Postoperative care fragmentation in bariatric surgery and risk of mortality: a nationwide study

The Role of Endoscopy in the Management of Adolescent Bariatric Patients: A Primer For Pediatric Gastroenterologists

PURPOSE OF REVIEW

The prevalence of childhood and adolescent obesity in the United States has reached alarming levels, necessitating effective interventions such as bariatric surgery. This article reviews the current state of bariatric surgery in the adolescent population, highlighting the common complications encountered in post-bariatric patients. Furthermore, it outlines the pivotal role of endoscopy in both the prevention and management of these bariatric complications.

RECENT FINDINGS

Though only a minority of eligible adolescent patients undergo bariatric surgery the number of cases continues to increase. Sleeve gastrectomy has emerged as the preferred type of surgery, with the best balance of safety and efficacy. However, only a small number of pediatric surgeons have additional bariatric training and a number of technical aspects of the surgery itself impact the risk for post-surgical complications. Gastric sleeve stenosis, anastomotic leaks and gastroesophageal reflux are the most common of these complications. Ability to perform dilation of sleeve stenosis, closure of anastomotic leaks and evaluation of reflux are critical tools in the endoscopic toolbox necessary for the management of these complicated patients. Bariatric surgery remains the most effective treatment available for management of morbid obesity in adolescents but has significant associated complications. Pediatric gastroenterologists must be familiar in the endoscopic management of these complications and are crucial in creating a high functioning adolescent bariatric program.

Precision Bariatric/Metabolic Medicine and Surgery

Indications and techniques of bariatric surgery (BS) have constantly evolved in recent decades and now face new challenges [...].

Follow-Up, Safety, and Satisfaction with Tele-bariatric Follow-Up Implemented During the COVID-19 French Lockdown: a 2-Year Follow-Up Study

BACKGROUND

The COVID-19 pandemic was initially responsible for a global restricted access to healthcare resources including the follow-up of at-risk populations such as bariatric patients. We substituted face-to-face bariatric follow-up outpatient clinics (FTFC) with teleclinics (TC) during the lockdown.

MATERIAL AND METHODS

We retrospectively reviewed data collected on all patients scheduled for TC during the French lockdown period (March 15 to May 15, 2020) (N = 87). Our aims were to present the patients' outcomes at one and 2 years post-TC implementation and describe patient/practitioner satisfaction.

RESULTS

Seven (8%) patients required FTFC, and 80 (92%) underwent TC (study population) for preoperative bariatric assessment (N = 3) and postoperative follow-up (N = 77) after 23.6 ± 29 months following surgery. TC was performed with video and audio (N = 46; 57.5%) or audio alone when video was impossible (N = 34; 42.5%). Sixteen (20%) patients presented at least one complication identified at the first TC and were managed accordingly. There were no readmissions at 30/90 days post-TC. At 1-year after the first TC, overall follow-up rate was 94.9% (TC: 73% vs FTFC: 27%). Patients surveyed on the main advantages of TC over FTFC (N = 46) cited: saving time (97.8%) at a mean 3.9 ± 6.4 h saved per TC, work-advantages (94.3%), and comparable relevance of TC (84.8%). At 2 years post-TC implementation, follow-up rate was 93.5% and satisfaction rate was 80%, with 33% of patients preferring to return to FTFC.

CONCLUSIONS

TC is a satisfactory substitute for FTFC, enabling continued bariatric follow-up during and beyond the pandemic setting without compromising patient safety. However, the modest satisfaction outcomes at 2 years highlight a need to discuss follow-up preferences in order to achieve optimal outcomes.

Outcomes of bariatric surgery in patients with inflammatory bowel disease from a French nationwide database

BACKGROUND

The outcomes of bariatric surgery (BS) in patients with chronic inflammatory bowel disease (IBD) remain rarely described. We aimed to evaluate the 90-day morbidity and mortality rates, and the risk of IBD complications 2 years after BS.

METHOD

Patients from the French Programme de Médicalisation des Systèmes d'Information (PMSI) database who underwent a primary BS between 2016 and 2018 were included. We identified patients with a previous diagnosis of IBD. Postoperative 90-day (POD90) morbidity and mortality rates were compared between the two groups. The evolution of IBD was followed 2 years after BS.

RESULTS

Between 2016 and 2018, 138 980 patients underwent primary BS, including 587 patients with IBD: 326 (55.5 per cent) with Crohn's disease (CD) and 261 (44.5 per cent) with ulcerative colitis (UC). The preferred surgical technique was sleeve gastrectomy, especially in the IBD group (81.1 per cent), followed by gastric bypass (14.6 per cent). Patients with IBD had more comorbidities (Charlson Comorbidity Index of 1 or more, hypertension, and diabetes; P < 0.001) than those without IBD. The POD90 mortality rate did not differ between the two groups (0.049 per cent in the IBD group versus 0 per cent in the non-IBD group), but more unscheduled rehospitalizations at POD90 were observed in patients with IBD (6.0 per cent versus 3.7 per cent; P = 0.004). Two years after BS, 86 patients (14.6 per cent) in the IBD group had at least one unplanned readmission for the management of their IBD; 15 patients stayed for 3 or more days. After multivariable analysis, patients with CD had an independent elevated risk of IBD-related unplanned readmissions 2 years after BS versus UC (adjusted odds ratio 1.90, 95 per cent c.i. 1.22 to 2.97; P = 0.005).

CONCLUSION

In a highly selected cohort of patients with well-controlled IBD, BS did not result in added mortality or morbidity. A point of vigilance must be underlined regarding BS in patients with CD.

Incidence, Burden, and Predictors of 11-Month Readmission in Patients Undergoing Bariatric Surgery

BACKGROUND

Bariatric surgery (BSx) is one of the most common surgical procedures performed in the USA. Nonetheless, data regarding 11-month period after BSx remain limited.

METHODS

A retrospective cohort study using the 2016 National Readmission Database. Adult patients admitted for BSx in January were included. The follow-up period was 11 months (February-December). The primary outcome was all-cause 11-month readmission. Secondary outcomes were index admission (IA) and readmission in-hospital mortality rate and healthcare resource use associated with readmission. Multivariate regression was performed to identify independent risk factors for readmission.

RESULTS

A total of 13,278 IA were included. The 11-month readmission rate was 11.1%. The mortality rate of readmission was 1.4% and 0.1% for IA (P < 0.01). The most common cause of readmission was hematemesis. Independent predictors were Charlson comorbidity index (CCI) score ≥ 3 (adjusted hazard ratio [aHR] 1.34; P = 0.05), increasing length of stay (aHR 1.01; P < 0.01), transfer to rehabilitation facilities (aHR 5.02; P < 0.01), undergoing laparoscopic Roux-en-Y gastric bypass (aHR 1.71; P = 0.02), adjustable gastric band (aHR 14.09; P < 0.01), alcohol use disorder (2.10; P = 0.01), and cannabis use disorder (aHR 3.37; P = 0.01). Private insurance as primary payer (aHR 0.65; P < 0.01) and BMI 45-49 kg/m² (aHR 0.72; P < 0.01) were associated with less odds of readmission. The cumulative total hospitalization charges of readmission were $69.9 million.

CONCLUSIONS

The 11-month readmission rate after BSx is 11.1%. Targeting modifiable predictors of readmission may help reduce the burden of readmissions on our healthcare system.

Integrated Care Model of Adiposity-Related Chronic Diseases

PURPOSE OF REVIEW

Although obesity is a disease, most patients with obesity do not undergo effective treatment nor adhere to long-term care. We examine the barriers that patients with obesity confront when searching for effective treatment and propose an integrated care model of adiposity-related chronic diseases in a cardio-renal metabolic unit.

RECENT FINDINGS

The current care of obesity is fragmented between primary care providers, medical specialists and metabolic bariatric surgeons with little or no coordination of care between these providers. The current care of obesity heavily focuses on weight loss as the primary aim of treatment thereby reenforcing the weight stigma and turning patients away from effective therapy like metabolic bariatric surgery. An interdisciplinary cardio-renal metabolic unit that, besides weight loss, emphasizes prevention/remission of adiposity-related chronic diseases may deliver thorough and rewarding care to most patients with obesity.