Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery最新文献

Background: Postoperative emergency department (ED) use and readmissions are key quality outcome measures for Metabolic & Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) centers. Given increasing costs, limiting postoperative resource use is of paramount importance.

Objectives: This study aimed to investigate disparities in postoperative resource use after metabolic and bariatric surgery (MBS) across primary payor status.

Settings: Two MBSAQIP-accredited centers.

Methods: Using data from our institutional MBSAQIP dataset (2020-2023), MBS cases were identified and categorized on the basis of primary payor type. Analysis of 30-day readmissions, reinterventions, and reoperations was performed on the basis of case characteristics and stratified by payor status to examine intergroup differences.

Results: Medicaid beneficiaries were overall younger (40.4 years versus 46.5 years; P < .05) than patients with private insurance (PI) and more likely to be female. Body mass index was significantly greater for Medicaid compared with PI or Medicare (49.8 versus 47.8 versus 48.2; P < .05). Medicaid recipients had significantly greater rates of ED use (P < .0001) compared with PI and self-pay and longer operative times compared with PI and Self-Pay (144.8 min versus 126.7 versus 108.1 min; P < .05). Patients with Medicaid status also had a longer length of stay than patients with PI (1.68 days versus 1.48 days, P < .05). Despite these differences, Medicaid status was not associated with increased composite complications, composite infection, length of stay >5 days, or readmission.

Conclusions: Postoperative ED use and readmission/reoperation rates were notably higher in publicly insured (Medicare or Medicaid) patients compared with those with PI or self-pay. This highlights the importance of implementing targeted quality improvement measures to improve access to care in this population.

Background: Patients with obesity and heart failure managed with ventricular assist devices (VADs) are a medically complex population who could benefit from metabolic and bariatric surgery (MBS), but are often considered prohibitively high risk.

Objectives: We wished to report the outcomes following MBS in patients with VADs in a contemporary North American cohort.

Setting: Accredited MBSAQIP centers in United States and Canada in 2022.

Methods: We used the 2022 MBSQIP participant user file (PUF) to identify all patients who had a preoperative ventricular assist device. We reported the baseline characteristics, hospitalization course, 30-day complications, and weight loss outcomes. We performed 1:1 nearest neighbor Mahalanobis distance matching without replacement to identify patients with similar comorbidities, and used g-computation to estimate the independent effect of VAD therapy on key outcomes.

Results: Of the 120 patients undergoing MBS with a history of VAD, 78 underwent sleeve gastrectomy and 17, Roux-en-Y gastric bypass. The median postoperative length of stay was 2 days, and with 119 patients surviving to hospital discharge, the overall 30-day risk of death was .8%. There were no recorded pulmonary embolism, stroke, cardiac arrest, or myocardial infarction events. Compared to their matched counterparts, VAD patients had an increased risk of length of stay >7 days (risk ratio 1.40, 95% CI: .91-2.14) and required more units of blood transfusion (mean difference .19, 95% CI: .06-.32). VAD therapy was not statistically significantly associated with an increased risk of death (risk ratio 1.04, 95% CI .76-1.42).

Conclusions: Early outcomes after bariatric surgery in patients with VADs suggest feasibility and safety. Larger studies with well-defined selection criteria and longer term follow up are needed to confirm these results.

Background: Obesity is associated with serious health and social consequences. Socioeconomically disadvantaged people are less likely to undergo metabolic and bariatric surgery (MBS) than their socioeconomically advantaged counterparts and experience increased complications or health care resource utilization, such as longer length of stay. The Economic Innovation Group's Distressed Communities Index (DCI) offers a metric to broadly assess socioeconomic distress.

Objectives: This study investigated the relationship between community distress, as determined by DCI, and complications following MBS, including length of hospital stay, likelihood of an emergency department (ED) visit, 30-day readmissions, and perioperative/postoperative occurrences.

Setting: Academic Medical Center, United States.

Methods: We conducted a retrospective analysis on a cohort of patients undergoing primary sleeve gastrectomy or Roux-en-Y bypass at a large academic hospital from 2016 to 2020 (n = 758). Patients were categorized based on the DCI of their community. We used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database to record each patient's postoperative complications. Descriptive statistics were used to evaluate the association between community distress and complications.

Results: Patients from distressed communities were more likely to have Medicaid and less likely to have private insurance (P < .001). Community distress was significantly correlated with longer hospital stay (P < .001) and a higher likelihood of an ED visit (P < .007). No significant correlation was observed between community distress and 30-day readmissions or perioperative/postoperative occurrences.

Conclusions: DCI is not an independent risk factor for complications after adjusting for other variables but increase resource utilization.

The addition of a Nissen fundoplication to the sleeve gastrectomy (SG) has been recently proposed to reduce the incidence of postoperative gastroesophageal reflux disease (GERD). The aim of this study was to assess the effectiveness and safety of laparoscopic Nissen Sleeve (LNS). A systematic review using the Medline database was performed to identify original articles analyzing outcomes after LNS. Main outcomes included weight loss, improvement of GERD symptoms, esophagitis, proton pump inhibitor (PPI) usage, and pH monitoring. Postprocedural complications were included as secondary outcomes. A meta-analysis of proportions and paired preintervention and postintervention tests were used to assess the effect of the procedure on the different outcomes. A total of 5 studies comprising 246 patients undergoing LNS were included in the analysis. Mean age was 43.22 (40-46.2) years and 201 (85.12%) were females. The mean preoperative body mass index (BMI) of patients was 38.10 (33.9-40.4) kg/m². After a mean follow up of 27 (12-60) months, there was a significant reduction in mean BMI (pre: 38.10 versus post: 29.36, P < .007) and a mean excess weight loss (EWL) of 59.10% (26%-82%). The proportion of patients with GERD symptoms (pre: 80.16% versus post: 11.22%, P = .001) were significantly reduced after the operation. The use of PPIs (pre: 69% versus post: 8.98%, P = .10) and presence of esophagitis (pre: 69.6% versus post: 18%, P = .05) also reduced after the procedure, but this was not statiscally significant. Overall morbidity rate was 4% (95% confidence interval [CI], 1%-11%), with a weighted pooled proportion of 2% (95% CI, 0%-6%) for leaks, 2% (95% CI, 1%-5%) for strictures, 1% (95% CI, 1%-3%) for bleeding, and 3% (95% CI, 1%-5%) for perforation. LNS seems to be a safe and effective operation with apparently better GERD-related outcomes than SG alone. Further studies with longer follow-up and objective measurement of reflux are needed to confirm the successful outcomes of the procedure.

Background: There is no gold standard for recurrent weight gain following Roux-en-Y gastric bypass (RYGB). Combining jejuno-jejunostomy distalization type 1 (JJD1) and sleeve resection of the gastrojejunostomy and gastric pouch (GJ-P) may be a potential approach for these patients.

Objectives: To describe 1-year perioperative and nutritional outcomes of patients who underwent JJD1 with sleeve resection of the GJ-P.

Setting: High-volume academic bariatric center of excellence.

Methods: Patients with recurrent weight gain after RYGB who underwent JJD1 with sleeve resection of the GJ-P from 2020 to 2022 were included and studied for 1 year postoperatively. During the procedure, we aimed for a total alimentary limb length (TALL) of 350-500 cm, a new common channel (CC) of 200-350 cm, and a gastrojejunostomy <2 cm in diameter.

Results: A total of 61 patients underwent this combined revisional procedure. The median preoperative body mass index (BMI) was 42.59 kg/m². The median lengths of the biliopancreatic limb (BPL) before and after distalizatiovn were 50 cm (interquartile range [IQR]: 42.5-75) and 175 cm (IQR: 150-200), respectively. After revision, the median new CC was 270 cm (IQR: 250-300) and the median TALL was 400 cm (interquartile range [IQR]: 362.5-450). The median total small bowel length (TSBL) was 580 cm (IQR 550-640 cm), and the median BPL/TSBL ratio was .32 (IQR .29-.34). At 1, 6, and 12 months, the median BMI of the cohort was reduced to 39.14, 35.55, and 32.9 kg/m², respectively. At 1 year, the total weight loss (%TWL) was 22.18%. Only 3 (n = 3) patients developed major complications at 1 year. After distalization, the resolution of all obesity-related co-morbidities improved, including type 2 diabetes (3.2%), sleep apnea (13.1%), hypertension (HTN) (11.4%), and hyperlipidemia (HLD) (1.6%).

Conclusions: The combination of JJD1 and sleeve resection of the GJ-P for RYGB revision was safe and effective, with substantial improvement in weight loss at 1 year.

Background: There is a paucity of literature on the impact for bariatric surgery on the progression from prediabetes (PDM) to type II diabetes mellitus (T2DM).

Objectives: To evaluate the progression from PDM to T2DM in bariatric surgery compared with a nonsurgical cohort.

Setting: Single academic institution, Center of Bariatric Excellence.

Methods: This retrospective study of patients with morbid obesity with patients with PDM who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2001 and 2022. Nonsurgical controls from a primary care cohort were directly matched by hemoglobin A1c, age, sex, and body mass index. DM was defined as a clinical diagnosis of type II diabetes or hemoglobin A1c ≥6.5%. Kaplan-Meier analysis was used to estimate time until T2DM. Cox regression was used to compare time until T2DM in RYGB versus sleeve gastrectomy and in bariatric surgery versus nonsurgical controls.

Results: A total of 1326 bariatric cases with PDM (n = 1154 RYGB, n = 172 SG) were identified. The cohort was 83% female, mean age = 45.3 years, mean body mass index 46.9 kg/m², and follow-up was 65% over 15 years. In bariatric cases, PDM progression to T2DM at 5, 10, and 15 years after surgery was 1.8%, 3.3%, and 6.7%, respectively. PDM progression to T2DM was almost 20 times greater in matched nonsurgical controls at 5, 10, and 15 years 31.1%, 51.4%, and 68.7%, respectively (hazard ratio 19.8, 95% confidence interval 13.9-28.4, P < .0001). When stratifying by bariatric surgery type, those with SG were 4 times more likely to progress to T2DM versus RYGB (hazard ratio 4.01, 95% confidence interval 1.71-9.39, P = .0014).

Conclusions: Bariatric surgery significantly decreases the conversion from PDM to T2DM. The impact was significantly greater for RYGB compared with SG.