Intrathoracic Sleeve Migrations After Sleeve Gastrectomy: A Compilation of Case Reports.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the United States. Postoperative migration of the stomach into the chest is a rare complication of this procedure. In this study, we present a compilation of acute and chronic intrathoracic sleeve migrations (ITSMs) after LSG and present possible underlying mechanisms of this complication, as described in the literature. Methods: We retrospectively reviewed the preoperative, intraoperative, and postoperative course of patients who had an ITSM after LSG between 2011 and 2019. Results: Two patients presented with this complication in the acute setting, whereas 3 patients developed ITSM as a chronic issue years after the primary procedure. All 5 were female patients, with a mean age and body mass index of 55.6 ± 9.5 (years) and 37.8 ± 2.9 kg/m2, respectively. None of the cases had a hiatal hernia repair during the initial operation. All cases were completed laparoscopically with reduction of the migrated sleeve into the abdomen and primary hiatal hernia repair. One case required a return to the operating room for an acute reherniation. Conclusion: In this article, we report a compilation of cases of ITSMs after LSG with distinct clinical features that highlight the diversity of possible reasons and risk factors for its development.

Ketorolac Use Shortens Hospital Length of Stay After Bariatric Surgery: a Single-Center 5-Year Experience.

INTRODUCTION: There has been a recent increased interest in the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac for post-operative pain management to minimize opioid use and decrease hospital length of stay (LOS). Although NSAID use has been controversial following bariatric surgery due to anecdotal concerns for increased gastric bleeding, the impact of ketorolac as an adjunct to opioids needs further investigation on LOS and post-operative complications like bleeding. OBJECTIVE: This study aims to evaluate the impact of post-operative ketorolac use on opioid consumption, LOS, and bleeding risk after bariatric surgery. METHODS: We retrospectively analyzed a prospectively maintained database of all bariatric surgery patients who either underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass surgery (RYGB) at a tertiary center between 2011 and 2015. Patients were stratified into 2 groups based on post-operative pain control regimen as follows: (1) ketorolac and opioids and (2) opioids alone. RESULTS: A total of 1555 patients were identified who underwent either SG (n = 1255) or RYGB (n = 300). The overall LOS was 1.81 ± .059 days for ketorolac-opioid patients vs. 2.09 ± .065 days for opioid-only patients (P < 0.001). Furthermore, the risk of post-operative bleeding was similar between the two groups (P = 0.097). CONCLUSION: Patients who received ketorolac as an adjunct to opioids had a significantly shorter LOS compared to opioid-only patients. Additionally, ketorolac use was not associated with increased risk of post-operative bleeding complications. Therefore, if not contraindicated, ketorolac should be considered routinely for post-operative pain control among bariatric surgery patients.

Is bariatric surgery effective for co-morbidity resolution in the super-obese patients?

BACKGROUND: Type 2 diabetes (T2D), obstructive sleep apnea (OSA), hypertension (HTN), and hyperlipidemia (HLD) are common co-morbidities that are strongly associated with obesity. OBJECTIVE: The purpose of this study was to compare the rate of obesity-related co-morbidity remission and percent total body weight loss of super-obese patients with a body mass index (BMI) ≥50 kg/m2 with bariatric patients who have a BMI of 30 to 49.9 kg/m2. SETTING: Academic hospital, United States. METHODS: A retrospective analysis of outcomes of a prospectively maintained database was done on obese patients with a diagnosis of ≥1 co-morbidity (T2D, OSA, HTN, or HLD) who at the time of initial visit had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass at our hospital between 2011 and 2015. The patients were stratified based on their preoperative BMI class, BMI of 30 to 49.9 kg/m2 versus BMI ≥50 kg/m2. RESULTS: Of the 930 patients, 732 underwent sleeve gastrectomy and 198 underwent Roux-en-Y gastric bypass. The 6-month follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m2 (n = 759) versus super-obese patients (n = 171) were 46.0% and 36.7% (P = .348) for T2D; 75.0% and 73.2% (P = .772) for OSA; 35.0% and 22.0% (P = .142) for HTN; and 37.0% and 21.0% (P = .081) for HLD, respectively. The 1-year follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m2 versus super-obese patients were 54.2% and 45.5% (P = .460) for T2D; 87.0% and 89.7% (P = .649) for OSA; 37.4% and 23.9% (P = .081) for HTN; and 43.2% and 34.6% (P = .422) for HLD, respectively. Furthermore, there was no difference in the mean percent total weight loss for patients with a preoperative BMI of 30 to 49.9 kg/m2 versus the super-obese at the 6-month (21.4%, 20.9%, P = .612) and 1-year (28.0%, 30.7%, P = .107) follow-ups. CONCLUSION: In our study, preoperative BMI did not have an impact on postoperative co-morbidity remission rates or percent total body weight loss. Future studies should investigate the effect of other factors, such as disease severity and duration.

Preoperative insulin therapy as a marker for type 2 diabetes remission in obese patients after bariatric surgery.

BACKGROUND: Obesity not only increases the chances of developing diabetes-one of the top causes of death in the United States-but it also results in further medical complications. OBJECTIVE: To compare the 6-month and 1-year postoperative remission rates of type 2 diabetic (T2D) patients after bariatric surgery based on preoperative glycosylated hemoglobin (A1C) stratification and pharmacologic therapy: insulin-dependent diabetic (IDD) versus noninsulin-dependent diabetic (NIDD). SETTING: Academic hospital, United States. METHODS: We retrospectively analyzed a prospectively maintained database of 186 obese patients with a diagnosis T2D who had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass surgery at our hospital. RESULTS: At 6 months (n = 180), patients who were stratified by preoperative A1C levels (<6.5; ≥6.5 to<8; ≥8) had 70.5%, 51.7%, and 30.0% remission rates (P<.001) and at 1 year (n = 118) patients had 72.0%, 54.0%, and 42.8% remission rates (P = .053), respectively. When patients were substratified by preoperative pharmacologic therapy, IDD and NIDD patients had different remission rates within the same A1C level. At 6-months follow-up within A1C ≥6.5 to<8 (IDD versus NIDD), the remission rate was 23.5% versus 64.1% (odds ratio [OR]: .173, confidence interval [CI]: .0471, .6308, P = .0079), and within A1C ≥8 the remission was 24.0% versus 37.5% (OR: .5263, CI: .2115, 1.3096, P = .1676), respectively. At 1-year follow-up within A1C ≥6.5 to<8, the remission rate was 30.0% versus 62.9% (OR: .2521, CI: .0529, 1.2019, P = .0838), and within A1C ≥8 the remission was 31.4% versus 61.9% (OR: .2821, CI: .0908, .8762, P = .0286), respectively. Furthermore, when IDD patients were compared between A1C ≥6.5 to<8 and A1C ≥8 the remission rates were nearly identical, and for NIDD patients A1C was not significantly associated with remission regardless of the level, except at 6 months. CONCLUSION: While a difference was observed between overall A1C levels-the lower the A1C level, the higher the remission rate-IDD patients had lower remission rates than NIDD patients irrespective of A1C levels; further, IDD patients performed similarly across A1C levels.

Resolution of Symptomatic Obstructive Sleep Apnea Not Impacted by Preoperative Body Mass Index, Choice of Operation Between Sleeve Gastrectomy and Roux-en-Y Gastric Bypass Surgery, or Severity.

BACKGROUND: Obstructive sleep apnea (OSA) is a serious obesity-associated disorder that causes significant short- and long-term medical consequences. OBJECTIVE: The objective of this study is to compare the 6-month and 1-year postoperative symptomatic OSA remission rates of patients undergoing bariatric surgery based on their preoperative body mass index (BMI) stratification, type of bariatric operation-sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)-and OSA severity. METHODS: We retrospectively analyzed 297 obese patients with a diagnosis of OSA who had undergone either SG or RYGB between 2011 and 2015. RESULTS: The overall 6-month symptomatic OSA remission rate for patients (n = 255) was 74.5%. At 6 months, patients with a preoperative BMI of 30-34.9 kg/m2 (class I), 35-39.9 kg/m2 (class II), and 40+ kg/m2 (class III) had 100, 70.0, and 75.0% (p = 0.2164) remission rates, respectively. The 6-month remission rates for SG and RYGB were 75.3 and 70.8% (p = 0.5165), respectively. The overall 1-year symptomatic OSA remission rate for patients (n = 162) was 87.1%. At 1 year, class I, II, and III patients had 100, 85.7, and 87.5% (p = 0.5740) remission rates, respectively. The 1-year remission rates for SG and RYGB were 89.2 and 81.2% (p = 0.2189), respectively. A sub-analysis (n = 69) based on preoperative OSA severity levels did not affect the remission outcome at either the 6-month (p = 0.3670) or 1-year (p = 0.3004) follow-up. CONCLUSION: Most obese patients experience symptomatic remission of their OSA after bariatric surgery, regardless of their preoperative BMI, choice of operation, or OSA severity.