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Guzman-Pruneda FA, Garcia A, Crum RW, Chen T, Krikhely A, Bessler M. Extended Post Discharge Prophylaxis for Venous Thromboembolism Prevention After Bariatric Surgery. Obes Surg 2024; 34:1217-1223. [PMID: 38409623 DOI: 10.1007/s11695-024-07100-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE The utility of routine post-discharge VTE prophylaxis after bariatric surgery remains a matter of debate. While inpatient chemical prophylaxis decreases the risk of fatal pulmonary embolism, most thromboembolic events occur after discharge and carry high morbidity and mortality. To address this risk, apixaban was introduced as extended prophylaxis for 30 days after surgery. MATERIALS AND METHODS The study ranges between 1/2014 and 7/2022. Apixaban was incorporated as routine extended prophylaxis protocol in 05/2017 and is dosed at 2.5 mg BID for 30 days. There were two study groups: those who received apixaban on discharge (n = 1443; 60%) and those who did not (n = 953; 40%). Patients with concern for postoperative bleeding (hypotension, unexplained tachycardia with hematocrit drop > 6%, hematocrit drop > 9%), or on preoperative anticoagulant/antiplatelet therapy (except aspirin), were not discharged on apixaban. Post-discharge VTE, readmission, transfusion, and reoperation rates were compared between groups. RESULTS There were 2396 consecutive primary bariatric operations: sleeve gastrectomy (1949; 81%), Roux-en-Y gastric bypass (419; 18%), and duodenal switch (28; 1%). There were no post-discharge VTEs in patients treated with apixaban vs. five (0.5%) VTEs in patients who did not receive treatment; p = 0.02. There was a higher incidence in post-discharge bleeding events in the apixaban group (0.5 vs 0.3%; p = 0.75), mostly requiring readmission for monitoring without intervention or transfusion. In the apixaban group, one patient underwent EGD for bleeding while another required blood transfusion; there were no reoperations for bleeding. CONCLUSION There were no post-discharge VTEs in patients who received apixaban. Treatment was associated with a higher risk of self-resolving bleeding events. This study adds to the increasing body of evidence supporting the benefit of routine, extended oral chemoprophylaxis after bariatric surgery.
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Affiliation(s)
- Francisco A Guzman-Pruneda
- Division of Metabolic and Bariatric Surgery, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, Rm 562, New York, NY, 10032, USA.
| | - Ambar Garcia
- Division of Metabolic and Bariatric Surgery, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, Rm 562, New York, NY, 10032, USA
| | - Robert W Crum
- Division of Metabolic and Bariatric Surgery, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, Rm 562, New York, NY, 10032, USA
| | - Theresa Chen
- Division of Metabolic and Bariatric Surgery, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, Rm 562, New York, NY, 10032, USA
| | - Abraham Krikhely
- Division of Metabolic and Bariatric Surgery, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, Rm 562, New York, NY, 10032, USA
| | - Marc Bessler
- Division of Metabolic and Bariatric Surgery, Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, Rm 562, New York, NY, 10032, USA
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O'Connell G, Shih S, Shui M, Krikhely A, Bessler M, Rohde CH. The financial toxicity of postbariatric body contouring surgery: a survey study of an urban tertiary care center's patients. Surg Obes Relat Dis 2024:S1550-7289(24)00075-3. [PMID: 38519294 DOI: 10.1016/j.soard.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/17/2023] [Accepted: 02/10/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Patients with obesity who undergo bariatric surgery achieve sustained weight loss but are often left with excess skin folds that cause functional and psychological deficits. To remove excess skin, patients can undergo postbariatric BCS; however, cost and lack of insurance coverage present a significant barrier for many patients. OBJECTIVES This study aimed to characterize the financial impact of treatment on all patients who received bariatric surgery and to compare between those receiving only bariatric surgery and those with postbariatric BCS. SETTING Email-based survey study at an urban tertiary care center. METHODS Surveys that included the COST-FACIT were sent to patients with a history of bariatric surgery and/or post-bariatric BCS. RESULTS One hundred and five respondents completed the survey, of which 19 reported having postbariatric BCS. Patients with postbariatric BCS had slightly higher COST scores than those receiving bariatric surgery only, but this difference was not significant (15.6 versus 17.8, P = .23). Most patients (76%) did not have an awareness of BCS or BCS cost prior to bariatric surgery, and many (68%) had more loose skin than anticipated. CONCLUSIONS Financial toxicity was similar across all postbariatric surgery patients surveyed regardless of history of BCS. However, survey respondents noted a gap between patient education and expectations around loose skin and body contouring that can be addressed through improved presurgical counseling.
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Affiliation(s)
- Gillian O'Connell
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Sabrina Shih
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Michelle Shui
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Abraham Krikhely
- Division of Bariatric Surgery, Department of Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Marc Bessler
- Division of Bariatric Surgery, Department of Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Christine H Rohde
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York.
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Lauren BN, Lim F, Krikhely A, Taveras EM, Woo Baidal JA, Bellows BK, Hur C. Estimated Cost-effectiveness of Medical Therapy, Sleeve Gastrectomy, and Gastric Bypass in Patients With Severe Obesity and Type 2 Diabetes. JAMA Netw Open 2022; 5:e2148317. [PMID: 35157054 PMCID: PMC8845022 DOI: 10.1001/jamanetworkopen.2021.48317] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022] Open
Abstract
Importance Bariatric surgery is recommended for patients with severe obesity (body mass index ≥40) and type 2 diabetes (T2D). However, the most cost-effective treatment remains unclear and may depend on the patient's T2D severity. Objective To estimate the cost-effectiveness of medical therapy, sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB) among patients with severe obesity and T2D, stratified by T2D severity. Design, Setting, and Participants This economic evaluation used a microsimulation model to project health and cost outcomes of medical therapy, SG, and RYGB over 5 years. Time horizons varied between 10 and 30 years in sensitivity analyses. Model inputs were derived from clinical trials, large cohort studies, national databases, and published literature. Probabilistic sampling of model inputs accounted for parameter uncertainty. Estimates of US adults with severe obesity and T2D were derived from the National Health and Nutrition Examination Survey. Data analysis was performed from January 2020 to August 2021. Exposures Medical therapy, SG, and RYGB. Main Outcomes and Measures Quality-adjusted life-years (QALYs), costs (in 2020 US dollars), and incremental cost-effectiveness ratios (ICERs) were projected, with future cost and QALYs discounted 3.0% annually. A strategy was deemed cost-effective if the ICER was less than $100 000 per QALY. The preferred strategy resulted in the greatest number of QALYs gained while being cost-effective. Results The model simulated 1000 cohorts of 10 000 patients, of whom 16% had mild T2D, 56% had moderate T2D, and 28% had severe T2D at baseline. The mean age of simulated patients was 54.6 years (95% CI, 54.2-55.0 years), 61.6% (95% CI, 60.1%-63.4%) were female, and 65.1% (95% CI, 63.6%-66.7%) were non-Hispanic White. Compared with medical therapy over 5 years, RYGB was associated with the most QALYs gained in the overall population (mean, 0.44 QALY; 95% CI, 0.21-0.86 QALY) and when stratified by baseline T2D severity: mild (mean, 0.59 QALY; 95% CI, 0.35-0.98 QALY), moderate (mean, 0.50 QALY; 95% CI, 0.25-0.88 QALY), and severe (mean, 0.30 QALY; 95% CI, 0.07-0.79 QALY). RYGB was the preferred strategy in the overall population (ICER, $46 877 per QALY; 83.0% probability preferred) and when stratified by baseline T2D severity: mild (ICER, $36 479 per QALY; 73.7% probability preferred), moderate (ICER, $37 056 per QALY; 85.6% probability preferred), and severe (ICER, $98 940 per QALY; 40.2% probability preferred). The cost-effectiveness of RYGB improved over a longer time horizon. Conclusions and Relevance These findings suggest that the effectiveness and cost-effectiveness of bariatric surgery vary by baseline severity of T2D. Over a 5-year time horizon, RYGB is projected to be the preferred treatment strategy for patients with severe obesity regardless of baseline T2D severity.
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Affiliation(s)
- Brianna N. Lauren
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Francesca Lim
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Abraham Krikhely
- Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Elsie M. Taveras
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston
| | | | - Brandon K. Bellows
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chin Hur
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Zheng Z, Nakamura K, Gershbaum S, Wang X, Thomas S, Bessler M, Schrope B, Krikhely A, Liu RM, Ozcan L, López JA, Tabas I. Interacting hepatic PAI-1/tPA gene regulatory pathways influence impaired fibrinolysis severity in obesity. J Clin Invest 2021; 130:4348-4359. [PMID: 32657780 PMCID: PMC7410057 DOI: 10.1172/jci135919] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/13/2020] [Indexed: 12/13/2022] Open
Abstract
Fibrinolysis is initiated by tissue-type plasminogen activator (tPA) and inhibited by plasminogen activator inhibitor 1 (PAI-1). In obese humans, plasma PAI-1 and tPA proteins are increased, but PAI-1 dominates, leading to reduced fibrinolysis and thrombosis. To understand tPA–PAI-1 regulation in obesity, we focused on hepatocytes, a functionally important source of tPA and PAI-1 that sense obesity-induced metabolic stress. We showed that obese mice, like humans, had reduced fibrinolysis and increased plasma PAI-1 and tPA, due largely to their increased hepatocyte expression. A decrease in the PAI-1 (SERPINE1) gene corepressor Rev-Erbα increased PAI-1, which then increased the tPA gene PLAT via a PAI-1/LRP1/PKA/p-CREB1 pathway. This pathway was partially counterbalanced by increased DACH1, a PLAT-negative regulator. We focused on the PAI-1/PLAT pathway, which mitigates the reduction in fibrinolysis in obesity. Thus, silencing hepatocyte PAI-1, CREB1, or tPA in obese mice lowered plasma tPA and further impaired fibrinolysis. The PAI-1/PLAT pathway was present in primary human hepatocytes, and associations among PAI-1, tPA, and PLAT in livers from obese and lean humans were consistent with these findings. Knowledge of PAI-1 and tPA regulation in hepatocytes in obesity may suggest therapeutic strategies for improving fibrinolysis and lowering the risk of thrombosis in this setting.
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Affiliation(s)
- Ze Zheng
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Keiko Nakamura
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Graduate School of Medicine and.,Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Shana Gershbaum
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Neuroscience and Behavior Department, Barnard College, New York, New York, USA
| | - Xiaobo Wang
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Sherry Thomas
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Marc Bessler
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Beth Schrope
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Abraham Krikhely
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Rui-Ming Liu
- Division of Pulmonary Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lale Ozcan
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - José A López
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Bloodworks Research Institute, Seattle, Washington, USA
| | - Ira Tabas
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Department of Physiology and.,Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
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Arakawa R, Febres G, Cheng B, Krikhely A, Bessler M, Korner J. Prospective study of gut hormone and metabolic changes after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. PLoS One 2020; 15:e0236133. [PMID: 32687546 PMCID: PMC7371190 DOI: 10.1371/journal.pone.0236133] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/29/2020] [Indexed: 02/06/2023] Open
Abstract
Background Laparoscopic sleeve gastrectomy (SG) has surpassed Roux-en-Y gastric bypass (RYGB) as the most prevalent bariatric procedure worldwide. While RYGB and SG demonstrate equivalent short-term weight loss, long-term weight loss tends to be greater after RYGB. Differences in the effect of these procedures on gastrointestinal hormones that regulate energy homeostasis are felt to partially underlie differences in outcomes. The objective of this study was to prospectively quantify blood levels of gut hormones of energy and glucose homeostasis at one year follow up to delineate possible reasons for greater efficacy of RYGB over SG in achieving weight loss. Methods Patients undergoing SG (n = 19) and RYGB (n = 40) were studied before surgery and at 2,12, 26, and 52 weeks postoperatively. Blood samples drawn in the fasted state and after a liquid mixed meal were assayed at baseline, 26, and 52 weeks for peptide YY (PYY), glucagon-like peptide-1 (GLP-1), ghrelin, insulin, glucose, and leptin. Fasting and postprandial appetitive sensations were assessed by visual analog scale. Results At 1 year there was greater weight loss in RYGB compared with SG patients (30% vs 27%; P = 0.03). Area under the curve (AUC) after the mixed meal for PYY was greater in RYGB patients (P<0.001). RYGB patients had significant increases in GLP-1 AUC compared to baseline (P = 0.002). Ghrelin levels decreased only after SG compared to baseline (P<0.001) but were not significantly different from RYGB. There was a trend toward decreased sweet cravings in RYGB patients (P = 0.056). Conclusions Differences in gastrointestinal hormones that regulate energy and glucose homeostasis are a possible mechanism for greater efficacy of RYGB compared to SG.
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Affiliation(s)
- Rachel Arakawa
- Division of Endocrinology & Metabolism, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Gerardo Febres
- Division of Endocrinology & Metabolism, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Bin Cheng
- Department of Biostatistics, College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Abraham Krikhely
- Division of Minimal Access/Bariatric Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Marc Bessler
- Division of Minimal Access/Bariatric Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Judith Korner
- Division of Endocrinology & Metabolism, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- * E-mail:
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Podolsky D, Nemeth SK, Krikhely A, Novitsky YW. Preoperative Frailty Associated with Worse Postoperative Outcomes in Patients Undergoing Abdominal Wall Reconstruction. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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