US national trends in bariatric surgery: A decade of study

Contemporary Management of Obesity: A Comparison of Bariatric Metabolic Surgery and Novel Incretin Mimetic Drugs

The global prevalence of obesity has risen sharply during the past half-century, reaching pandemic proportions and creating a public health crisis. Obesity is a recognized risk factor for the development of diabetes, atherosclerosis, hypertension, hepatic steatosis, and many other cardiometabolic disorders with significant resultant morbidity and mortality. Though treatment of obesity can prevent or slow the progression of the aforementioned illnesses, efforts to help patients achieve reliable and sustainable weight loss have had limited success. Improving nutrition and increasing physical activity results in a host of health benefits; however, the weight loss achieved with lifestyle interventions alone is modest and difficult to sustain. Early attempts at medical and surgical treatment of obesity were plagued with adverse effects and complications. Moreover, these approaches failed to demonstrate long-term health benefits, even when weight loss was achieved. Recently, novel incretin-based therapies targeting glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptors have gained popularity because of their effectiveness in achieving substantial weight loss in patients both with and without diabetes. Following many successful clinical trials, there are now multiple GLP-1 receptor agonists and one dual GLP-1-GIP receptor agonist approved by the Food and Drug Administration for chronic weight management. Advancements in laparoscopic surgical technique and refinements in procedure selection have similarly improved the safety and efficacy of bariatric metabolic surgery for patients with obesity. In this review, we discuss the advantages and disadvantages of contemporary pharmacologic and surgical weight management strategies. We review the data regarding expected weight loss, glycemic control, cardiometabolic benefits, and potential adverse effects of various treatment approaches. As obesity rates continue to rise worldwide, it is imperative that clinicians keep these considerations in mind in order to better care for patients.

Weight loss after Roux-en-Y gastric bypass and single anastomosis duodenoileostomy following failed sleeve gastrectomy

OBJECTIVE

While sleeve gastrectomy (SG) results in sustained weight loss for the majority of patients, some will experience inadequate weight loss or weight regain requiring revision. The objective of this study was to evaluate differences in weight loss over time between patients undergoing Roux-en-Y gastric bypass (RYGB) or single anastomosis duodenoileostomy (SADI) after SG.

METHODS

We queried a single institution's bariatrics registry to identify patients who underwent RYGB or SADI after previous SG over a three-year period. Demographics, operative characteristics, and post-operative complications were evaluated. Interval total body weight loss (TBWL) and excess body weight loss (EBWL) were calculated from available follow-ups within 2 years.

RESULTS

We identified 124 patients who underwent conversion to RYGB (n = 61) or SADI (n = 63) following previous SG. There were no differences in sex, age, or medical comorbidities between groups. The median initial BMI was higher in the SADI group (44.9 vs. 41.9 for RYGB, p = 0.03) with greater excess body weight (56.7 vs. 64.3 kg, p = 0.04). The SADI group had a shorter median operative duration (157 vs. 182 min for RYGB, p < 0.01) and lower readmission rates (0 vs. 14.75%, p < 0.01). There was no difference in post-operative complications or need for rehydration therapy between the groups. Among 122 patients (98.4%) that had follow-up weights available, there were no differences in TBWL between groups. RYGB patients had a higher EBWL at 2, 3, and 6 months (p < 0.05 for all comparisons), but there were no differences between RYGB and SADI at 1 or 2 years.

CONCLUSIONS

Both RYGB and SADI conversions proved effective for further weight loss following failed SG at our academic center. While neither demonstrated clear superiority in long-term (> 1 year) weight loss, RYGB's restrictive gastric pouch may explain its early weight loss advantage.

Association Between Indole-3-Pyruvic Acid and Change in Fat-Free Mass Relative to Weight Loss in Patients Undergoing Sleeve Gastrectomy

Sleeve gastrectomy typically leads to weight loss, including a reduction in fat-free mass (FFM). Studies have shown significant FFM loss within 1 year after the procedure but with individual variations. This study aimed to assess whether preoperative amino acid metabolite levels can predict FFM changes following sleeve gastrectomy. This study involved 42 patients. Body weight, fat mass (FM), and FFM were measured preoperatively and 3, 6, and 12 months postoperatively. All participants experienced weight loss, FM reduction, and FFM decrease for up to 3 months after surgery. However, the following distinct groups emerged from 3 to 6 months postoperatively: one showed FFM gain relative to weight loss, whereas the other exhibited continued FFM reduction relative to weight loss. This trend persisted for up to 12 months postoperatively and became more pronounced. The group with FFM gain had lower preoperative BMI and higher levels of indole-3-pyruvic acid (IPyA). Logistic regression and ROC curve analyses confirmed IPyA's ability to predict FFM gain between 3 and 6 months after sleeve gastrectomy, with a useful cutoff value of 20.205. Preoperative IPyA levels were associated with FFM gain relative to weight loss in the 3 to 6 months following sleeve gastrectomy. These findings suggest that IPyA may be a potential predictor for FFM changes during this period.

Positive end-expiratory pressure and postoperative pulmonary complications in laparoscopic bariatric surgery: systematic review and meta-analysis

BACKGROUND

This study compares the effect of positive end-expiratory pressure (PEEP) on postoperative pulmonary complications (PPCs) in patients with obesity undergoing laparoscopic bariatric surgery (LBS) under general anesthesia with mechanical ventilation.

METHODS

A comprehensive search was conducted in PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, China National Knowledge Internet, Wanfang database, and Google Scholar for studies published up to July 29, 2023, without time or language restrictions. The search terms included "PEEP," "laparoscopic," and "bariatric surgery." Randomized controlled trials comparing different levels of PEEP or PEEP with zero-PEEP (ZEEP) in patients with obesity undergoing LBS were included. The primary outcome was a composite of PPCs, and the secondary outcomes were intraoperative oxygenation, respiratory compliance, and mean arterial pressure (MAP). A fixed-effect or random-effect model was selected for meta-analysis based on the heterogeneity of the included studies.

RESULTS

Thirteen randomized controlled trials with a total of 708 participants were included for analysis. No statistically significant difference in PPCs was found between the PEEP and ZEEP groups (risk ratio = 0.27, 95% CI: 0.05-1.60; p = 0.15). However, high PEEP ≥ 10 cm H2O significantly decreased PPCs compared with low PEEP < 10 cm H2O (risk ratio = 0.20, 95% CI: 0.05-0.89; p = 0.03). The included studies showed no significant heterogeneity (I2 = 20% & 0%). Compared with ZEEP, PEEP significantly increased intraoperative oxygenation and respiratory compliance (WMD = 74.97 mm Hg, 95% CI: 41.74-108.21; p < 0.001 & WMD = 9.40 ml cm H2O- 1, 95% CI: 0.65-18.16; p = 0.04). High PEEP significantly improved intraoperative oxygenation and respiratory compliance during pneumoperitoneum compared with low PEEP (WMD = 66.81 mm Hg, 95% CI: 25.85-107.78; p = 0.001 & WMD = 8.03 ml cm H2O- 1, 95% CI: 4.70-11.36; p < 0.001). Importantly, PEEP did not impair hemodynamic status in LBS.

CONCLUSIONS

In patients with obesity undergoing LBS, high PEEP ≥ 10 cm H2O could decrease PPCs compared with low PEEP < 10 cm H2O, while there was a similar incidence of PPCs between PEEP (8-10 cm H2O) and the ZEEP group. The application of PEEP in ventilation strategies increased intraoperative oxygenation and respiratory compliance without affecting intraoperative MAP. A PEEP of at least 10 cm H2O is recommended to reduce PPCs in patients with obesity undergoing LBS.

REGISTRATION NUMBER

CRD42023391178 in PROSPERO.

Cholelithiasis, Gut Microbiota and Bile Acids after Bariatric Surgery-Can Cholelithiasis Be Prevented by Modulating the Microbiota? A Literature Review

BACKGROUND

Cholelithiasis is one of the more common complications following bariatric surgery. This may be related to the rapid weight loss during this period, although the exact mechanism of gallstone formation after bariatric surgery has not been fully elucidated.

METHODS

The present literature review focuses on risk factors, prevention options and the impact of the gut microbiota on the development of gallbladder stones after bariatric surgery.

RESULTS

A potential risk factor for the development of cholelithiasis after bariatric surgery may be changes in the composition of the intestinal microbiota and bile acids. One of the bile acids-ursodeoxycholic acid-is considered to reduce the concentration of mucin proteins and thus contribute to reducing the formation of cholesterol crystals in patients with cholelithiasis. Additionally, it reduces the risk of both asymptomatic and symptomatic gallstones after bariatric surgery. Patients who developed gallstones after bariatric surgery had a higher abundance of Ruminococcus gnavus and those who did not develop cholelithiasis had a higher abundance of Lactobacillaceae and Enterobacteriaceae.

CONCLUSION

The exact mechanism of gallstone formation after bariatric surgery has not yet been clarified. Research suggests that the intestinal microbiota and bile acids may have an important role in this.

A multifaceted and inclusive methodology for the detection of sarcopenia in patients undergoing bariatric surgery: an in-depth analysis of current evidence

Bariatric surgery is widely recognized as the most effective intervention for obesity and offers benefits beyond weight loss. However, not all patients achieve satisfactory weight loss, balanced changes in body composition, and resolution of comorbidities. Therefore, thorough pre- and postoperative evaluations are important to predict success and minimize adverse effects. More comprehensive assessments require broadening the focus beyond body weight and fat measurements to consider quantitative and qualitative evaluations of muscles. Introducing the concept of sarcopenia is useful for assessing the degradative and pathological changes in muscles associated with cardiometabolic function, physical performance, and other obesity-related comorbidities in patients undergoing bariatric surgery. However, there is currently no consensus or definition regarding the research and clinical use of sarcopenia in patients undergoing bariatric surgery. Therefore, this review aimed to define the concept of sarcopenia applicable to patients undergoing bariatric surgery, based on the consensus reached for sarcopenia in the general population. We also discuss the methods and significance of measuring muscle mass, quality, and strength, which are key variables requiring a comprehensive assessment.

Pharmacotherapy as an Augmentation to Bariatric Surgery for Obesity

A global obesity pandemic is one of the most significant health threats worldwide owing to its close association with numerous comorbidities such as type 2 diabetes mellitus, arterial hypertension, dyslipidemia, heart failure, cancer and many others. Obesity and its comorbidities lead to a higher rate of cardiovascular complications, heart failure and increased cardiovascular and overall mortality. Bariatric surgery is at present the most potent therapy for obesity, inducing a significant weight loss in the majority of patients. In the long-term, a substantial proportion of patients after bariatric surgery experience a gradual weight regain that may, in some, reach up to a presurgical body weight. As a result, anti-obesity pharmacotherapy may be needed in some patients after bariatric surgery to prevent the weight regain or to further potentiate weight loss. This article provides an overview of the use of anti-obesity medications as an augmentation to bariatric surgery for obesity. Despite relatively limited published data, it can be concluded that anti-obesity medication can serve as an effective adjunct therapy to bariatric surgery to help boost post-bariatric weight loss or prevent weight regain.

Ligamentum Teres Augmentation for Hiatus Hernia Repair After Bariatric Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

Hiatal hernia (HH) and symptomatic gastroesophageal reflux disease are common complications after metabolic bariatric surgery. This meta-analysis aims to investigate the safety and efficacy of ligamentum teres augmentation (LTA) for HH repair after metabolic and bariatric surgeries (MBS).

MATERIALS AND METHODS

CENTRAL, Embase, PubMed, and Scopus were searched for articles from their inception to September 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system.

RESULTS

Five studies met the eligibility criteria, with a total of 165 patients undergoing LTA for HH repair after MBS. The distribution of patients based on surgical procedures included 63% undergoing sleeve gastrectomy, 21% Roux-en-Y gastric bypass, and 16% having one anastomosis gastric bypass. The pooled proportion of reflux symptoms before LTA was 77% (95% CI: 0.580-0.960; I2 = 89%, n = 106). A pooled proportion of overall postoperative symptoms was 25.6% (95% CI: 0.190-0.321; I2 = 0%, n = 44), consisting of reflux at 14.5% (95% CI: 0.078-0.212; I2 = 0%, n = 15). The pooled proportion of unsuccessful LTA outcomes was 12.5% (95% CI: 0.075-0.175; I2 = 0%, n = 21).

CONCLUSION

Our meta-analysis demonstrated that LTA appears to be a safe and efficacious procedure in the management of HH after MBS.

Exercise interventions following bariatric surgery are poorly reported: A systematic review and a call for action

OBJECTIVES

This study assessed the transparency and replicability of exercise-based interventions following bariatric surgery by evaluating the content reporting of exercise-based clinical trials.

DESIGN

The study design of the present article is a systematic review.

DATA SOURCES

PubMed, Scopus, Web of Sciences, PsycINFO, and Cochrane were searched from their inception to May 2023.

ELIGIBILITY CRITERIA

Eligible studies were clinical trials including exercise interventions in participants following bariatric surgery. There were 28 unique exercise interventions. Two independent reviewers applied the exercise prescription components of Frequency, Intensity, Time, and Type (FITT; four items) and the Consensus on Exercise Reporting Template (CERT; 19 items). Exercise interventions were organized into four major exercise components: aerobic training, resistance training, concurrent training, and "others."

RESULTS

The FITT assessment revealed that 53% of the trials did not report the training intensity, whereas 25% did not indicate the duration of the major exercise component within the training session. The mean CERT score was 5 out of a possible score of 19. No studies reached CERT score >10, while 13 out of the total 19 CERT items were not adequately reported by ≥75% of the studies.

CONCLUSION

This study highlights that the exercise interventions following bariatric surgery are poorly reported, non-transparent, and generally not replicable. This precludes understanding the dose-response association of exercise and health-related effects and requires action to improve this scientific field.

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.

Harnessing artificial intelligence in bariatric surgery: comparative analysis of ChatGPT-4, Bing, and Bard in generating clinician-level bariatric surgery recommendations

BACKGROUND

The formulation of clinical recommendations pertaining to bariatric surgery is essential in guiding healthcare professionals. However, the extensive and continuously evolving body of literature in bariatric surgery presents considerable challenge for staying abreast of latest developments and efficient information acquisition. Artificial intelligence (AI) has the potential to streamline access to the salient points of clinical recommendations in bariatric surgery.

OBJECTIVES

The study aims to appraise the quality and readability of AI-chat-generated answers to frequently asked clinical inquiries in the field of bariatric and metabolic surgery.

SETTING

Remote.

METHODS

Question prompts inputted into AI large language models (LLMs) and were created based on pre-existing clinical practice guidelines regarding bariatric and metabolic surgery. The prompts were queried into 3 LLMs: OpenAI ChatGPT-4, Microsoft Bing, and Google Bard. The responses from each LLM were entered into a spreadsheet for randomized and blinded duplicate review. Accredited bariatric surgeons in North America independently assessed appropriateness of each recommendation using a 5-point Likert scale. Scores of 4 and 5 were deemed appropriate, while scores of 1-3 indicated lack of appropriateness. A Flesch Reading Ease (FRE) score was calculated to assess the readability of responses generated by each LLMs.

RESULTS

There was a significant difference between the 3 LLMs in their 5-point Likert scores, with mean values of 4.46 (SD .82), 3.89 (.80), and 3.11 (.72) for ChatGPT-4, Bard, and Bing (P < .001). There was a significant difference between the 3 LLMs in the proportion of appropriate answers, with ChatGPT-4 at 85.7%, Bard at 74.3%, and Bing at 25.7% (P < .001). The mean FRE scores for ChatGPT-4, Bard, and Bing, were 21.68 (SD 2.78), 42.89 (4.03), and 14.64 (5.09), respectively, with higher scores representing easier readability.

CONCLUSIONS

LLM-based AI chat models can effectively generate appropriate responses to clinical questions related to bariatric surgery, though the performance of different models can vary greatly. Therefore, caution should be taken when interpreting clinical information provided by LLMs, and clinician oversight is necessary to ensure accuracy. Future investigation is warranted to explore how LLMs might enhance healthcare provision and clinical decision-making in bariatric surgery.

Surveying the Knowledge and Practices of Primary Care Residents in Managing Adult Patients with Obesity

BACKGROUND

The prevalence of obesity is increasing worldwide at an alarming rate, yet obesity remains under-addressed during clinic encounters. A lack of training in how to treat obesity is one crucial factor contributing to this deficiency.

OBJECTIVE

This study explored resident physicians' perceptions of their education on obesity and its relationship with confidence and practice behaviors when caring for patients with obesity.

DESIGN

A survey was distributed to residency directors to share with residents in their programs. Participation was voluntary and anonymous. Data was collected over a 3-month period.

PARTICIPANTS

Residents in Family Medicine and Internal Medicine programs in West Virginia and Indiana who saw adult patients in an ambulatory care setting.

MAIN MEASURES

The electronic survey queried the presence of a formal curriculum on Obesity Medicine (OM) and each resident's knowledge, confidence, practice behaviors, and attitudes pertaining to OM.

KEY RESULTS

The survey was distributed to 490 residents in 12 programs. Response rate was 22.9% (112 resident physicians). All respondents felt that medical training in obesity should be strengthened. Residents who reported having a formal curriculum on OM were more likely than those without a curriculum to rate their confidence as "high" when discussing weight (35.0% vs. 16.7%, p = 0.03) and when counseling patients about diet and nutrition (37.5% vs. 18.1%, p = 0.02). They also more frequently reported learning enough from faculty to manage obesity (65.0% vs. 29.2%, p < 0.001). Residents with an OM curriculum reported discussing obesity as a problem with patients (100.0% vs. 86.1%, p = 0.01), and completing motivational interviews (90.0% vs. 58.3%, p =  < 0.001), more frequently than their peers without a curriculum.

CONCLUSIONS

Residents with a formal OM curriculum were more confident in addressing and discussing obesity with patients. Formal training in OM will strengthen resident training to better address and treat patients with obesity.

Trends in gastric surgery operative experience among general surgery residents in the United States: A nationwide retrospective analysis

BACKGROUND

Gastric surgery is a crucial component of general surgery training. However, there is a paucity of high-quality data on operative volume and the diversity of surgical procedures that general surgery residents are exposed to.

METHODS

We conducted a retrospective analysis of operative case logs of all general surgery residents graduating from the American College of Graduate Medical Education-accredited program from 2009 to 2022. Data on the mean number of gastric procedures, including the mean in each subcategory, were retrieved. A Mann-Kendall trend test was used to investigate trends in operative volume.

RESULTS

Between 2009 and 2022, the mean overall logged gastric procedures rose significantly (τ = 0.722, P < .001) from 36.2 in 2009 to 49.2 in 2022 (35.9% increase). The most substantial growth was seen in laparoscopic gastric reduction for morbid obesity (mean 1.9 in 2017 to 19 in 2022; τ = 0.670, P = .009). A statistically significant increase was also seen in laparoscopic partial gastric resections, repair of gastric perforation, and "other major stomach procedures" (P < .05 for all comparisons). Open gastrostomy, open partial gastric resections, and open vagotomy all significantly decreased (P < .05 for all comparisons). There was no significant change in the volume of laparoscopic gastrectomy, total gastric resections, and non-laparoscopic gastric reductions for morbid obesity (P > .05 for all comparisons).

CONCLUSION

There has been a substantial increase in the volume of gastric surgery during residency over the past 14 years, driven mainly by an increase in laparoscopic gastric reduction. However, there may still be a need for further gastric surgical training to ensure well-rounded general surgeons.

The impact of COVID-19 pandemic on patient selection and access to care, approach type, and postoperative outcomes in bariatric surgery

BACKGROUND

The COVID-19 pandemic had affected the health systems across the world since early 2020 with a concern about access to medical care during the first wave of COVID-19 pandemic.

OBJECTIVES

The objective of this study was to examine how the COVID-19 pandemic influenced patient selection, approach type, and postoperative outcomes in elective bariatric surgery.

SETTING

United States.

METHODS

Data from the MBSAQIP database for the years 2016-2020 were queried. Wilcoxon rank-sum test and Fisher's exact test were employed for continuous and categorical variables, respectively. Postoperative outcomes within 30 days were assessed separately and based on the Clavien-Dindo (CD) classification of III-V. χ2 test and logistic regression were used to compare outcomes between procedure and approach types, as well as surgical operation periods.

RESULTS

A total of 741,620 patients underwent robotic and laparoscopic sleeve gastrectomy and Roux-en-Y gastric-bypass. The cases performed in 2020 exhibited lower comorbidities and postoperative complications compared to prepandemic years, regardless of the approach type. Notably, the proportion of White patients decreased during the pandemic, while there was an increase in the number of African American and Hispanic patients who had bariatric surgery.

CONCLUSIONS

Patients who underwent bariatric surgery during the COVID-19 pandemic appeared to be healthier with fewer comorbidities and experienced fewer adverse postoperative outcomes compared to those who had surgery prior to the pandemic. This study highlights the limited access to bariatric surgery for high-risk patients during the pandemic.

Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures

Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.

Preoperative comorbidities as a predictor of EBWL after bariatric surgery: a retrospective cohort study

INTRODUCTION

The purpose of this study is to investigate the impact of preoperative comorbidities, including depression, anxiety, type 2 diabetes mellitus, obstructive sleep apnea, hypothyroidism, and the type of surgery on %EBWL (percent estimated body weight loss) in patients 1 year after bariatric surgery. Patients who choose to undergo bariatric surgery often have other comorbidities that can affect both the outcomes of their procedures and the postoperative period. We predict that patients who have depression, anxiety, diabetes mellitus, obstructive sleep apnea, or hypothyroidism will have a smaller change in %EBWL when compared to patients without any of these comorbidities.

METHODS AND PROCEDURES

Data points were retrospectively collected from the charts of 440 patients from March 2012-December 2019 who underwent a sleeve gastrectomy or gastric bypass surgery. Data collected included patient demographics, select comorbidities, including diabetes mellitus, obstructive sleep apnea, hypothyroidism, depression, and anxiety, and body weight at baseline and 1 year postoperatively. Ideal body weight was calculated using the formula 50 + (2.3 × height in inches over 5 feet) for males and 45.5 + (2.3 × height in inches over 5 feet) for females. Excess body weight was then calculated by subtracting ideal body weight from actual weight at the above forementioned time points. Finally, %EBWL was calculated using the formula (change in weight over 1 year/excess weight) × 100.

RESULTS

Patients who had a higher baseline BMI (p < 0.001), diabetes mellitus (p = 0.026), hypothyroidism (p = 0.046), and who had a laparoscopic sleeve gastrectomy rather than Roux-en-Y gastric bypass (p < 0.001) had a smaller %EBWL in the first year after bariatric surgery as compared to patients without these comorbidities at the time of surgery. Controversially, patients with anxiety or depression (p = 0.73) or obstructive sleep apnea (p = 0.075) did not have a statistically significant difference in %EBWL.

CONCLUSION

A higher baseline BMI, diabetes mellitus, hypothyroidism, and undergoing laparoscopic sleeve gastrectomy may lead to lower %EBWL in the postoperative period after bariatric surgery. At the same time, patients' mental health status and sleep apnea status were not related to %EBWL. This study provides new insight into which comorbidities may need tighter control in order to optimize weight loss outcomes after bariatric surgery.

Seat Belt Injury and Efferent Loop Laceration Following a Single Anastomosis Duodenal Switch: A Case Report

Blunt abdominal trauma patients who have had prior bariatric procedures may present a diagnostic and therapeutic challenge. The single anastomosis duodenal-ileal bypass with sleeve (SADI-S) is a modified duodenal switch procedure that is relatively uncommon. This case report describes a patient who previously underwent a SADI-S for the management of obesity and subsequently sustained a seat belt injury in a motor vehicle collision resulting in a laceration of the efferent loop. The patient presented with symptoms of acute abdominal pain and was diagnosed through imaging studies. Prompt surgical intervention was performed with resection and primary anastomosis of the damaged section of the jejunum, and repair of a large mesenteric laceration. We discuss the importance of early recognition and intraoperative decision-making in the case of this patient concerning her SADI-S.

Don't Fear the Bleed: Assessing Postoperative Bleeding Incidence After Instituting a Standardized Prophylactic Heparin Protocol in Bariatric Patients

Background: Bariatric surgery is a frequently performed procedure in the United States, accounting for ∼40,000 procedures annually. Patients undergoing bariatric surgery are at high risk for postoperative thrombosis, with a venous thromboembolism (VTE) rate of up to 6.4%. Despite this risk, there is a lack of guidelines recommending postoperative VTE prophylaxis and it is not routine practice at most hospitals. The postoperative bleeding rate after bariatric surgery is only 1.5%; however, the risk of bleeding may lead to hesitancy for more liberal VTE prophylaxis. Methods: This is a retrospective analysis of bariatric surgeries at a single institution in 2019 and 2021. Data were obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and electronic medical record review for all patients undergoing sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or conversion to RYGB. The primary outcomes were composite bleeding events, which included postoperative transfusion, postoperative endoscopy or return to operating room (OR) (for bleeding), intra-abdominal hematoma, gastrointestinal (GI) bleeding, or incisional hematoma. Results: There were a total of 2067 patients in the cohort, with 1043 surgeries in 2019 and 1024 surgeries in 2021. There was no difference between bleeding events after instituting a deep venous thrombosis (DVT) prophylaxis protocol in 2021 (27 versus 28 events, P = .76). There was no difference in individual bleeding events between 2019 and 2021. Additionally, there was no significant difference in the rate of VTE between 2019 and 2021 (2 versus 5 events, P = .28). Conclusions: After instituting a standard protocol of prophylactic heparin postdischarge, we did not find an increased rate of bleeding events in patients undergoing bariatric surgery. Thus, surgeons can consider prescribing postdischarge chemical VTE prophylaxis without concern for bleeding.

Flowchart in Post-Bariatric Surgery: A Research for the Appropriate Type and Timing of Plasties Reshaping the Body

INTRODUCTION

Obesity is a chronic disease with significant health implications. Bariatric surgery is an effective treatment for obesity-related conditions. However, the timing of post-bariatric body contouring surgery remains uncertain.

MATERIALS AND METHODS

We conducted a retrospective study of 1336 patients who underwent bariatric surgery. We analyzed weight trends and variations after different types of bariatric procedures. The Pittsburgh Index was used to evaluate body contouring outcomes.

RESULTS

The majority of patients were women, and sleeve gastrectomy was the most common procedure. Weight loss varied depending on the surgery type, with different outcomes for male and female patients. The Pittsburgh Index remained stable in most cases.

CONCLUSION

Our findings suggest that the timing of body contouring surgery should be tailored to the type of bariatric procedure performed. Abdominoplasty is recommended as a last procedure for sleeve gastrectomy patients, while gastric bypass patients are suitable candidates for early abdominoplasty. Biliopancreatic diversion patients should stabilize their weight before abdominoplasty. The Pittsburgh Index is a valuable tool for assessing the timing of post-bariatric plastic surgery. Further research is needed to optimize surgical planning and outcomes.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Up-to-date review into the evolving world of bariatric interventions: a guide for radiologists

Obesity is a worldwide health concern leading to several chronic health problems and comorbidities. Its treatment requires a multidisciplinary approach where lifestyle changes are fundamental. Additionally, in the past decade, the use of different surgical procedures of various levels of complexity has grown, with the objective of reducing the gastric capacity, creating diversions, or a combination of both. The aim of this article is to review and illustrate the major types of bariatric surgical techniques, their normal post-surgical anatomy, and the possible associated complications, to aid the radiologist in their assessment and timely diagnosis.

Predicting operative time for metabolic and bariatric surgery using machine learning models: a retrospective observational study

BACKGROUND

Predicting operative time is essential for scheduling surgery and managing the operating room. This study aimed to develop machine learning (ML) models to predict the operative time for metabolic and bariatric surgery (MBS) and to compare each model.

METHODS

The authors used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database between 2016 and 2020 to develop ML models, including linear regression, random forest, support vector machine, gradient-boosted tree, and XGBoost model. Patient characteristics and surgical features were included as variables in the model. The authors used the mean absolute error, root mean square error, and R 2 score to evaluate model performance. The authors identified the 10 most important variables in the best-performing model using the Shapley Additive exPlanations algorithm.

RESULTS

In total, 668 723 patients were included in the study. The XGBoost model outperformed the other ML models, with the lowest root mean square error and highest R 2 score. Random forest performed better than linear regression. The relative performance of the ML algorithms remained consistent across the models, regardless of the surgery type. The surgery type and surgical approach were the most important features to predict the operative time; specifically, sleeve gastrectomy (vs. Roux-en-Y gastric bypass) and the laparoscopic approach (vs. robotic-assisted approach) were associated with a shorter operative time.

CONCLUSIONS

The XGBoost model best predicted the operative time for MBS among the ML models examined. Our findings can be useful in managing the operating room scheduling and in developing software tools to predict the operative times of MBS in clinical settings.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

Using Claims Data to Predict Pre-Operative BMI Among Bariatric Surgery Patients: Development of the BMI Before Bariatric Surgery Scoring System (B3S3)

Background

Lack of body mass index (BMI) measurements limits the utility of claims data for bariatric surgery research, but pre-operative BMI may be imputed due to existence of weight-related diagnosis codes and BMI-related reimbursement requirements. We used a machine learning pipeline to create a claims-based scoring system to predict pre-operative BMI, as documented in the electronic health record (EHR), among patients undergoing a new bariatric surgery.

Methods

Using the Optum Labs Data Warehouse, containing linked de-identified claims and EHR data for commercial or Medicare Advantage enrollees, we identified adults undergoing a new bariatric surgery between January 2011 and June 2018 with a BMI measurement in linked EHR data ≤30 days before the index surgery (n=3226). We constructed predictors from claims data and applied a machine learning pipeline to create a scoring system for pre-operative BMI, the B3S3. We evaluated the B3S3 and a simple linear regression model (benchmark) in test patients whose index surgery occurred concurrent (2011-2017) or prospective (2018) to the training data.

Results

The machine learning pipeline yielded a final scoring system that included weight-related diagnosis codes, age, and number of days hospitalized and distinct drugs dispensed in the past 6 months. In concurrent test data, the B3S3 had excellent performance (R2 0.862, 95% confidence interval [CI] 0.815-0.898) and calibration. The benchmark algorithm had good performance (R2 0.750, 95% CI 0.686-0.799) and calibration but both aspects were inferior to the B3S3. Findings in prospective test data were similar.

Conclusion

The B3S3 is an accessible tool that researchers can use with claims data to obtain granular and accurate predicted values of pre-operative BMI, which may enhance confounding control and investigation of effect modification by baseline obesity levels in bariatric surgery studies utilizing claims data.

Popularity of Surgical and Pharmacological Obesity Treatment Methods Searched by Google Users: the Retrospective Analysis of Google Trends Statistics in 2004-2022

PURPOSE

Many individuals search for obesity treatment options on the Internet. We aimed to analyze the popularity of pharmacological and surgical obesity treatment methods searched by Google users.

MATERIAL AND METHODS

We used Google Trends to identify topics representing the following: recommended surgical methods (n = 9), recommended pharmacological methods (n = 10), and not recommended pharmacological methods (n = 34). The data was generated for 2004-2022 and 2020-2022. Relative search volume (RSV) was adjusted using "Gastric bypass surgery" as a benchmark. We analyzed the geographical and temporal trends of the topics.

RESULTS

In 2004-2022, the topics representing recommended surgical methods numerically gained the most popularity among Google users, but in 2020-2022 the recommended drugs exceeded other obesity treatment methods. The most popular individual topics since 2004 were "flaxseed," "Spirulina," "Carnitine," "Bariatric surgery," and "Orlistat." The most dynamic increases of searches since 2004 were observed for "Sleeve gastrectomy," "Curcumin," "Psyllium," and "Bupropion/Naltrexon." Since 2018, topics representing GLP-1 analogs such as "Semaglutide" and "Saxenda" revealed exponential increases in RSV, causing that "Semaglutide" to become the fourth most popular topic in 2020-2022.

CONCLUSIONS

Google users across the world were the most interested in topics representing bariatric surgery, but recently recommended drugs for the treatment of obesity gained the most attention. The most popular individual topics were dietary supplements with uncertain effects on weight loss.

Evaluating the Impact of Enhanced Recovery After Surgery Protocols on Surgical Outcomes Following Bariatric Surgery-A Systematic Review and Meta-analysis of Randomised Clinical Trials

BACKGROUND

Enhanced recovery after surgery (ERAS) programmes are evidence-based care improvement processes for surgical patients, which are designed to decrease the impact the anticipated negative physiological cascades following surgery.

AIM

To perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the impact of ERAS protocols on outcomes following bariatric surgery compared to standard care (SC).

METHODS

A systematic review was performed in accordance with PRISMA guidelines. Meta-analysis was performed using Review Manager version 5.4 RESULTS: Six RCTs including 740 patients were included. The mean age was 40.2 years, and mean body mass index was 44.1 kg/m2. Overall, 54.1% underwent Roux-en-Y gastric bypass surgery (400/740) and 45.9% sleeve gastrectomy (340/700). Overall, patients randomised to ERAS programmes had a significant reduction in nausea and vomiting (odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.95, P = 0.040), intraoperative time (mean difference (MD): 5.40, 95% CI: 3.05-7.77, P < 0.001), time to mobilisation (MD: - 7.78, 95% CI: - 5.46 to - 2.10, P < 0.001), intensive care unit stay (ICUS) (MD: 0.70, 95% CI: 0.13-1.27, P = 0.020), total hospital stay (THS) (MD: - 0.42, 95% CI: - 0.69 to - 0.16, P = 0.002), and functional hospital stay (FHS) (MD: - 0.60, 95% CI: - 0.98 to - 0.22, P = 0.002) compared to those who received SC.

CONCLUSION

ERAS programmes reduce postoperative nausea and vomiting, intraoperative time, time to mobilisation, ICUS, THS, and FHS compared to those who received SC. Accordingly, ERAS should be implemented, where feasible, for patients indicated to undergo bariatric surgery. Trial registration International Prospective Register of Systematic Reviews (PROSPERO - CRD42023434492.

Current Management and Treatment Paradigms of Gastroesophageal Reflux Disease following Sleeve Gastrectomy

Obesity is associated with serious comorbidities and economic implications. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, are effective options for weight loss and the improvement of obesity-related comorbidities. With the growing obesity epidemic, there has been a concomitant rise in bariatric surgeries, particularly in sleeve gastrectomy, which has been the most widely performed bariatric surgery since 2013. Gastroesophageal reflux disease (GERD) is highly prevalent in obese individuals, can significantly impact quality of life and may lead to serious complications. Obesity and GERD both improve with weight loss. However, as the incidence of sleeve gastrectomy rises, recent data have revealed a risk of exacerbation of pre-existing GERD or the development of de novo GERD following sleeve gastrectomy. We performed a detailed review of GERD post-sleeve gastrectomy, including its overall incidence, pathophysiology and current treatment paradigms.

The Utilisation of Digital Applications for Measuring Patient Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis of Comparative Studies

In the context of escalating obesity rates, bariatric surgery holds a crucial role in managing severely obese patients. With a demonstrated effectiveness in weight loss and with the advent of ambulatory surgery, bariatric surgery allows for a streamlined care pathway, ideally suited for postoperative surveillance using digital health applications. The aim of this systematic review and meta-analysis is to evaluate the effect of eHealth-delivered health services or support for adults undergoing bariatric surgery. Five studies, encompassing 2210 patients, were analysed. The intervention group showed a 10% increase in total weight reduction and a 22% reduction in excess weight loss. ED visitation rates also trended towards reduction. Despite the absence of clear statistical superiority for DHA, the findings suggest potential benefits of DHA in postoperative monitoring.

Comparing Perioperative Outcomes of Total Intravenous Anesthesia (TIVA) With Volatile Anesthesia in Patients With Obesity: A Systematic Review

In this systematic review, the perioperative outcomes of total intravenous anesthesia (TIVA) and volatile anesthesia were compared in obese adults (BMI ≥ 30 kg/m²) undergoing elective surgery. The review analyzed data from 12 randomized-controlled trials involving 935 patients, sourced from PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online), Cochrane, Scopus, and Web of Science databases. The focus was on intraoperative vital signs, emergence time, postoperative nausea and vomiting (PONV), duration of post-anesthesia care unit (PACU) stay, and ICU admission rates. Findings showed that TIVA (using propofol) might reduce PONV, but there were no significant differences in other outcomes compared to volatile anesthesia (with desflurane as the most common agent). The review highlights the need for more research, especially comparing sevoflurane with TIVA, to establish clear clinical guidelines for anesthesia in obese patients.

Revisional bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity.

RESULTS

4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications.

CONCLUSION

GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.

Analyzing the Impact of Social and Psychiatric Factors in Patients Who Undergo Body Contouring Procedures

BACKGROUND

As the prevalence of obesity increases, the number of patients seeking body contouring procedures after bariatric surgery for massive weight loss is increasing. Although the positive impact of bariatric surgery on physical and emotional health is well-described, few studies have reported on the psychosocial well-being of patients undergoing body contouring procedures. Psychosocial well-being can impact patient satisfaction and maintenance of weight loss, and is an important area to study.

OBJECTIVE

The aim of this study was to characterize social and psychiatric factors of patients undergoing body contouring surgery, and to evaluate their impact on maintenance of weight loss.

METHODS

A retrospective review was performed of patients who presented to a single institution for body contouring procedures between 2002 and 2018. Demographic details, medical history, psychosocial support, and operative details were collected. Univariate analysis and multinomial logistic regressions were performed with R statistical software (version 1.3.1093).

RESULTS

A total of 1187 patients underwent at least 1 body contouring procedure during the study time frame. Mean BMI at presentation was 31.21 ± 10.49 kg/m2. Patients diagnosed with obesity at age 18 or older had significantly greater odds of suffering from generalized anxiety disorder (odds ratio [OR] 1.08 [95% CI, 1.02-1.15], P = .008). Patients with spousal support had 1.93 times higher odds of having maintained postbariatric weight loss at their 6-month follow-up (OR 1.93 [95% CI, 1.84-2.01], P = .028).

CONCLUSIONS

Social support and age of obesity diagnosis impact psychological well-being and maintenance of weight loss following body contouring procedures.

LEVEL OF EVIDENCE: 3

Metabolic and Bariatric Surgery Utilization Trends in the United States: Evidence From 2012 to 2021 National Electronic Medical Records Network

Background

Bariatric surgery has evolved over the past 2 decades yet assessing trends of bariatric surgery utilization in the growing eligible population is lacking.

Aim

This study aimed to update the trends in bariatric surgery utilization, changes in types of procedures performed, and the characteristics of patients who underwent bariatric surgery in the United States, using real-world data.

Method

This retrospective descriptive observational study was conducted using the TriNetX, a federated electronic medical records network from 2012 to 2021, for adult patients 18 years old or older who had bariatric surgery. Descriptive statistical analysis was conducted to assess patients' demographics and characteristics. Annual secular trend analyses were conducted for the annual rate of bariatric surgery, and the specific procedural types and proportions of laparoscopic surgeries.

Results

A steady increase in the number of procedures performed in the United States over the first 6 years of the study, a plateau for the following 2 years, and then a decline in 2020 and 2021 (during the coronavirus disease 2019 pandemic). The annual rate of bariatric surgery was lowest in 2012 at 59.2 and highest in 2018 at 79.6 surgeries per 100,000 adults. During the study period, 96.2% to 98.8% of procedures performed annually were conducted laparoscopically as opposed to the open technique. Beginning in 2012, the Roux-en-Y gastric bypass (RYGB) procedure fell to represent only 17.1% of cases in 2018, along with a sharp decline in the adjustable gastric band (AGB) procedure, replaced by a sharp increase in the sleeve gastrectomy (SG) procedure to represent over 74% of cases in 2018.

Conclusions

Bariatric surgery utilization in the United States showed a moderate decline in the number of RYGB procedures, which was offset by a substantial increase in the number of SG procedures and a precipitous drop in the annual number of AGB procedures.

The Global Burden of premature cardiovascular disease, 1990-2019

Aims

Premature cardiovascular disease (pCVD) definition varies in literature, with age cut-offs ranging from 50-65 years. While there is some literature available on pCVD in North America, comprehensive data on its global burden is still lacking which hinders the development of efficient strategies for early detection and prevention. In this study we aimed to investigate the global trends in pCVD related morbidity and mortality from 1990 to 2019.

Methods

The 1990-2019 Global Burden of Disease (GBD) database was utilized to examine global trends in cardiovascular disease-related total mortality, mortality rates, and Disability-Adjusted Life Years (DALYs) within individuals aged 15-49 years. The findings were further analyzed based on factors such as age, sex, and Socio-Demographic Index (SDI).

Results

From 1990 to 2019, the number of global annual pCVD deaths increased by 25%, from 992,067 (95% UI 1,042,261 - 946,383) to 1,241,484 (95% UI 1,339,193 -1,146,252). The rate of associated mortality decreased by 13%. Metabolic conditions were the most significant risk factors for pCVD mortality. Ischemic heart disease and stroke are the leading causes of death across all age groups. pCVD mortality presented progressive widening between high and low SDI regions. Additionally, sex-specific disparities in CVD mortality were significantly greater in the premature age group as compared to all-age groups.

Conclusion

pCVD is an increasingly significant global cause of morbidity and mortality that disproportionately affects males and individuals living in less privileged regions. Furthermore, ischemic heart disease and stroke were identified as the main drivers of pCVD global burden.

Experience of Robotic Complex Revisional Bariatric Surgery in a High-Volume Center

PURPOSE

A revisional bariatric surgery (RBS) is necessary in about 28% of the patients. The role of robotic surgery in RBS is still a subject of debate. We aim to report the outcomes of robotic-assisted RBS at our institution.

MATERIALS AND METHODS

We identified patients who underwent robotic-assisted RBSs between January 1, 2016, and May 31, 2022. We analyzed patient demographics and indications for surgery. Measured outcomes included peri- and postoperative morbidity, comorbidity management, and weight loss outcomes.

RESULTS

A total of 106 patients were included. Primary procedures were adjustable gastric band 44 (41.5%), sleeve gastrectomy 42 (39.6%), Roux-en-Y gastric bypass (RYGB) 18 (17%), duodenal switch (DS) 1 (0.9%), and vertical banded gastroplasty 1 (0.9%). RBSs performed included 85 (78.7%) RYGB, 16 (14.8%) redo-gastrojejunostomy, and 5 (4.6%) DS. The median time to revision was 8 (range 1-36) years, and the main indication was insufficient weight loss (49%). Median length of hospital stay was 2 (range 1-16) days, and 9 (8.5%) patients were readmitted during the first 30 days. Only 4 (3.7%) patients had early Clavien-Dindo grade III or higher adverse events. No anastomotic leaks were documented. Median excess weight loss was 35.1%, 42.23%, and 45.82% at the 6-, 12-, and 24-month follow-up. Of 57 patients with hypertension, 29 (50.9%) reduced their medication dosage, and 20/27 (74.1%) reduced their diabetes mellitus medication dosage. Finally, of the 75 patients with symptoms, 64 (85.3%) reported an improvement after the RBS.

CONCLUSION

Robotic-assisted RBS is feasible, significantly improves patients' comorbidities and symptoms, and leads to considerable weight loss.

Impact of maternal cardiometabolic status after bariatric surgery on the association between telomere length and adiposity in offspring

The impact of bariatric surgery on metabolic and inflammatory status are reflected in the epigenetic profile and telomere length mediated by the changes in the metabolic status of the patients. This study compared the telomere length of children born before versus after maternal bariatric surgery as a surrogate to test the influence of the mother's metabolic status on children's telomere length. DNA methylation telomere length (DNAmTL) was estimated from Methylation-EPIC BeadChip array data from a total of 24 children born before and after maternal bariatric surgery in the greater Quebec City area. DNAmTL was inversely associated with chronological age in children (r = - 0.80, p < 0.001) and significant differences were observed on age-adjusted DNAmTL between children born before versus after the maternal bariatric surgery. The associations found between body mass index and body fat percentage with DNAmTL in children born after the surgery were influenced by maternal triglycerides, TG/HDL-C ratio and TyG index. This study reports the impact of maternal bariatric surgery on offspring telomere length. The influence of maternal metabolic status on the association between telomere length and markers of adiposity in children suggests a putative modulating effect of bariatric surgery on the cardiometabolic risk in offspring.

Bariatric Surgery and Malpractice: an Extensive Review of Demographics, Complications, Litigation, and Proactive Mitigation Strategies

The rising prevalence of severe obesity has led to a parallel increase in bariatric surgeries, raising a complex array of medicolegal issues. This review aims to analyze and synthesize literature on bariatric surgery malpractice, focusing on patient demographics, surgical complications, litigation costs, and the nature of malpractice cases. A systematic search was conducted across multiple databases for relevant studies published up to May 2023. Our review endeavors to provide insights into these medicolegal challenges and their implications and foster an informed dialogue on strategies for their effective management. By doing so, we hope to enhance ethical and legally sound bariatric practices, safeguarding both patient welfare and surgical practitioners from legal repercussions.

A machine learning framework for optimizing obesity care by simulating clinical trajectories and targeted interventions

OBJECTIVE

This study aimed to determine the important clinical management bottlenecks that contribute to underuse of weight loss surgery (WLS) and assess risk factors for attrition at each of them.

METHODS

A multistate conceptual model of progression from primary care to WLS was developed and used to study all adults who were seen by a primary care provider (PCP) and eligible for WLS from 2016 to 2017 at a large institution. Outcomes were progression from each state to each subsequent state in the model: PCP visit, endocrine weight management referral, endocrine weight management visit, WLS referral, WLS visit, and WLS.

RESULTS

Beginning with an initial PCP visit, the respective 2-year Kaplan-Meier estimate for each outcome was 35% (n = 2063), 15.6% (n = 930), 6.3% (n = 400), 4.7% (n = 298), and 1.0% (n = 69) among 5876 eligible patients. Individual providers and clinics differed significantly in their referral practices. Female patients, younger patients, those with higher BMI, and those seen by trainees were more likely to progress. A simulated intervention to increase referrals among PCPs would generate about 49 additional WLS procedures over 3 years.

CONCLUSIONS

This study discovered novel insights into the specific dynamics underlying low WLS use rates. This methodology permits in silico testing of interventions designed to optimize obesity care prior to implementation.

Safety and Efficacy of Outpatient Drainless Abdominoplasty: A Single-Surgeon Experience of 454 Consecutive Patients

BACKGROUND

The incidence of seroma after abdominoplasty is accepted as approximately 10% (with a range) in the literature. Progressive tension sutures (PTS) have arisen as a means of reducing seroma, however there are conflicting data regarding their efficacy.

OBJECTIVES

The primary aim of this study was to describe the incidence of postabdominoplasty seroma in the setting of drainless abdominoplasty with PTS.

METHODS

A retrospective chart review was performed of all abdominoplasties (n = 454) during a 20-year period. At approximately the halfway point of this time frame, the abdominoplasty technique was changed from the use of 2 drains to the use of PTS without drains. Additionally, pulsed electromagnetic field therapy (PEMF) and liposomal bupivacaine (Exparel, Pacira Pharmaceuticals, Inc., Parsippany, NJ) were added as pain control adjuncts.

RESULTS

There were 194 patients in the drain group and 260 patients in the PTS/no drains group. The group without drains contained a significantly higher proportion of massive weight loss patients (4.1% vs 9.2%, P = .041). The majority of the group without drains underwent outpatient surgery (89.7% vs 98.8%, P < .001). The overall complication rate was significantly lower in the no drains group (31.4% vs 13.8%, P < .001). The incidence of seroma was dramatically reduced in the group without drains (24.7% vs 0.0%, P < .001).

CONCLUSIONS

PTS are highly effective in preventing seroma and can be safely employed as an alternative to drains in abdominoplasty. PEMF may play a role in seroma prevention and is also helpful for pain control. With these techniques to mitigate complications and minimize postoperative pain, abdominoplasty can be performed safely and effectively in a purely outpatient setting.

LEVEL OF EVIDENCE: 3

A life-threatening presentation of postgastrectomy exocrine pancreatic insufficiency: A case report

Key Clinical Message

Physicians must be alert for the exocrine pancreatic insufficiency diagnosis through the follow-up of postgastrectomy patients, regardless the severity and lag time. Urgent albumin and pancreatic enzyme replacement should be considered when diagnosed.

Abstract

It is documented that exocrine pancreatic insufficiency (EPI) can develop after gastrectomy. Steatorrhea, malnutrition, and weight loss are common symptoms of the disease; however, it is usually mild to moderate postgastrectomy. This article reports a case of EPI manifested by hypoalbuminemia leading to dyspnea and anasarca, which are not typical symptoms of postgastrectomy EPI. A 61-year-old man with a history of gastric adenocarcinoma treated by total gastrectomy and chemoradiotherapy was admitted to the hospital with dyspnea and anasarca. Despite being diagnosed as a case of malignancy recurrence in another hospital, based on the symptoms described, no evidence of malignancy was found. His ascites and pleural effusion were determined to be caused by hypoalbuminemia. In addition, he claimed steatorrhea, and his stool elastase was lower than expected. EPI was diagnosed based on his medical history, paraclinical tests, and examinations. He remained asymptomatic for 1 year after being treated with albumin and pancreatic enzymes. Postgastrectomy EPI may be severe enough to cause steatorrhea or hypoalbuminemia. Hence, regardless of the severity of the presentation, physicians must be alert for this diagnosis throughout the follow-up of patients with a history of gastrectomy. Urgent albumin and pancreatic enzyme replacement should be considered when diagnosed.

Calorie restriction outperforms bariatric surgery in a murine model of obesity and triple-negative breast cancer

Obesity promotes triple-negative breast cancer (TNBC), and effective interventions are urgently needed to break the obesity-TNBC link. Epidemiologic studies indicate that bariatric surgery reduces TNBC risk, while evidence is limited or conflicted for weight loss via low-fat diet (LFD) or calorie restriction (CR). Using a murine model of obesity-driven TNBC, we compared the antitumor effects of vertical sleeve gastrectomy (VSG) with LFD, chronic CR, and intermittent CR. Each intervention generated weight and fat loss and suppressed tumor growth relative to obese mice (greatest suppression with CR). VSG and CR regimens exerted both similar and unique effects, as assessed using multiomics approaches, in reversing obesity-associated transcript, epigenetics, secretome, and microbiota changes and restoring antitumor immunity. Thus, in a murine model of TNBC, bariatric surgery and CR each reverse obesity-driven tumor growth via shared and distinct antitumor mechanisms, and CR is superior to VSG in reversing obesity's procancer effects.

Application of machine learning to predict postoperative gastrointestinal bleed in bariatric surgery

BACKGROUND

Postoperative gastrointestinal bleeding (GIB) is a rare but serious complication of bariatric surgery. The recent rise in extended venous thromboembolism regimens as well as outpatient bariatric surgery may increase the risk of postoperative GIB or lead to delay in diagnosis. This study seeks to use machine learning (ML) to create a model that predicts postoperative GIB to aid surgeon decision-making and improve patient counseling for postoperative bleeds.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was used to train and validate three types of ML methods: random forest (RF), gradient boosting (XGB), and deep neural networks (NN), and compare them with logistic regression (LR) regarding postoperative GIB. The dataset was split using fivefold cross-validation into training and validation sets, in an 80/20 ratio. The performance of the models was assessed using area under the receiver operating characteristic curve (AUROC) and compared with the DeLong test. Variables with the strongest effect were identified using Shapley additive explanations (SHAP).

RESULTS

The study included 159,959 patients. Postoperative GIB was identified in 632 (0.4%) patients. The three ML methods, RF (AUROC 0.764), XGB (AUROC 0.746), and NN (AUROC 0.741) all outperformed LR (AUROC 0.709). The best ML method, RF, was able to predict postoperative GIB with a specificity and sensitivity of 70.0% and 75.4%, respectively. Using DeLong testing, the difference between RF and LR was determined to be significant with p < 0.01. Type of bariatric surgery, pre-op hematocrit, age, duration of procedure, and pre-op creatinine were the 5 most important features identified by ML retrospectively.

CONCLUSIONS

We have developed a ML model that outperformed LR in predicting postoperative GIB. Using ML models for risk prediction can be a helpful tool for both surgeons and patients undergoing bariatric procedures but more interpretable models are needed.

Trends and predictors of nutritional deficiencies after bariatric surgeries: analysis of real-world data

BACKGROUND

Bariatric surgery (BS) can lead to postoperative nutritional deficiencies (NDs) due to restrictive and malabsorptive mechanisms, but there is limited literature quantifying NDs' prevalence over time and their predictors among patients undergoing BS.

OBJECTIVE

To characterize time trends and predictors of postoperative NDs.

SETTING

This retrospective cohort study used the U.S. IBM MarketScan commercial claims database (2005-2019) to include adults who underwent BS with continuous enrollment.

METHODS

BS included Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), adjustable gastric band (AGB), and biliopancreatic diversion with duodenal switch. NDs included protein malnutrition, deficiencies in vitamins D and B12, and anemia that may be related to NDs. Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of NDs across BS types after adjusting for other patient factors.

RESULTS

Within 83,635 patients (mean age [SD], 44.5 [9.5] yr; 78% female patients), 38.7%, 32.9%, and 28% underwent RYGB, SG, and AGB, respectively. Age-adjusted prevalence of any NDs within 1, 2, and 3 years after BS ranged from 23%, 34%, and 42%, respectively (in 2006) to 44%, 54%, and 61%, respectively (in 2016). Relative to the AGB group, the adjusted OR of any 3-year postoperative NDs was 3.00 (95% CI, 2.89-3.11) for the RYGB group and 2.42 (95% CI, 2.33-2.51) for the SG group.

CONCLUSIONS

RYGB and SG were associated with 2.4- to 3.0-fold odds of developing 3-year postoperative NDs compared with AGB, independent of baseline ND status. Pre- and postoperative nutritional assessments are recommended for all patients undergoing BS to optimize postoperative outcomes.

Gastroesophageal Reflux Disease in Obesity: Bariatric Surgery as Both the Cause and the Cure in the Morbidly Obese Population

Gastrointestinal reflux disease (GERD) is a chronic, highly prevalent condition in the United States. GERD can significantly impact quality of life and lead to complications including aspiration pneumonia, esophageal stricture, Barrett's esophagus (BE) and esophageal cancer. Obesity is a risk factor for GERD, which often improves with weight loss and bariatric surgery. Though the incidence of bariatric surgery, in particular, minimally invasive sleeve gastrectomy, has risen in recent years, emerging data has revealed that the severity or new onset of GERD may follow bariatric surgery. We performed a literature review to provide a detailed analysis of GERD with an emphasis on bariatric surgery as both the cure and the cause for GERD in the morbidly obese population. We also describe the pathophysiological mechanisms, management approach and treatment strategies of GERD following bariatric surgery.

A Population-Based Cohort Study on Efficacy and Safety of Bariatric Surgery in Young Adults Versus Adults

PURPOSE

Bariatric surgery is the most effective treatment for severe obesity in adults and has shown promising results in young adults. Lack of insight regarding efficacy and safety outcomes might result in delayed bariatric surgery utilization in young adults. Therefore, this study aimed to assess the efficacy and safety of bariatric surgery in young adults compared to adults.

METHODS

This is a nationwide population-based cohort study utilizing data from the Dutch Audit Treatment of Obesity (DATO). Young adults (aged 18-25 years) and adults (aged 35-55 years) who underwent primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were included. Primary outcome was percentage total weight loss (%TWL) until five years postoperatively.

RESULTS

A total of 2,822 (10.3%) young adults and 24,497 (89.7%) adults were included. The follow-up rates of the young adults were lower up to five years postoperatively (46.2% versus 56.7% three years postoperatively; p < 0.001). Young adults who underwent RYGB showed superior %TWL compared to adults until four years postoperatively (33.0 ± 9.4 versus 31.2 ± 8.7 three years after surgery; p < 0.001). Young adults who underwent SG showed superior %TWL until five years postoperatively (29.9 ± 10.9 versus 26.2 ± 9.7 three years after surgery; p < 0.001). Postoperative complications ≤ 30 days were more prevalent among adults, 5.3% versus 3.5% (p < 0.001). No differences were found in the long term complications. Young adults revealed more improvement of hypertension (93.6% versus 78.9%), dyslipidemia (84.7% versus 69.2%) and musculoskeletal pain (84.6% versus 72.3%).

CONCLUSION

Bariatric surgery appears to be at least as safe and effective in young adults as in adults. Based on these findings the reluctance towards bariatric surgery in the younger age group seems unfounded.

A National Analysis of Socioeconomic Variables of Access to Inpatient Body Contouring Procedures After Bariatric Surgery

BACKGROUND

Weight loss following bariatric surgery often results in excess skin, which has led to a population of patients seeking body contouring surgery (BCS). This study aimed to investigate the prevalence of patients who underwent BCS following bariatric surgery using the national inpatient sample (NIS) database and to assess the demographic and socioeconomic variables of this cohort.

METHODS

NIS database was queried from 2016 to 2019 using ICD-10 codes to identify patients that underwent bariatric surgery procedures. Patients who subsequently underwent BCS were compared to those who did not. Multivariate logistic regression was used to identify factors associated with receipt of BCS.

RESULTS

A total of 263,481 patients that underwent bariatric surgery were identified. Of those, 1777 (0.76%) patients underwent subsequent inpatient BCS. Being female was associated with greater odds of undergoing body contouring (OR 1.28 95% CI 1.13-1.46, p = 0.0001). Patients who underwent BCS were more likely to have their procedure performed in large and government-controlled hospitals than bariatric surgery-only patients (55% vs. 50%, p < 0.0001, and 11% vs. 9.4%, respectively). Higher-income did not impose higher odds of receiving BCS compared to lowest income quartile (OR 0.99, 95% CI 0.86-1.16, p = 0.99066). Lastly, compared to Medicare holders, self-payers (OR 3.5, 95% CI 2.83-4.30, p < 0.0001) or private insurance (OR 1.23, 95% CI 1.09-1.40, p = 0.001) had greater odds of undergoing BCS.

CONCLUSIONS

There is a gap in access to BCS procedures, with cost and insurance coverage being the principal barriers. Developing policies that allow for holistic evaluation of patients is crucial to improve access to these procedures.

The Impact of Bariatric Surgery on the Incidence of Colorectal Cancer in Patients with Obesity-a Systematic Review and Meta-analysis of Registry Data

PURPOSE

Cancer and obesity represent two of the most significant global health concerns. The risk of malignancy, including colorectal cancer (CRC), increases with obesity. The aim of this study was to perform a systematic review and meta-analysis to determine the value of bariatric surgery in reducing CRC risk in patients with obesity using registry data.

MATERIALS AND METHODS

A systematic review and meta-analysis were performed as per PRISMA guidelines. The risk of CRC was expressed as a dichotomous variable and reported as odds ratios (OR) with 95% confidence intervals (CIs) using the Mantel-Haenszel method. A multi-treatment comparison was performed, examining the risk reduction associated with existing bariatric surgery techniques. Analysis was performed using RevMan, R packages, and Shiny.

RESULTS

Data from 11 registries including 6,214,682 patients with obesity were analyzed. Of these, 14.0% underwent bariatric surgery (872,499/6,214,682), and 86.0% did not undergo surgery (5,432,183/6,214,682). The mean age was 49.8 years, and mean follow-up was 5.1 years. In total, 0.6% of patients who underwent bariatric surgery developed CRC (4,843/872,499), as did 1.0% of unoperated patients with obesity (54,721/5,432,183). Patients with obesity who underwent bariatric surgery were less likely to develop CRC (OR: 0.53, 95% CI: 0.36-0.77, P < 0.001, I2 = 99%). Patients with obesity undergoing gastric bypass surgery (GB) (OR: 0.513, 95% CI: 0.336-0.818) and sleeve gastrectomy (SG) (OR: 0.484, 95% CI: 0.307-0.763) were less likely to develop CRC than unoperated patients.

CONCLUSION

At a population level, bariatric surgery is associated with reduced CRC risk in patients with obesity. GB and SG are associated with the most significant reduction in CRC risk.

PROSPERO REGISTRATION

CRD42022313280.

Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis

Internal hernias are a worrying complication from laparoscopic Roux-en-Y gastric bypass (LRGB), with potential small bowel necrosis and obstruction. An electronic database search of Medline, Embase, and Pubmed was performed. All studies investigating the internal hernia rates in patients whose mesenteric defects were closed vs. not closed during LRGB were analysed. Odds ratios were calculated to assess the difference in internal hernia rate. A total of 14 studies totalling 20,553 patients undergoing LRGB were included. Internal hernia rate (220/12,445 (2%) closure vs. 509/8108 (6%) non-closure) and re-operation for small bowel obstruction (86/5437 (2%) closed vs. 300/3132 (10%) non-closure) were reduced when defects were closed. There was no difference observed when sutures were used to close the defects compared to clips/staples.

Positive Predictive Value for Multitarget Stool DNA After Bariatric and Metabolic Surgery

BACKGROUND AND AIMS

Bariatric and metabolic surgery (BMS) may adversely affect noninvasive stool tests for colorectal cancer (CRC) screening through several mechanisms. Multitarget stool DNA (mt-sDNA) is approved for CRC screening; however, performance in post-BMS patients is unknown. As the rates of BMS are anticipated to increase with rising incidence of obesity, it is important to evaluate mt-sDNA test performance among these patients.

METHODS

In a multisite academic and community-based practice, we obtained mt-sDNA results from 10/2014 to 12/2019 through electronic records and an institutional BMS registry. Average CRC risk patients with BMS prior to a positive mt-sDNA underwent a detailed chart review. Follow-up colonoscopy findings were compared to those among BMS patients screened with colonoscopy alone and a historical cohort of patients without BMS, screened by mt-sDNA. The primary study endpoint was the positive predictive value (PPV) for advanced colorectal neoplasia.

RESULTS

Among 336 average-risk patients who had mt-sDNA after BMS, mt-sDNA was positive in 49 (14.6%), 47/49 (96%) underwent follow-up colonoscopy, and the PPV for advanced neoplasia was 12/47 (25.5%). This is similar to the PPV for advanced colorectal neoplasia (425/1542, 28%) in a historical cohort of persons without prior BMS, screened by mt-sDNA at our center (P = .86). Among those who had prior BMS, the rate of advanced neoplasia was higher after mt-sDNA compared to screening colonoscopy alone.

CONCLUSION

Despite anatomic and physiologic mechanisms that could alter blood or DNA content in stool, BMS does not appear to adversely affect the PPV of mt-sDNA.

Marginal Ulcers after Roux-en-Y Gastric Bypass: Etiology, Diagnosis, and Management

Marginal ulcer (MU) is a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6%. Early identification and prompt intervention are crucial to mitigating further complications. The pathophysiology of MU is complex and involves multiple factors, including smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size. Patients with MU may experience acute or chronic abdominal pain. Rarely, they may present with a complication from the ulceration, such as bleeding, perforation, or strictures. Following diagnosis by endoscopy, management of MU typically involves modification of risk factors and medical therapy focused on proton pump inhibitors. In case of complicated ulcers, surgical intervention is often required for the repair of the perforation or resection of the stricture. For recurrent or recalcitrant ulcers, endoscopic coverage of the ulcer bed, resection of the anastomosis, and abdominal or thoracoscopic truncal vagotomy may be considered. This review aims at providing an overview of the etiology, diagnosis, and management of MU after RYGB.

Predicting and preventing heart failure in type 2 diabetes

The burden of heart failure among people with type 2 diabetes is increasing globally. People with comorbid type 2 diabetes and heart failure often have worse outcomes than those with only one of these conditions-eg, higher hospitalisation and mortality rates. Therefore, it is essential to implement optimal heart failure prevention strategies for people with type 2 diabetes. A detailed understanding of the pathophysiology underlying the occurrence of heart failure in type 2 diabetes can aid clinicians in identifying relevant risk factors and lead to early interventions that can help prevent heart failure. In this Review, we discuss the pathophysiology and risk factors of heart failure in type 2 diabetes. We also review the risk assessment tools for predicting heart failure incidence in people with type 2 diabetes as well as the data from clinical trials that have assessed the efficacy of lifestyle and pharmacological interventions. Finally, we discuss the potential challenges in implementing new management approaches and offer pragmatic recommendations to help overcome these challenges.

Gastric cancer after Bariatric Bypass Surgery. Do they relate? (A Systematic Review)

Bariatric bypass surgery has been an effective treatment for morbid obesity. However, there is an increasing number of reported cases of gastric cancer after bypass surgery. Our systematic review showed an increasing trend of gastric cancer cases after bariatric bypass surgery in the last decade, mostly located in the excluded stomach (77%) and diagnosed in an advanced stage. In addition to known risk factors such as tobacco smoking (17%), H. pylori infection (6%), and family history of gastric cancer (3%), bile reflux, a recently proposed cancer-promoting factor, was also estimated in 18% of the cases. Our data suggest that gastric cancer risk assessment should be considered before gastric bypass surgery, and further investigations are needed to determine the value of post-operative gastric cancer surveillance.