Risk of Atrial Fibrillation and Stroke After Bariatric Surgery in Patients With Morbid Obesity With or Without Obstructive Sleep Apnea.

Background and Purpose: Weight loss in morbidly obese patients reduces atrial fibrillation (AF); however, it is unknown whether similar benefits are maintained in patients with obstructive sleep apnea (OSA). We sought to determine whether incident AF and stroke rates are affected by OSA after weight loss and to identify predictors of AF and stroke. Methods: Differences in laparoscopic adjustable gastric banding­induced weight loss on incident AF and stroke events in those with and without OSA in the entire and in propensity-matched cohorts were determined longitudinally, and independent predictors of AF and stroke were identified. Results: Of 827 morbidly obese patients who underwent laparoscopic adjustable gastric banding (mean age, 44±11 years; mean body mass index, 49±8 kg/m2), incident AF was documented in 4.96% and stroke in 5.44% of patients during a mean 6.0±3.2-year follow-up. Despite a similar reduction in body weight (19.6% and 21% in 3 years), new-onset AF was significantly higher in patients with OSA than without OSA in the entire (1.7% versus 0.5% per year; P<0.001) and propensity-matched cohorts. Incident stroke was higher in the OSA than in the non-OSA group (2.10% versus 0.47% per year; P<0.001), but only 20% of patients with stroke had documented AF. On multivariate analysis, OSA (hazard ratio, 2.88 [95% CI, 1.45­5.73]), age, and hypertension were independent predictors of new-onset AF, and OSA (hazard ratio, 5.84 [95% CI, 3.02­11.30]), depression, and body mass index were for stroke events. Conclusions: In morbidly obese patients who underwent laparoscopic adjustable gastric banding, despite similar weight loss, patients with OSA had a higher incidence of AF and stroke than patients without OSA. Both non-AF and AF-related factors were involved in increasing stroke risk. Further investigation is warranted into whether OSA treatment helps reduce AF or stroke events in this population.

The beneficial effect of weight reduction on adverse cardiovascular outcomes following bariatric surgery is attenuated in patients with obstructive sleep apnea.

Weight loss after bariatric surgery is associated with reduction in adverse cardiovascular outcomes; however, the impact of obstructive sleep apnea (OSA) on reduction of cardiovascular outcomes after bariatric surgery in morbidly obese patients is not known. We retrospectively assessed differences in cardiovascular events after laparoscopic adjustable gastric banding (LAGB)-induced weight loss in patients with and without OSA before and after propensity score matching for age, sex, body mass index (BMI), and major comorbidities between the two groups and determined predictors of poor outcomes. OSA was present in 222 out of 830 patients (27 per cent) who underwent LAGB between 2001 and 2011. Despite a similar reduction in BMI (20.0 and 20.8 per cent), a significantly higher percentage of cardiovascular events were observed in patients with than without OSA (35.6 vs 6.9 per cent; p < 0.001) at 3 years (mean follow-up 6.0 ± 3.2; range: 0.5 to 13 years). The differences in the cumulative endpoint of new onset stroke, heart failure, myocardial infarction, venous thrombosis, and pulmonary embolism between the OSA and non-OSA groups were maintained after propensity matching. Patients with OSA treated with continuous positive airway pressure (CPAP) during sleep [n = 66] had lower cardiovascular event rates at 30 months compared with those not treated (p < 0.041). OSA (hazard ratio: 6.92, 95% CI: 3.39-14.13, p < 0.001) remained an independent predictor of cardiovascular events after multivariate analysis. Thus, patients with OSA, despite a similar initial weight loss after LAGB, had a higher incidence of cardiovascular events compared with a propensity-matched group without OSA. Treatment with CPAP appears to reduce such events.

Endoscopic balloon dilation of stomal stenosis following gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) is a common operation for severely obese patients, particularly those with co-morbid disease. Postoperative complications include those amenable to endoscopic therapy, specifically those involving the gastric stoma. METHODS: 26 patients with prior history of RYGBP for morbid obesity presented with symptoms of gastric outlet obstruction. Symptoms included accelerated weight loss (n=22), nausea/vomiting (n=26), dehydration (n=5), and dysphagia (n=2). Endoscopic dilatation was performed using through-the-scope dilating balloons (8-15 mm). Following dilatation, a steroid solution was injected to prevent re-stenosis. RESULTS: Patients underwent 1-7 dilating sessions (mean 2.7/patient) at 2-week intervals. Estimated stoma diameter prior to dilation ranged from 1 mm to 8 mm (mean 3.5). Following dilation, diameter of the stoma increased to 10 to 15 mm (mean 12.4) at final endoscopy. In patients requiring a single dilating session (n=7), predilation stoma size was a mean 5.8 mm (range 3-8 mm), which increased to a mean of 12.7 mm (range 10-15 mm). In patients requiring multiple dilating sessions (n=19), pre-dilation stoma size was a mean of 2.7 mm (range 0-4 mm), which increased to a mean of 12.2 mm (range 10-14 mm). 25 of 26 patients had good long-term response, with follow-up of 6-38 months (mean 26). No treatment-related complications occurred. All had appropriate weight loss as determined at the bariatric clinic following endoscopic therapy. CONCLUSIONS: Of the complications following bariatric surgery that are amenable to endoscopic therapy, stomal stenosis appears to be relatively common. Endoscopic balloon dilation is an effective nonsurgical method for treatment of stomal stenosis, with no complications observed in this, the largest reported, series.

Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision.

BACKGROUND: Obesity affects more than 30% of the U.S. population and is associated with the development of life-threatening complications. Numerous therapeutic approaches to the problem have been advocated, including low-calorie diets, anoretic drugs, behavior modifications, and exercise therapy. The only treatment proven to be effective in the long-term management of morbid obesity is surgical intervention. Complications of bariatric surgery include stomal stenosis and/or ulcer and stomal dilation (secondary to overeating). The latter complication can result in a gain of previously lost weight. OBJECTIVE: To determine the effect of endoscopic injection by using a sclerosant (sodium morrhuate) to induce stomal stenosis in patients who present with stomal dilatation complicated by weight gain. DESIGN: Bariatric patients with a large gastric stoma were treated with sodium morrhuate stomal injection. Diameters of the stoma were followed at repeat endoscopy. Weight loss at scheduled clinic visits were compared with pretherapy weights. PATIENTS: Twenty-eight patients (10 men, 18 women; age range, 27-58 years), after bariatric surgery with GI bypass, were referred with weight gain after initial weight loss. Weight gain was believed to be the result of a large gastric stoma. INTERVENTIONS: Treatment included injection of sodium morrhuate (1-2 mL circumferentially) surrounding the stoma. A total of 1 to 3 injection sessions were performed in an attempt to achieve a stoma diameter of 1.2 cm or smaller. MAIN OUTCOME MEASUREMENTS: Treatment success was defined as a decrease of stoma size to or=75% of the weight the patient gained after establishing a steady state post bariatric surgery weight. RESULTS: A total of 2.3 injection sessions were performed. Successful endotherapy was achieved in 18 of 28 patients (64%). One patient developed symptoms of stomal stenosis, which required 2 separate balloon dilating sessions. No other complications were encountered. LIMITATIONS: Retrospective case series. CONCLUSIONS: Endoscopic injection of sodium morrhuate surrounding the dilated gastric stoma complicating bariatric surgery appears to be a successful, less-invasive therapeutic alternative to surgical revision.