Midterm benefits of metabolic surgery on symptom remission and medication use in patients with pseudotumor cerebri.

BACKGROUND: Pseudotumor cerebri is a serious obesity-related disorder that can result in severe complications. The aim of this study was to compare metabolic surgery with medical management of pseudotumor cerebri at a single bariatric center. METHODS: After institutional review board approval, a retrospective review was conducted of individuals with severe obesity and pseudotumor cerebri (nonbariatric group) and patients with preoperative pseudotumor cerebri (bariatric group). The variables included demographic characteristics, comorbidities, and pseudotumor cerebri-related risk factors. Symptoms, medication use, and body mass index were analyzed during a 4-year follow-up. RESULTS: A total of 86 patients with pseudotumor cerebri were included in the analysis. In the nonbariatric group (n = 77), the mean age was 34.1 ± 10.5 years and initial body mass index 37.2 ± 6.5 kg/m2. Initially, the most common symptom was headache (90.9%; n = 70), with a mean lumbar opening pressure of 341.94 ± 104.50 mm H2O. In the bariatric group (n = 9), the mean age was 36.1 ± 8.9 years and preoperative body mass index 46.1 ± 5.5 kg/m2. The most common preoperative symptom was headache (100%; n = 9), with a lumbar opening pressure of 320 ± 44.27 mm H2O. During the 4-year follow-up, both groups presented with a significant decrease in pseudotumor cerebri-related symptoms at 3 months (P < .0001). Additionally, pseudotumor cerebri medication use significantly decreased after 3 months in the bariatric group (P = .0406), whereas in the nonbariatric group decreased at 18 months (P = .023). Bariatric patients presented with a significant decrease in body mass index in ≤3 months of surgery (P = .0380), which was not observed in nonbariatric patients (P = .6644). CONCLUSION: Metabolic surgery seems to provide a greater decrease in pseudotumor cerebri symptoms and medication use in a shorter period of time compared with medical management alone.

Effect of Intraoperative Urinary Catheter Use on Postoperative Urinary Retention After Laparoscopic Inguinal Hernia Repair: A Randomized Clinical Trial.

Importance: Urinary catheters are commonly placed during laparoscopic inguinal hernia repair as a presumed protection against postoperative urinary retention (PUR), one of the most common complications following this operation. Data from randomized clinical trials evaluating the effect of catheters on PUR are lacking. Objective: To investigate the effect of intraoperative catheters on PUR after laparoscopic inguinal hernia repair. Design, Setting, and Participants: This 2-arm registry-based single-blinded randomized clinical trial was conducted at 6 academic and community hospitals in the US from March 2019 to March 2021 with a 30-day follow-up period following surgery. All patients who presented with inguinal hernias were assessed for eligibility, 534 in total. Inclusion criteria were adult patients undergoing laparoscopic, elective, unilateral, or bilateral inguinal hernia repair. Exclusion criteria were inability to tolerate general anesthesia and failure to understand and sign the written consent form. A total of 43 patients were excluded prior to intervention. Interventions: Patients in the treatment arm had placement of a urinary catheter after induction of general anesthesia and removal at the end of procedure. Those in the control arm had no urinary catheter placement. Main Outcomes and Measures: PUR rate. Results: Of the 491 patients enrolled, 241 were randomized to catheter placement, and 250 were randomized to no catheter placement. The median (IQR) age was 61 (51-68) years, and 465 participants (94.7%) were male. Overall, 44 patients (9.1%) developed PUR. There was no difference in the rate of PUR between the catheter and no-catheter groups (23 patients [9.6%] vs 21 patients [8.5%], respectively; P = .79). There were no intraoperative bladder injuries. In the catheter group, there was 1 incident of postoperative urethral trauma in a patient who presented to the emergency department with PUR leading to a suprapubic catheter placement. Conclusions and Relevance: Intraoperative urinary catheters did not reduce the risk of PUR after laparoscopic inguinal hernia repair. While their use did not appear to be associated with a high rate of iatrogenic complications, there may be a low rate of catastrophic complications. In patients who voided urine preoperatively, catheter placement did not appear to confer any advantage and thus their use may be reconsidered. Trial Registration: ClinicalTrials.gov Identifier: NCT03835351.

Outcomes of laparoscopic sleeve gastrectomy with and without antrectomy in severely obese subjects. Evidence from randomized controlled trials.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has been proven safe and effective in achieving weight loss. However, the distance from the pylorus where resection should begin has been debated. OBJECTIVES: To compare the clinical outcomes of laparoscopic SG with antrum resection (AR) versus preservation (AP) for bariatric purposes by conducting a meta-analysis of randomized controlled trials (RCT). SETTING: Academic hospital, United States. METHODS: PubMed and Cochrane Library were queried for RCTs from establishment to August 2020. The following key search terms were used: "sleeve gastrectomy" AND ("antrectomy" OR "antrum") AND ("randomized" OR "random"). The following data were extracted: author, publication year, country, sample size, follow-up duration, and clinical outcomes, including weight-related: excess weight loss (EWL), total weight loss (TWL), body mass index (BMI), operation time, length of hospital stay, complication rates, and resolution of obesity-related comorbidities. RESULTS: A total of 9 unique RCTs including 492 AR and 385 AP patients were screened and included in the final quantitative analysis. Patients who underwent SG with AR showed higher EWL and TWL at 6 months (EWL: P < .001; TWL: P = .006), and 1 year (EWL: P = .013; P < .001) postoperatively. The BMI was also lower in the AR group 3 months (P = .013) and 6 months (P = .003) postoperatively. However, the EWL and BMI at 2 years were comparable between both groups (P = .222 and P = .908, respectively). No statistical significance was observed in terms of operating time, staple line disruption, bleeding, complications with a Clavien-Dindo Grade >III, resolution of comorbidities (hypertension, diabetes, hyperlipidemia, arthritis/back pain), and de novo gastroesophageal reflux disease (P > .05). AP was associated with a slightly shorter postoperative hospital stay (4.0 versus 3.1 days, P = .039). CONCLUSION: Laparoscopic SG with AR is associated with superior weight loss in the short-term compared with AP. However, mid-term follow-up beyond 1 year showed no significant differences in BMI or incidence of de novo gastroesophageal reflux disease.

Bariatric surgery is associated with reduced admission for aortic dissection: a nationwide case-control analysis.

BACKGROUND: Aortic dissection (AD) is an uncommon but life-threatening condition associated with high morbidity and mortality. Hypertension (HTN) and hyperlipidemia (HLD) are common modifiable risk factors. OBJECTIVES: Since bariatric surgery is associated with remission of obesity-related co-morbidities, we hypothesize that surgical weight loss might be protective against this feared aortic pathology. SETTING: A cross-sectional analysis was performed using the National Inpatient Sample database from 2010 to 2015. METHODS: The treatment group included bariatric patients and the control group patients with obesity (body mass index [BMI] ≥ 35kg/m2) without previous bariatric surgery. Analyzed covariates included demographics, co-morbidities, aortic diseases, and AD. A multivariate logistic regression analysis (MLRA) was performed to assess the odds of admission for AD in both groups. RESULTS: A total of 2,300,845 patients were identified (2,004,804 controls and 296,041 cases). The mean (SEM) age was 54.4 (.05) versus 51.9 (.05) years, for the control and treatment groups, respectively (P < .0001). Bariatric patients posed a significantly lower prevalence of type 2 diabetes (T2D), HTN, HLD, aortic aneurysm, and bicuspid aortic valve (P < .0001) than control subjects. In the control group, 1411 individuals (.070%) had AD, whereas only 94 patients (.032%) in the bariatric surgery group had such diagnosis (P < .0001). The MLRA showed that non-bariatric obese patients had a significantly higher likelihood of suffering from AD (OR = 1.8 [95%CI 1.44-2.29] P < .0001). Considering different age groups, bariatric surgery was found to be less associated with admission for AD for individuals below and above 40 years of age (OR = 2.95 [95%CI 1.09-7.99] P = .0345) and (OR = 1.75 [95%CI 1.38-2.22] P < .0001), respectively. CONCLUSIONS: Bariatric surgery could be a protective factor against aortic dissection and should be considered in patients with obesity and risk factors for this cardiovascular complication.

Sleeve gastrectomy versus Roux-en-Y gastric bypass in patients Aged ≥65 years: a comparison of short-term outcomes.

BACKGROUND: Bariatric surgery in the elderly population has been reported as feasible and safe. Sleeve gastrectomy (SG) seems to have fewer complications than Roux-en-Y gastric bypass (RYGB) even in the 65 years of age population. We analyzed the difference in weight loss between SG and RYGB in patients age 65 years. OBJECTIVES: To analyze and compare outcomes between SG and RYGB in patients 65 years of age and older. SETTING: Academic hospital, United States. METHODS: After internal review board approval, we retrospectively reviewed 2486 patients who underwent either SG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative body mass index (BMI), and co-morbidities were described. We identified all patients age ≥65 years and subsequently divided them into 2 groups based on type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were completed. Postoperative BMI was reviewed at 6, 12, and 24 months and percent excess BMI loss (%EBMIL, as defined by the ASMBS clinical committee) was calculated accordingly. The t test and χ2 analysis were performed for nominal and categorical variables, respectively. RESULTS: From 2486 patients reviewed, 22.7% (n = 565) were aged ≥65 years. From these, 43.1% (n = 244) underwent SG and 56.8% (n = 321) underwent RYGB. White and female patients were predominant in both groups. Mean age was similar for both populations (SG: 71.1 ± 4.0, RYGB: 71.7 ± 4.5; P = .12). Pre-procedure mean BMI for both groups was close in value, but the difference was statistically significant (40.5 ± 5.5 for SG versus 43.7 ± 7.2 for RYGB; P < .0001). Postoperative follow-up rates were similar in both groups at 12 and 24 months (SG: 51.2% and 31.6%; RYGB: 48.3% and 34.3%; P = .49 and P = .5). The %EBMIL at 6, 12, and 24 months was higher for the RYGB group than the SG group (59.3 ± 27.9, 72.1 ± 29.5, 77.4 ± 26.1 versus 50.2 ± 21.9, 55.2 ± 25.6, 43.9 ± 32.2; P < .01, P < .01, and P < .01, respectively). Complication rates were significantly higher in RYGB versus SG (27.7% versus 9.4%; P < .01). We observed significantly higher anastomotic ulcer and stricture rates for RYGB versus SG (7.2% and 5.9 versus 0% and 0%; P < .01 and P < .01, respectively). RYGB had a higher rate for gastrointestinal obstruction requiring intervention (2.2% versus .4%; P = .07). A similar de novo gastroesophageal reflux disease rate was noted in both procedures (3.7% versus 3.7%; P = .98). No leaks were reported in either group. CONCLUSIONS: Both SG and RYGB are effective weight loss procedures for patients aged ≥65 years. RYGB seems to have higher %EBMIL at 1 and 2 years; however, when compared with SG, complication rates appear to be almost 3 times higher.

Left ventricular mass index and ventricular contractility improvement in patients with severe obesity following rapid weight loss after bariatric surgery.

BACKGROUND: Obesity is a well-known risk factor for heart disease, resulting in a broad spectrum of cardiovascular changes. Left ventricular mass (LVM) and contractility are recognized markers of cardiac function. OBJECTIVES: To determine the changes of LVM and contractility after bariatric surgery (BaS). SETTING: University hospital, United States METHODS: To determine the cardiac changes in ventricular mass, ventricular contractility, and left ventricular shortening fraction (LVSF), we retrospectively reviewed the 2-dimensional echocardiographic parameters of patients with obesity who underwent BaS at our institution. We compared these results before and after BaS. RESULTS: A total of 40 patients met the inclusion criteria. The majority were females (57.5%; n = 23), with an average age of 63.5 ± 12.1. The excess body mass index (BMI) lost at 12 months was 48.9 ± 28.9%. The percent total weight loss after BaS was 16.46 ± 9.9%. The left ventricular mass was 234.9 ± 88.1 grams before and 181.5 ± 52.7 grams after BaS (P = .002). The LVM index was 101.3 ± 38.3 g/m2 before versus 86.7 ± 26.6 g/m2 after BaS (P = .005). The LVSF was 31% ± 8.8% before and 36.3% ± 8.2% after BaS (P = .007). We found a good correlation between the decrease in LVM index and the BMI after BaS (P = .03). CONCLUSION: Rapid weight loss results in a decrease of the LVM index, as well as improvement in the left ventricular muscle contractility. Our results suggest that there is left ventricular remodeling and an improvement of heart dynamics following bariatric surgery. Further studies are needed to better assess these findings.

Complications of feeding jejunostomy placement: a single-institution experience.

BACKGROUND: Feeding jejunostomy is an alternative route of enteral nutrition in patients undergoing major gastrointestinal operations when a feeding gastrostomy is not suitable. METHODS: A single institution review of patients who underwent open or laparoscopic jejunostomy tube (JT) placement between 2009 and 2019 was performed. Data collected included demographics, preoperative serum albumin, surgery indication, concomitancy of procedure, size of JT tube and time to its removal. JT complications were analyzed in the early postoperative period (< 30 days) and in a long-term follow-up (> 30 days). The Chi-square test was used to compare rates of complications according to tube size. RESULTS: Seventy-three patients underwent JT placement, and gastroesophageal cancer (n = 48, 65.7%) was the most common indication. The JT was most frequently placed concomitantly (n = 56, 76.7%) to the primary operation and through a laparoscopic approach (n = 66, 90.4%). A total of 14 patients (19.1%) had early complications and 15 had late complications (20.5%). The reasons for early complications were clogged JT (n = 8, 10.9%), JT dislodgement (n = 3, 4.1%), leakage (n = 2, 2.7%), small bowel obstruction adjacent to the site of the jejunostomy tube (n = 2, 2.7%), JT site infection (n = 1, 1.3%), and intraperitoneal JT displacement (n = 1, 1.3%). The reasons for late complications were clogged JT (n = 6, 8.2%), JT dislodgement (n = 6, 8.2%), JT site infection (n = 3, 4.1%), and JT leakage (n = 1, 1.3%). There was no procedure-related mortality in this series. However, 12 patients (16.4%) died due to their baseline disease. The mean time to tube removal was 83.4 ± 93.6 days. The most frequently used JT size was 14 French (n = 39, 53.4%) but in nine patients the tube size was not reported. No statistical significance (p = 0.75) was found when comparing the two most commonly used sizes to rates of complications. CONCLUSION: The rate of JT complications in our study is comparable to other published reports in literature. As an alternative route for nutritional status optimization, the procedure appears to be safe despite the number of complications.

Is bariatric surgery safe in patients with history of cardiac revascularization?

BACKGROUND: The number of patients undergoing bariatric surgery with prior cardiac revascularization (CR) is rising. However, scarce data exist regarding the safety of bariatric procedures in these patients. OBJECTIVES: The aim of this study is to compare postoperative cardiovascular and noncardiovascular outcomes among patients with different CR procedures. SETTING: Academic hospital, United States. METHODS: We retrospectively reviewed 2884 patients undergoing bariatric surgery from 2009-2018. Patients with prior CR were included and stratified into groups: coronary artery bypass graft (CABG), percutaneous coronary intervention with stent (PCI), and CABG + PCI. We described patient demographic characteristics, co-morbidities, smoking status, history of myocardial infarction, type of bariatric surgery, number of vessels grafted/stents, time from CR to bariatric surgery, length of stay, and cardiovascular and noncardiovascular 30-day outcomes. A control group composed of patients without prior CR undergoing bariatric surgery was used to compare the rate of complications to the total patients with prior CR. For continuous and categorical variables, t test and χ2 tests were performed, respectively. RESULTS: We identified 76 patients with prior CR undergoing bariatric surgery. The mean patient age was 61.4 ± 7.9 years, the mean body mass index was 41.7 ± 6.5 kg/m2, and male sex was predominant (71.1%). Among these, 50% (n = 38) had PCI, 39.4% (n = 30) had CABG, and 10.5% (n = 8) had CABG + PCI. Early cardiovascular complications rate included ST-segment-elevation myocardial infarction (n = 2), pulmonary embolism (n = 1), supraventricular arrhythmia (n = 2), ventricular arrhythmia (n = 1), and pacemaker/defibrillator-insertion (n = 1). The overall rate of cardiovascular and noncardiovascular complications was 9.2% (n = 7) and 10.5% (n = 8) during the 30 days. Mortality rate was 0%. Comparison of rate of complications between groups did not show any statistical difference; no significant difference was found when comparing patients with prior CR to the 76 patients in the control group (P > .05). CONCLUSIONS: Although revascularized individuals have severe co-morbidities and are high-risk patients, bariatric surgery remains safe in this population when outcomes are compared with bariatric patients without prior CR.

Outcomes of reoperative surgery in severely obese patients after sleeve gastrectomy: a single-institution experience.

BACKGROUND: Despite its popularity, sleeve gastrectomy (SG) is not devoid of postoperative complications and weight regain. Some of these cases warrant conversion to Roux-en-Y gastric bypass or proximal gastrectomy with Roux-en-Y esophagojejunostomy. Complications after conversion are scarcely reported in the literature. OBJECTIVES: Report and review the outcomes of reoperation on severely obese patients with weight regain or complications after SG. SETTING: Bariatric Surgery Center of Excellence; Community Hospital, United States. METHODS: We retrospectively reviewed the medical records of patients converted from SG to Roux-en-Y gastric bypass/proximal gastrectomy with Roux-en-Y esophagojejunostomy at our center, from 2004 to 2018. Patients were stratified by reason for conversion. Group A included those converted for complications (leaks, strictures, or gastroesophageal reflux disease) and group B for reported weight regain. Demographic characteristics, postoperative outcomes, and complications were described. RESULTS: From 77 conversions identified, 63.6% (n = 49) underwent primary SG at an outside hospital. We observed predominant female (68.8%; n = 53) and Caucasian (76.6%; n = 59) populations. Conversions for complications were performed in 67.5% (n = 52) and for weight regain in 32.4% (n = 25). The most common conversion indication in group A was chronic leak (29.9%; n = 23), followed by gastroesophageal reflux disease (20.8%; n = 16), and stricture (16.9%; n = 13). Overall, major complications occurred in 16.9% (n = 13) and minor complications in 19.4% (n = 15). In group A, most common major complications were anastomotic leak and organ space surgical site infection (3.9%; n = 2 each); the most common minor complication was nonperforated marginal ulcer (7.7%; n = 4). In group B, the most common major complication was perforated marginal ulcer (8%; n = 2); the most common minor complication was stricture (16%; n = 4). Group B mean preconversion body mass index was 38.4 ± 4.3 and percentage excess body mass index loss was 48 ± 33, 63 ± 45, 59 ± 63, and 73 ± 25 (12, 24, 36, ≥48 mo). CONCLUSIONS: Our experience shows that major complications can occur in up to 17% of patients after conversion. Conversion to Roux-en-Y gastric bypass in nonresponders appears to be a safe and effective option for body mass index reduction.