (P = 0.003). Food insecurity was not associated with higher rates of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program reported 30-d postoperative complications including emergency department/urgent care visits (P = 0.34) and hospital readmissions (P = 0.94).

CONCLUSIONS

Food insecurity was prevalent at 38% of the bariatric surgical population. Food insecure patients had a statistically longer length of stay after primary bariatric surgery but were not associated with an increased risk of 30-d complications. Future studies are needed to determine the mid-term and long-term effects of food insecurity status on bariatric surgical outcomes and the potential impact of food insecurity on length of stay.

Analysis of postoperative emergency admission and hospitalization of patients who underwent bariatric surgery: A single-center experience

BACKGROUND

Bariatric surgery is a treatment with a low risk of complications that is becoming common in obesity treatment.

OBJECTIVE

The aim of this study is to evaluate postoperative visits to the emergency department by patients who underwent bariatric surgery and to investigate what postoperative conditions are encountered in these patients and what can be done to prevent emergency room admission and hospitalization.

SETTING

University Hospital.

METHODS

The study included 394 patients aged 18 years underwent bariatric surgery for obesity. Emergency department (ED) admissions and diagnoses of patients who underwent bariatric surgery were analyzed in two groups, surgery-related and surgery-unrelated.

RESULTS

It was found that 22% (n: 87) of patients visited the ED at least once; 4.8% (n: 19) of them were hospitalized; and 78.1% (n: 68) of 87 patients did not need to be hospitalized. Low preoperative iron, folic acid, and ferritin levels increase the number of visits to ED with a bariatric surgery-related complaint, urinary tract infection was the most common diagnosis and did not require hospitalization; the most common diagnosis of hospitalized patients was gastrointestinal perforation, pulmonary embolism, intra-abdominal abscess.

CONCLUSION

Despite the low risk of complications, bariatric surgery is a surgery associated with a high number of preventable postoperative emergency visits. ED visits can be reduced by calling these patients for more frequent outpatient check-ups, providing intravenous hydration therapy in outpatient clinics and, if necessary, providing prescribed treatment.

Robotic Bariatric Surgery in Older Adults, Is It Safer Than the Laparoscopic Approach? A 7-Year Analysis of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database

BACKGROUND

Utilization of the robotic platform in bariatric surgery has increased over the past several years. The population of older adults who benefit from bariatric surgery is also growing. This study evaluated the safety of robotic-assisted bariatric surgery in older adults using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database.

METHODS

Adults who underwent gastric bypass or sleeve gastrectomy and were ≥ 65 years old between the years 2015 and 2021 were included. The 30-day outcomes were assessed and stratified based on Clavien-Dindo (CD) classification of III-V. Univariable and multivariable logistic regressions were performed to identify predictors of CD ≥ III complications.

RESULTS

A total of 62,973 bariatric surgery patients were included. Most of the patients (90%) underwent laparoscopic surgery, and the remainder (10%) underwent robotic surgery. Robotic sleeve gastrectomy (R-SG) was associated with lower odds of developing CD ≥ III complications compared to three other procedures (adjusted odds ratio (aOR), 0.741; confidence interval (CI), 0.584-0.941; p 0.014).

CONCLUSIONS

Bariatric surgery using a robotic approach is considered safe for older patients. Robotic sleeve gastrectomy (R-SG) has the lowest morbidity and mortality rates compared to laparoscopic sleeve gastrectomy (L-SG), laparoscopic Roux-en-Y gastric bypass (L-RYGB), and robotic Roux-en-Y gastric bypass (R-RYGB). The findings of this study can help surgeons and their elderly patients to make informed decisions regarding the safety of different bariatric surgical approaches.

Impact of bariatric surgery on oral health: a systematic review and meta-analysis

OBJECTIVE

To evaluate the impact of bariatric surgery (BS) on the oral health status of obese individuals.

MATERIAL AND METHODS

The search was performed on the Cochrane Library, Embase, Latin American and Caribbean Literature on Health Sciences (LILACS), LIVIVO, PubMed/Medline, Scopus, and Web of Science databases. Grey literature was also consulted through Google Scholar, OpenGrey, ProQuest, and MedRxiv. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tool. Pre- and post-surgical moments were compared through random effects meta-analysis. The GRADE (Grading of Recommendations, Assessment, Development and Evaluations) assessment tool was used to judge the certainty of evidence.

RESULTS

After searching the databases, 908 references were retrieved, with 30 articles selected for synthesis. When comparing the pre- and postoperative moments, there was no difference in the index of decayed, missing, or filled teeth. Furthermore, salivary flow and probing depth presented a slight increase. Post-surgery patients showed an increase (%) in tooth wear at the dentin level [MD = -6.23; IC95% = -8.45--4.01; I² = 0%].

CONCLUSION

Patients undergoing BS show no difference when considering the rate of caries or missing teeth and little to no effect was observed on salivary flow rates and periodontal probing depth. On the other hand, greater attention should be given to dentin wear in post-surgical patients of BS.

CLINICAL RELEVANCE

Patients undergoing BS should receive careful monitoring regarding oral health by doctors, dentists, and the entire multidisciplinary team involved before and after the surgical procedure.

eHealth Intervention via LINE® Social Media as an Adjunct for Postoperative Care After Bariatric-Metabolic Surgery: Single Institution Experience

PURPOSE

Applying eHealth interventions via social media is common in modern medicine. LINE® is a popular communication app in Taiwan that can deliver messages 24 h a day. In addition to being free of charge, it also allows bariatric nurses (BNs) and patients to enjoy bidirectional communication via telecommunication services instead of direct, face-to-face contact for patients undergoing bariatric-metabolic surgery (BMS). We conducted this retrospective study to determine the frequency and reasons for early post-discharge of LINE® messages/calls and investigate the relationship between this frequency and contents of these messages and postoperative outcomes after BMS.

MATERIALS AND METHODS

A retrospective review of prospectively collected data was conducted in an Asian weight management center. The study period ran from August 2016 to December 2021, and a total of 143 native patients with severe obesity were enrolled. All patients were informed of the necessity of a postoperative dietitian consultation before bariatric surgery. The patterns of LINE® communication with the BN and associated actions to resolve patients' needs within 180 days after index BMS were analyzed.

RESULTS

Among the 143 enrolled patients, 100 underwent laparoscopic sleeve gastrectomy and 43 underwent laparoscopic Roux-en-Y gastric bypass. A total of 1205 messages/calls were analyzed concomitantly; most LINE® communications focused on diet problems (47.97%; n = 578), weight problems (11.54%; n = 139), and medications (9.21%; n = 111). Most problems could be resolved by LINE® communications directly, and only a small portion (5.6%) was directed to local clinics or emergency departments. During the COVID-19 pandemic, the usage of LINE® communications significantly increased (12.2 ± 10.4 vs. 6.4 ± 4.9; p < 0.01); nonetheless, a higher frequency of LINE® communications would not hinder the regular clinic visits (r = 0.359; p = 0.01).

CONCLUSION

Based on our limited experience, the LINE® consultation service operated by the BN could effectively address patients' problems. Moreover, it might reduce the need for emergency department visits or unexpected clinic appointments for patients after BMS.

Care of the Patient After Metabolic and Bariatric Surgery

Weight loss surgery, also known as metabolic and bariatric surgery (MBS), is an effective weight loss treatment and is associated with reduced mortality and improvements in obesity-related health conditions and quality of life. Postsurgical anatomical and physiologic changes include decreased absorption of micronutrients and alterations in gut-brain hormonal regulation that affect many aspects of health. Patients require ongoing monitoring of their physical and mental health for lasting success. Internists, particularly primary care clinicians, are in an ideal position to monitor for nonserious complications in the short and long term, adjust management of chronic diseases accordingly, and monitor for mental health changes. This article reviews key issues that internists should be aware of for supporting patients' health in the short and long term after MBS.

Risk Factors and a New Prediction Model for Pancreatic Fistula After Pancreaticoduodenectomy

Aim

In order to find the risk factors of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) according to the latest definition and grading system of International Study Group of Pancreatic Surgery (ISGPS) (version 2016) and propose a nomogram for predicting POPF.

Methods

We conducted a retrospective analysis of 232 successive cases of PD performed at our hospital by the same operator from August 2012 to June 2020. POPF was diagnosed in accordance with the latest definition of pancreatic fistula from the ISGPS. The risk factors of POPF were analyzed by univariate and multivariate logistic regression analysis. A nomogram model to predict the risk of POPF was constructed based on significant factors.

Results

There were 18 cases of POPF, accounting for 7.8% of the total. Among them, 17 cases were classified into ISGPF grade B and 1 case was classified into ISGPF grade C. In addition, 35 cases were classified into biochemical leak. Univariate and multivariate analysis showed that hypertension, non-diabetes, no history of abdominal surgery, antecolic gastrojejunostomy and soft pancreas were independent risk factors of POPF. Based on significant factors, a nomogram is plotted to predict the risk of POPF. The C-index of this nomogram to assess prediction accuracy was 0.916 (P < 0.001) indicating good prediction performance.

Conclusion

Hypertension, non-diabetes, no history of abdominal surgery, antecolic gastrojejunostomy and soft pancreas were independent risk factors of POPF. Meanwhile, a nomogram for predicting POPF with good test performance and discriminatory capacity was constituted.

Oral health profile of postbariatric surgery individuals: A case series

Objectives

To describe the oral health profile of individuals who had undergone gastric bypass surgery (GBP) or sleeve gastrectomy (SG) to generate hypotheses for further studies.

Material and Methods

Fourteen individuals treated with GBP or SG surgery ≥ 2 years ago and with observed and/or perceived oral problems were recruited to a case series. The documentation included clinical and radiographic examinations, biomedical sampling, and self‐reported diet and questionnaires. The results are presented descriptively.

Results: The age range was 31 to 66 years and all had a BMI > 25 (range 25.4–44.7). Only four participants were fully dentate. Eleven out of 14 individuals exhibited severe decay. A majority had poor oral hygiene and high bacterial counts. The flow rates of unstimulated saliva were extremely low and hyposalivation was present in ten of the fourteen cases. Most perceived several oral health problems, such as chewing difficulty and tooth hypersensitivity.

Conclusions

Individuals who had undergone GBP or SG surgery had poor clinically diagnosed oral health and perceived oral health problems. Longitudinal studies are needed to monitor the patients' oral health, from before bariatric surgery to long‐term postoperatively.

Porto-mesenteric vein thrombosis after laparoscopic sleeve gastrectomy. A case report

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Porta-mesenteric vein thrombosis (PMVT) is a serious complication that maybe seen after sleeve gastrectomy.

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Abdominal pain is the most significant symptom of PMVT.

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Some patients may develop life-threatening intestinal ischemic symptoms.

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Early diagnosis and anticoagulant therapy are very important.

İntroduction and importance

Porta-mesenteric vein thrombosis (PMVT) is a rare but fatal complication in patients who are undergoing bariatric surgery. In this report, we present a rare case of a PMVT after laparoscopic sleeve gastrectomy (LSG).

Case presentation

A 52-year-old male patient with a body mass index of 42 kg/m² was admitted to our clinic for morbid obesity. Standart LSG was performed with 5 trocar technique. 15 days after LSG, the patient admitted to the emergency department with complaints of abdominal pain, nausea and vomiting. The patient was dehydrated. His C-reactive protein level was 138 mg/L. Abdominal computerized tomography with contrast was performed and showed thickening of a part of small bowel wall in 10 cm length. Also, major trombosis were detected in the superior mesenteric vein branches and portal vein. The patient was hospitalized and 2 × 10,000 IU/1.0 mL high dosage low moleculer weight heparin (LMWH) therapy was initiated. The patient’s clinical signs recovered rapidly following treatment.

Clinical discussion

İn LSG, if the gastroepiploic venous arcus, which runs along the greater curvatura, and has a direct connection to the portal circulation is damaged, a local thrombus may form and move towards the portal system over time. Dehydration is another significant predisposing factor for PMVT. Some patients may develop life-threatening intestinal ischemia. Abdominal tomography with contrast plays a major role in diagnosis.

Conclusion

PMVT should be considered as a serious complication after LSG in patients with abdominal pain. With early diagnosis and anticoagulant therapy, patients’s clinical symptoms may improve quicly.

Stratification of Readmission after Bariatric Surgery by Day of Post-Discharge Presentation

INTRODUCTION/PURPOSE

Reasons of postoperative readmissions may vary based on the timing of rehospitalization. This study characterizes predictors and causes for readmission after bariatric surgery on day-to-day basis after discharge.

MATERIALS AND METHODS

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data, patients who underwent Roux-en-Y gastric bypass or sleeve gastrectomy were identified. Perioperative factors of early readmissions (post-discharge days 0-9) were compared to those of late readmissions (post-discharge days 10-30). Multivariable analysis was conducted to identify predictors of early versus late readmissions. Reasons for readmissions were characterized on day-to-day basis.

RESULTS

Of 509,631 operations, 19,061 (3.7%) cases were readmitted. Of these, 9666 (50.7%) were early, while 9395 (49.3%) were late readmissions. White race (OR = 1.2, CI = [1.1-1.3]), revisional surgery (OR = 1.2, CI = [1.1-1.4]), Roux-en-Y gastric bypass (OR = 1.2, CI = [1.1-1.3]), pulmonary complication (OR = 1.8, CI = [1.5-2.3]), bleeding (OR = 2, CI = [1.6-2.6]), and post-acute care (OR = 1.8, CI = [1.2-2.6]) were predictors of early readmission. Late readmission was associated with body mass index ≥ 40 (CI = 0.83, OR = [0.77-0.89]), renal/urological complication (OR = 0.6, CI = [0.5-0.8]), and deep vein thrombosis (OR = 0.5, CI = [0.4-0.6]). PO intolerance or dehydration/electrolyte imbalance was the most common readmission reason, peaking on post-discharge days 19-30. Pain, medical complications, obstruction, and bleeding were causes of early readmissions. However, venous thromboembolism readmissions peaked after post-discharge day 9.

CONCLUSION

Complex bariatric operations and patients who require post-discharge extended care are associated with early readmissions. Such readmissions are due to early post-discharge complications. However, late readmissions are driven by interrelated risk factors and complications. These findings suggest that targeting patients at risk for delayed rehospitalization is the most efficient approach to minimize readmissions after bariatric surgery.