Bariatric Population Research Articles

A5170 - Effect of Preoperative Physical Function Status on Perioperative Bariatric Surgery Outcomes

More than one-third (35.7 %) of the adult population in the United States suffers from obesity. Bariatric surgery remains the only effective long-term weight loss option for this population. Perioperative determinants of morbidity and mortality in the bariatric surgery population are continuously being studied. Some of these factors include patient age, gender, comorbidities, BMI, chronic corticosteroid use, smoking and functional limitation. The purpose of this study was to determine if self-reported preoperative physical function status affects 30-day post-operative bariatric surgical outcomes.

A5094 - Chronic Pain in an Adult Bariatric Surgery Population

A5094 - Chronic Pain in an Adult Bariatric Surgery Population

Editorial introductions

Editorial introductions

A306 - A Brief Four Session CBT Group To Increase Knowledge and Coping Skills in a High-Risk Bariatric Surgery Population: Who Is Referred and Who Responds Best?

A306 - A Brief Four Session CBT Group To Increase Knowledge and Coping Skills in a High-Risk Bariatric Surgery Population: Who Is Referred and Who Responds Best?

A309 - Brief Group Treatment of Binge Eating Behaviors in a Pre-Surgical Bariatric Population in a Rural Setting

A309 - Brief Group Treatment of Binge Eating Behaviors in a Pre-Surgical Bariatric Population in a Rural Setting

Bariatric Care Requires Much More Than Just Bigger Beds

LOS ANGELES — More than a third of people in the United States older than 65 are estimated to be obese, and the percentage may be higher than 40% among those 65 to 74. These numbers could translate to millions of seniors who will need bariatric care when they arrive in American nursing homes. The problem: Many nursing facilities aren’t ready to meet the special needs of the extremely obese. It’s not just a matter of seeking heavy-duty walkers, wheelchairs, and Hoyer lifts. A huge variety of extra-large devices and supplies are needed, ranging from slippers, incontinence pads, and toilets to armchairs, stretchers, shower chairs, and much more. The key is to understand and meet the unique needs of obese individuals, said Traci Clark, RN, director of nursing at Creekside Rehabilitation & Behavioral Health in Santa Rosa, CA. And that’s not all. Nursing staff must also understand how the size of residents affects their medical care in unexpected ways. “There’s no way to do CPR on someone who’s bariatric,” Ms. Clark said at the California Association of Long-Term Care Medicine’s annual meeting.Similarly, the Heimlich maneuver may require more than one person. “You can’t do a Heimlich maneuver if you can’t get your arms around them,” she said. “My arms will not go around a 56-inch chest. You need to have two people do it. These are some of the things that no one thinks about.” Five years ago, the Centers for Disease Control & Prevention examined statistics from 2007–2010 and estimated that 35% of adults 65 and older were obese — about 13 million people. The CDC estimated that 41% of those 65 to 74 years old were obese, as were 28% of those 75 and older. Researchers noted that several groups were at higher risk of obesity as seniors: black women (49% of those 75 and older were obese) and women with less than a high school education. Over time, from 1999 to 2010, senior men saw a major jump in obesity levels, including a remarkable rise from 18% in 1999–2002 to 27% in 2007–2010 (NCHS Data Brief, no. 106, September 2012). Although bariatric patients may need extra nursing care because of their comorbid conditions, there is a major gap in one area of nursing home medicine — hospice. Ms. Clark pointed to a 2017 study that looked at 5,677 Medicare beneficiaries who died from 1998 to 2012. Of those, 117 had BMIs of at least 40; only 23% of them received care in hospice compared with 34% of all beneficiaries (Ann Intern Med 2017;166:381–389). Ms. Clark recommended that nursing homes lease or buy these supplies and devices to serve a bariatric population: •Tape measures.•Extra-wide bedpans, commodes (up to 42 inches wide), beds (expandable up to 54 inches wide), armchairs and stretcher chairs (up to 32 inches wide), and wheelchairs (with widths of 26 inches, 28 inches, and larger).•Bariatric-size friction-reducing devices such as slider sheets.•Trapeze bar systems over beds.•Extra-capacity walkers, floor and ceiling lifts, slings, shower chairs (or shower stretchers), aids for standing and raising, and stepstools.•Extra-large or even larger clothing, including gowns, briefs, incontinence pads, and slippers.•Extra-wide stretchers with 1,000-pound capacity.•Appropriately sized medical tools such as longer needles and larger blood pressure cuffs. Everyone must keep in mind the Hoyer lift’s weight capacity, Ms. Clark advised, and understand that even 450 pounds may not be enough. Ms. Clark also advised nursing facilities to consider whether their rooms are large enough to handle bariatric patients. “Think about six people simultaneously turning someone, plus a lift,” she said. “Sleep apnea is almost guaranteed,” she added, so accommodations may need to include a continuous positive airway pressure (CPAP) machine and an oxygen concentrator, as well as a bedside commode. Ms. Clark pointed to other challenges such as the need for intensive skin management, and she encouraged acceptance of patients who don’t change their eating habits. “We need to support these people even though they’re bringing this on themselves. We have to honor that choice and not chastise.” Randy Dotinga is a San Diego-based freelance writer.

Abdominal imaging post bariatric surgery: predictors, usage and utility

PurposeA lack of well-defined postoperative imaging guidelines for bariatric patients may lead to false-positive findings, radiation exposure, additional cost, and patient anxiety. We investigated our institutional usage and utility of nonroutine postoperative abdominal imaging. Methods and materialsLaparoscopic gastric bypass and sleeve gastrectomy patients over a 5-year period were retrospectively identified. All bariatric-related nonroutine initial and all subsequent prompted abdominal and pelvic imaging was included. ResultsA total of 578 patients were included (399 gastric bypass, 179 sleeve gastrectomy); 907 nonroutine studies in 69% of patients were performed, and 36% patients underwent computed tomography (CT). Only 20.3% of findings were symptom-related, 26% had benign incidental findings, and 50% were negative. Incidental findings prompted 71 additional studies. Bypass procedure (sleeve versus bypass, odds ratio [OR] .3), older age (median 43 versus 48 years), and lower initial body mass index (BMI) (median 43 versus 45) increased the likelihood of imaging. History of prior abdominal surgery and dyspepsia increased the probability of undergoing CT by an odds ratio of 1.8 and 2.0, respectively (P<.05). History of ulcer (OR .6) or reflux on routine upper gastrointestinal imaging (OR .3) decreased probability (P<.05). Patients who underwent CT were more likely to undergo other abdominal imaging (3 versus 1 study per patient, P<.01). ConclusionsPostoperative abdominal imaging in the bariatric population is common, with almost 70% of patients undergoing imaging and 70% of findings not related to patient symptoms. Bypass procedure, older age, and lower initial BMI were associated with a higher likelihood of patients undergoing imaging. Heightened understanding of this important subject is necessary to help streamline cost-effective imaging protocols for these patients.

Validation of the Nexfin® non-invasive continuous blood pressure monitoring validated against Riva-Rocci/Korotkoff in a bariatric patient population

Study objectiveThe present study aimed to validate the Nexfin® monitor and to assess the accuracy compared to classical sphygmomanometry (Riva-Rocci/Korotkoff (RRK)) blood pressure (BP) measurements in patients with obesity scheduled for bariatric surgery. DesignValidation study. SettingOutpatient clinic for bariatric surgery. Patients33 patients scheduled for bariatric surgery. MeasurementsThe validation process was done according to the protocols developed by the European Society of Hypertension from 2010. The Nexfin® monitor (Edwards Lifesciences/BMEYE B.V., Amsterdam, The Netherlands) calculates beat-to-beat blood pressure from finger pulse wave analysis. Measurements of systolic and diastolic BP were obtained using classical sphygmomanometry and the Nexfin® alternatingly. Main resultsIn total 99 pairs of BP measurements were used. The device failed pass phase 1 as 65 systolic readings fell within 5mmHg (73 required). And 61, 76 and 90 diastolic readings fell within 5, 10 and 15mmHg respectively. Finally, it failed to pass phase 2 as 23 patients for systolic and 25 for diastolic had at least 2/3 of their comparisons falling within 5mmHg (24 required) but 10 subjects for systolic and 8 for diastolic had all three comparisons more than 5mmHg different from the RRK readings (zero allowed). Mean differences were 7.8±6.9mmHg for SBP and 8.0±7.2mmHg for DBP. ConclusionUsing the revised protocol, the Nexfin® device was not able to pass validation. However using the original protocol, the Nexfin® device passed phase 1 and 2.1 of the validation process and failed to pass phase 2.2.

Maladaptive eating behavior assessment among bariatric surgery candidates: Evaluation of the Eating Disorder Diagnostic Scale

BackgroundEating pathology among bariatric surgery candidates is common and associated with adverse outcomes. However, its assessment is complicated by the inconsistent use of standardized measures. We addressed this by examining the use of the Eating Disorder Diagnostic Scale (EDDS) in a large bariatric sample (N = 343). ObjectivesTo evaluate the EDDS among bariatric surgery candidates via examination of: (1) Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) and fifth edition (DSM-5) rates of binge eating disorder, bulimia nervosa, and maladaptive eating behaviors, and (2) the relationship between response biases and self-reported eating disorder symptoms. SettingParticipants were bariatric surgery candidates at a large public hospital in the Midwest. MethodsAs part of a larger preoperative evaluation, 343 patients seeking bariatric surgery completed the EDDS and measures of problematic response bias. ResultsApproximately 16% of the sample met full threshold criteria for binge eating disorder using DSM-5 criteria. Using the DSM-IV-TR, rates were lower but still substantial at 13%. Rates for bulimia nervosa were 8% (DSM-5) and 6% (DSM-IV-TR). The majority (66.1%) of participants reported at least one binge-eating episode per week. The most commonly used compensatory behavior was fasting (20.4%), followed by excessive exercise (11.7%), laxative use (5.6%), and vomiting (1.8%). An inverse relationship between severity of the eating symptomatology and problematic response bias emerged. ConclusionThe EDDS shows promise as a screening tool that uses diagnostic criteria to provide rates of binge eating and eating psychopathology among surgical candidates. Our findings suggest that subsequent validation studies of this measure are needed, should address potential response bias concerns, and should employ clear definitions of binge eating to promote standardization of eating pathology assessment in the bariatric population.

RYGB and Drug Disposition: How to Do Better? Analysis of Pharmacokinetic Studies and Recommendations for Clinical Practice.

An important issue in the follow-up of patients with bariatric surgery remains to determine whether their therapeutic management should be different after surgery. In this article, we first reviewed all pharmacokinetic studies involving at least four subjects who underwent the Roux-en-Y gastric bypass (RYGB) bariatric surgery. Twenty-five publications were selected and, overall, 25 drugs were studied. Drug solubility and permeability parameters for each drug were defined using different parameters or classifications. Increased rates of oral drug absorption were predominantly observed. Conversely, drug exposure differed from one drug to another. Considering the galenic formulation and the Biopharmaceutics Classification System (BCS) class may help the prediction of oral drug exposure outcome after RYGB. We propose a strategy aiming to guide prescription and drug monitoring in patients with RYGB. But further research is clearly needed due to the unique characteristics of the bariatric population. Priority should be given to drugs that do not have clinical or biological surrogates for dose adaptation.

Sleeve gastrectomy in the elderly: A case-control study with long-term follow-up of 3 years

BackgroundAdvanced age is considered to be a relative contraindication to bariatric surgery because of increased perioperative risk and suboptimal excess weight loss. ObjectivesThe aim of this study was to analyze the safety and effectiveness of the sleeve gastrectomy (SG) procedure in a cohort of elderly patients (aged≥60 yr) compared with younger patients (aged<60 yr). SettingHospital clinic, Barcelona, Spain. MethodsA retrospective analysis of all cases of SG in patients≥60 years old between January 2006 and December 2012 was performed. ResultsThe study included 206 patients, 103 in each group. The mean age was 63.3±2.8 years, and the body mass index was 45.8±22.8 kg/m2. The overall complication rate within the elderly group was 9.7% versus 15.5% in the younger group (P = .2). After SG, there was no statistical difference in body mass index between the groups until 24 (33.4 versus 31.5 kg/m2, P = .01) and 36 (34.6 versus 32.8 kg/m2, P = .01) months of follow-up, favoring the younger cohort. Mean percent excess weight loss was similar between the groups during all periods of follow-up. The mean percent total weight loss change was statistically higher in the younger group at 3 (15.1% versus 17.1%, P = .03); 6 (25.2% versus 27.5%, P = .04); 12 (32.4% versus 35.2%, P = .03); 24 (26.7% versus 32.4%, P<.01); and 36 months (24.9% versus 29.1%, P<.01). Neither groups revealed a statistical difference in resolution of all co-morbidities, except for obstructive sleep apnea (P = .02) in the younger group. ConclusionsSG is a safe and feasible procedure in the elderly with results comparable to those in the standard bariatric population.

Systems innovation model: an integrated interdisciplinary team approach pre- and post-bariatric surgery at a veterans affairs (VA) medical center

BackgroundProvision of bariatric surgery in the Veterans Health Administration must account for obese veterans’ co-morbidity burden and the geographically dispersed location of patients relative to Veterans Affairs (VA) bariatric centers. ObjectivesTo evaluate a collaborative, integrated, interdisciplinary bariatric team of surgeons, bariatricians, psychologists, dieticians, and physical therapists working in a hub-and-spokes care model, for pre- and post-bariatric surgery assessment and management. MethodsThis is a description of an interdisciplinary clinic and bariatric program at a VA healthcare system and a report on program evaluation findings. Retrospective data of a prospective database was abstracted. For program evaluation, we abstracted charts to characterize patient data and conducted a patient survey. ResultsSince 2009, 181 veterans have undergone bariatric surgery. Referrals came from 7 western U.S. states. Mean preoperative body mass index was 46 kg/m2 (maximum 71). Mean age was 53 years, with 33% aged>60 years; 79% were male. Medical co-morbidity included diabetes (70%), hypertension (85%), and lower back or extremity joint pain (84%). A psychiatric diagnosis was present in 58%. At 12 months, follow-up was 81% and percent excess body mass index loss was 50.5%. Among 54 sequential clinic patients completing anonymous surveys, overall satisfaction with the interdisciplinary team approach and improved quality of life were high (98% and 94%, respectively). ConclusionThe integrated, interdisciplinary team approach using a hub-and-spokes model is well suited to the VA bariatric surgery population, with its heavy burden of medical and mental health co-morbidity and its system of geographically dispersed patients receiving treatment at specialty centers. As the VA seeks to expand the use of bariatric surgery as an option for obese veterans, interdisciplinary models crafted to address case complexity, care coordination, and long-term outcomes should be part of policy planning efforts.

Comparison of two methods for measuring 25-OH vitamin D in the follow-up of patients after bilio-pancreatic diversion bariatric surgery

ObjectiveOur objective was to compare the ECLIA from Roche versus the LC–MS/MS method for quantitation of serum 25-hydroxy-vitamin D in patients who have undergone bariatric surgery. Design and methodsCross-sectional and correlational studies were performed on three different groups for the 25-OH-D levels quantitated by both methods. The control group of apparently healthy subjects was randomly selected in a clinical chemistry laboratory. Test groups were patients who had undergone bilio-pancreatic diversion (BPD) and were supplemented either with vitamin D2 or with vitamin D3. The number of samples per group was established according to the CLSI recommendation protocol (EPO9-A2-IR). ResultsThe agreement of LC-MS/MS with the Roche method was acceptable in the apparently healthy subjects group and in the post-BPD D3-supplemented group with an average bias of −1.7% and −9.2%, respectively. However, this agreement was unacceptable in the post-BPD D2-supplemented group with an average bias of −45.3%. The LC–MS/MS enabled us to detect four patients who had excess vitamin D or poisoning with vitamin D for which it was necessary to stop the supplementation with vitamin D in the D2 -supplemented group. ConclusionDespite the apparent good agreement between the Roche method and LC–MS/MS in the healthy subjects group and in the post-DBP D3-supplemented patient group, a considerable bias seems to exist, particularly in the presence of D2. The LC–MS/MS method is therefore the most accurate method to follow the vitamin D2 -supplemented bariatric population.

Quality of life and bariatric surgery: a systematic review of short- and long-term results and comparison with community norms.

Currently the effects of bariatric surgery are generally expressed in excess weight loss or comorbidity reduction. Therefore the aim of this review was to provide insight in the available prospective evidence regarding the short and long-term effects of bariatric surgery on Quality of Life (QoL) and a comparison with community norms. A systematic multi-database search was conducted for 'QoL' and 'Bariatric surgery'. Only prospective studies with QoL before and after bariatric surgery were included. The 'Quality Assessment Tool for Before-After Studies with No Control Group' was used to assess the methodological quality. Thirty-six studies met the inclusion criteria. Most studies were assessed to be of 'fair' to 'good' methodological quality. Ten different questionnaires were used to measure QoL. Follow-up ranged from 6 months to 10 years, sample sizes from 26 to 1276 and follow-up rates from 45 to 100%. A significant increase in QoL after bariatric surgery was found in all studies (P⩽0.05), however, mostly these outcomes stay below community norms. Only outcomes of the IWQoL, SF-36 and OWQoL show QoL outcomes that exceed community norms. The QoL is increased after bariatric surgery on both the short and long term. However, due to the heterogeneity of the studies and the generality of the questionnaires is it hard to make a distinction between different surgeries and difficult to see a relation with medical profit. Therefore, tailoring QoL measurements to the bariatric population is recommended as the focus of future studies.

Androgen and Estrogen Shifts in Men Before and After Bariatric Surgery and Links to Vitamins and Trace Elements.

Androgens and estrogens play a key role regarding sexual life and reproduction. Along with hypotestosteronemia, obese men exhibit a 2-fold increase in estradiol concentration, adversely infl uencing these parameters. Estrogens and adipokines also infl uence bone metabolism, exerting a direct effect on vitamin D, calcium homeostasis and bone health. Bariatric procedures normalize some sex hormones, and may reverse several obesity-related conditions. Estrogens levels may remain elevated postoperatively, and despite its protective effect on the skeleton, bariatric patients are more prone to fractures when compared to the general population. Multiple nutritional defi cits are common after bariatric interventions, and hypozincemia is the most likely to negatively infl uence reproductive parameters. Zinc is an essential element for normal spermatogenesis, and severe hypozincemia is associated with infertility in both sexes. Vitamin D also acts as a regulator of several enzymes involved in steroid hormone production, and its defi ciency could impair reproductive function. Few studies have addressed changes in sex hormones and in reproductive function in the male bariatric population, as they represent a minority of surgical candidates. Although obesity rates and burden are similar for both sexes, society is more lenient with the obese male. Moreover, 73 % of overweight/obese men are satisfi ed with their health, causing body weight and obesity-related health problems to increase when they opt for bariatric surgery. In the present article, we discuss shifts of sex hormones before and after bariatric surgery, surgery impact on semen quality, skeletal health and nutrients, and new research directions regarding links between vitamin D, zinc, androgens and reproduction.

Abdominoplasty with Scarpa fascia preservation – comparative study in a bariatric population

BackgroundAbdominoplasty techniques using a more superficial plane of dissection with Scarpa fascia preservation have been shown to improve recovery and reduce complications in nonbariatric patients. Patients who have experienced massive weight loss frequently need body contour procedures and represent a high-risk group. ObjectiveTo evaluate the effect of this technique in patients with massive weight loss after bariatric surgery. SettingUniversity hospital, Portugal. MethodsThis was a single-center retrospective study of 51 postbariatric patients who had been undergone either a classic full abdominoplasty (group A) or a similar procedure except for the preservation of Scarpa fascia below the umbilicus (group B). General characteristics of both groups were analyzed, and recorded outcomes were total and daily volume of drain output, time until drain removal, time until hospital discharge, and local and systemic complications. ResultsThere were no statistically significant differences between groups regarding general characteristics or complications. The Scarpa fascia preservation group had a highly significant reduction of 79% on the total drain output, 7 days until drain removal, and 5 days’ hospital stay. Long drainers (7 days or more with drains) were eliminated (reduction from 52% in group A to 3% in group B) and seroma had a 65% reduction. ConclusionPreserving Scarpa fascia during a full abdominoplasty in postbariatric patients improves recovery by reducing total drain output and hospital stay, allowing earlier drain removal, eliminating long periods with suction drains, and reducing seroma incidence. Clear benefits for the patient were obtained.

Duration of Nil Per Os is causal in hospital length of stay following laparoscopic bariatric surgery.

A recent bariatric surgical study demonstrated an inverse relationship of intraoperative hydration with the incidence of extended hospital length of stay (ehLOS: >1 postoperative hospital day). In that study, a post hoc analysis of the preoperative duration of Nil Per Os (NPO) past midnight revealed a significant dose-response association on the incidence of ehLOS, with the lowest incidence (10-12%) predicted within the 2-5-h NPO interval. As NPO is associated with a state of compensatory dehydration, the objectivesof this study were to prospectively examine the role of decreasing preoperative NPO intervals on the incidence of ehLOS in a similar bariatric surgical population and to establish causality of this association. Following IRB approval, 168 bariatric surgeries were analyzed following institution of a revised oral water ad libitum policy until 2h prior to surgery on the incidence of ehLOS. The role of duration of NPO on the incidence of ehLOS was assessed by logistic fit graphs and misclassification rates on the two groups. A statistical process control chart monitored the efficacy of the revised NPO guidelines. There were statistically significant, but not clinical, differences in the incidences of histories of anemia, gastroesophageal reflux disease, previous percutaneous cardiac intervention/percutaneous transluminal coronary artery angioplasty, or preoperative albumin levels between the two groups. There were no perioperative pulmonary aspirations of gastric contentsin either group. Following reduction of the oral hydration interval to ≥2h, a 13-15% incidence of ehLOS was observed within the 2-5-h NPO interval with similar misclassification rates observed between the two groups. Allowing bariatric patients access to ad libitum water for up to 2h prior to surgery decreased the incidence of ehLOS. Comparison of the dose-response curves within the 2-5-h NPO intervals before and after introduction of the revised NPO guidelines was similar and confirms causality.

Barium swallow for hiatal hernia detection is unnecessary prior to primary sleeve gastrectomy

BackgroundHiatal hernia (HH) is common in the bariatric population. Its presence imposes various degrees of difficulty in performing laparoscopic sleeve gastrectomy (LSG). Preoperative upper gastrointestinal evaluation consists of fluoroscopic and or endoscopic studies ObjectivesTo evaluate the efficacy of routine, preoperative barium swallow in identifying HH in patients undergoing LSG, and determine if such foreknowledge changes operative and immediate postoperative course regarding operative time, intraoperative adverse events, and length of hospital stay (LOS). In addition, to quantify HH prevalence in these patients and correlate preoperative patient characteristics with its presence. SettingHigh-volume bariatric practice in a private hospital in Israel MethodsRetrospective analysis of prospectively collected data between October 2010 and March 2015: anthropometrics, co-morbidities, previous barium swallow, preoperative HH workup (type and result), operative and immediate postoperative course. ResultsPrimary LSG was performed in 2417 patients. The overall prevalence of HH was 7.3%. Preoperative diagnosis of gastroesophageal reflux disease and female gender were independent risk factors for HH presence. Operative times were significantly longer when HH was concomitantly repaired but “foreknowledge” thereof did not assist in shortening this time. Looking for an HH that was suggested in preoperative upper gastrointestinal evaluation slightly prolonged surgery. LOS was not changed in a significant fashion by HH presence and repair, whether suspected or incidentally found. ConclusionRoutine, pre-LSG barium swallow does not seem to offer an advantage over selective intraoperative hiatal exploration, in the discovery and management of HH. Conversely, when preoperative workup yields a false-positive result, surgery is slightly prolonged.

A5108 - Marijuana use and outcomes in the bariatric population

A5108 - Marijuana use and outcomes in the bariatric population

A5043 - “Factors that Influence Blood Pressure Following Bariatric Surgery”

The effect that bariatric surgery may have on blood pressure (BP) of hypertensive and non-hypertensive patients is not well understood. In this study we aim to examine the predictors of postoperative (postop) systolic and diastolic blood pressure values in the bariatric population.