Elective Bariatric Surgery Research Articles

ADVANTAGES OF USING DEXMEDETOMIDINE AS AN ADJUVANT IN LAPAROSCOPIC BARIATRIC SURGERIES

The global rise in obesity rates has necessitated an increased frequency of bariatric surgeries, posing intricate challenges in anesthesia management. Dexmedetomidine, an α2-adrenergic receptor agonist, has emerged as a potential adjunct to general anesthesia in this context. This study aimed to evaluate the efficacy and safety of dexmedetomidine in 1306 adult patients undergoing elective bariatric surgery between January 2017 and September 2023, comparing outcomes with a placebo group.Dexmedetomidine was administered during both the maintenance phase of anesthesia. Key parameters including intraoperative and postoperative complications, analgesic requirements, hemodynamics, and recovery profiles were meticulously monitored and analyzed. Dexmedetomidine demonstrated sedative and analgesic-sparing effects, coupled with cardiovascular stabilization and preservation of respiratory function. Notably, it significantly reduced the utilization of anesthetic drugs, postoperative opioids, and propofol during the surgical procedure. Furthermore, dexmedetomidine exhibited efficacy in attenuating propofol injection pain, mitigating stress responses during the critical phase of extubation, and diminishing postoperative pain along with associated analgesic requirements. However, a nuanced approach to dosage was imperative, as higher doses correlated with delayed respiratory recovery and an increased incidence of bradycardia.To summarize, dexmedetomidine as an adjuvant to general anesthesia in bariatric surgery presents notable advantages in enhancing recovery profiles, mitigating complications, and improving patient comfort. Optimal dosing strategies are paramount to harnessing its benefits while mitigating potential adverse effects, thereby optimizing perioperative care in this patient population.

The impact of COVID-19 pandemic on patient selection and access to care, approach type, and postoperative outcomes in bariatric surgery

BackgroundThe COVID-19 pandemic had affected the health systems across the world since early 2020 with a concern about access to medical care during the first wave of COVID-19 pandemic. ObjectivesThe objective of this study was to examine how the COVID-19 pandemic influenced patient selection, approach type, and postoperative outcomes in elective bariatric surgery. SettingUnited States. MethodsData from the MBSAQIP database for the years 2016–2020 were queried. Wilcoxon rank-sum test and Fisher's exact test were employed for continuous and categorical variables, respectively. Postoperative outcomes within 30 days were assessed separately and based on the Clavien-Dindo (CD) classification of III-V. χ2 test and logistic regression were used to compare outcomes between procedure and approach types, as well as surgical operation periods. ResultsA total of 741,620 patients underwent robotic and laparoscopic sleeve gastrectomy and Roux-en-Y gastric-bypass. The cases performed in 2020 exhibited lower comorbidities and postoperative complications compared to prepandemic years, regardless of the approach type. Notably, the proportion of White patients decreased during the pandemic, while there was an increase in the number of African American and Hispanic patients who had bariatric surgery. ConclusionsPatients who underwent bariatric surgery during the COVID-19 pandemic appeared to be healthier with fewer comorbidities and experienced fewer adverse postoperative outcomes compared to those who had surgery prior to the pandemic. This study highlights the limited access to bariatric surgery for high-risk patients during the pandemic.

Opportunistic Salpingectomy at the Time of General Surgery Procedures: A Systematic Review and Narrative Synthesis of Current Knowledge

Opportunistic salpingectomy (OS) for the primary prevention of ovarian cancer is performed by gynecologists. Advocates have suggested expanding its use to other surgical specialties. General surgeons are the other group to routinely perform intraperitoneal operations in women and could play a role in ovarian cancer prevention. Herein, we review the current evidence and perioperative factors requiring consideration prior to OS implementation in select general surgery cases. A systematic search was conducted for English-language studies evaluating OS during general surgery. The primary outcomes of this study were the feasibility and safety of OS during general surgery procedures. Secondary outcomes included pre-operative considerations (patient selection and the consent process), operative factors (technique and surgical specialty involvement), and post-operative factors (follow-up and management of operative complications). We evaluated 3977 studies, with 9 meeting the eligibility criteria. Few studies exist but preliminary evidence suggests relative safety, with no complication attributable to OS among 140 patients. Feasibility was reported in one study, which showed the capacity to perform OS in 98 out of 105 cholecystectomies (93.3%), while another study reported quick visualization of the fallopian tubes in >80% of cases. All patients in the included studies were undergoing elective procedures, including cholecystectomy, interval appendectomy, colorectal resection, bariatric surgery, and laparoscopic hernia repair. Studies only included patients ≥ 45 years old, and the mean age ranged from 49 to 67.5 years. Gynecologists were frequently involved during the consent and surgical procedures. OS represents a potential intervention to reduce the risk of ovarian cancer. Ongoing studies evaluating the general surgeon’s understanding; the consent process; the feasibility, operative outcomes, and risks of OS; and surgeon training are required prior to consideration.

Population pharmacokinetics of prophylactic cefoxitin in elective bariatric surgery patients: a prospective monocentric study

BackgroundThis study describes the population pharmacokinetics of cefoxitin in obese patients undergoing elective bariatric surgery and evaluates different dosing regimens for achievement of pre-defined target exposures. MethodsSerial blood samples were collected during surgery with relevant clinical data. Total serum cefoxitin concentrations were measured by chromatographic assay and analysed using a population PK approach with Pmetrics®. The cefoxitin unbound fraction (fu) was estimated. Dosing simulations were performed to ascertain the probability of target attainment (PTA) to achieve cefoxitin fu above minimum inhibitory concentrations (MIC) from surgical incision to wound closure. Fractional target attainment (FTA) was calculated against MIC distributions of common pathogens. ResultsA total of 123 obese patients (median BMI 44.3 kg/m2) were included with 381 cefoxitin concentration values. Cefoxitin was best described by a one-compartment model, with a mean clearance and volume of distribution of 10.9 ± 6.1 L/h and 23.4 ± 10.5 L, respectively. In surgery <2 h, a 2 and a 4 g doses were sufficient for an MIC up to 4 and 8 mg/L (fu 50%), respectively. In prolonged surgery (2–4 h), only continuous infusion enabled optimal PTA for an MIC up to 16 mg/L. Optimal FTAs were obtained against Staphylococcus aureus and Escherichia Coli only when simulating with 50% cefoxitin protein binding (intermittent regimen) and regardless of the protein binding for the continuous infusion. ConclusionIntermittent dosing regimens resulted in optimal FTAs against susceptible MIC distributions of S. aureus and E. coli when simulating with 50% cefoxitin protein binding. Continuous infusion of cefoxitin may improve FTA regardless of protein binding. Study registrationRegistration on ClinicalTrials.gov, NCT03306290

Characterization of Early Small Bowel Obstructions Following Elective Bariatric Surgery.

Small bowel obstruction (SBO) after bariatric surgery is an uncommon but important complication. We sought to characterize bariatric surgery patients who developed SBO, to compare 30-day complications, and to determine the influence of patient and procedure factors on the development of SBO. All data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database using the 2020 operative year. Multivariable logistic regression modelling was used to determine the influence of patient and operative factors on the development of SBO. Of a total of 142 111 patients, 408 (0.3%) were identified as having developed an SBO. SBO patients were older (45.7 ± 11.5 vs. 43.5 ± 11.9years; p = 0.0002), of reduced BMI (43.6 ± 6.8 vs. 45.1 ± 7.7; p = 0.0001), and more likely to be of female sex (92.2% vs. 81.1%; p < 0.0001). At 30days post-operation, serious complications were increased in SBO patients. Roux-en-Y gastric bypass (RYGB) was the largest independent predicator of the development of SBO (OR 11.91; 95% CI 8.92-15.90; p < 0.0001). With regard to patient factors, COPD (OR 2.60; 95% CI 1.54-4.38; p < 0.0001) and prior DVT (OR 2.37; 95% CI 1.49-3.77; p < 0.0001) were found to be independently predictive of the development of SBO. Additionally having a lower BMI and being of female sex were found to be independently predictive. SBO occurred in approximately 0.3% of MBSAQIP cases. SBO is associated with serious outcome measures and patients of female sex and reduced index BMI, and those undergoing RYGB may be at an increased risk.

The outcomes of Re-Redo bariatric surgery—results from multicenter Polish Revision Obesity Surgery Study (PROSS)

The increasing prevalence of bariatric surgery has resulted in a rise in the number of redo procedures as well. While redo bariatric surgery has demonstrated its effectiveness, there is still a subset of patients who may not derive any benefits from it. This poses a significant challenge for bariatric surgeons, especially when there is a lack of clear guidelines. The primary objective of this study is to evaluate the outcomes of patients who underwent Re-Redo bariatric surgery. We conducted a retrospective cohort study on a group of 799 patients who underwent redo bariatric surgery between 2010 and 2020. Among these patients, 20 individuals underwent a second elective redo bariatric surgery (Re-Redo) because of weight regain (15 patients) or insufficient weight loss, i.e. < 50% EWL (5 patients). Mean BMI before Re-Redo surgery was 38.8 ± 4.9 kg/m2. Mean age was 44.4 ± 11.5 years old. The mean %TWL before and after Re-Redo was 17.4 ± 12.4% and %EBMIL was 51.6 ± 35.9%. 13/20 patients (65%) achieved > 50% EWL. The mean final %TWL was 34.2 ± 11.1% and final %EBMIL was 72.1 ± 20.8%. The mean BMI after treatment was 31.9 ± 5.3 kg/m2. Complications occurred in 3 of 20 patients (15%), with no reported mortality or need for another surgical intervention. The mean follow-up after Re-Redo was 35.3 months. Although Re-Redo bariatric surgery is an effective treatment for obesity, it carries a significant risk of complications.

A Comparison of Miller Straight Blade and Macintosh Blade Laryngoscopes for Intubation in Morbidly Obese Patients

The primary objective of this study was to demonstrate whether the Miller blade laryngoscope could provide better visualization of the vocal cords in morbidly obese patients than the Macintosh blade laryngoscope. The secondary objective was to identify the patient-measured factors associated with better visualization of the vocal cords when using the Miller vs. Macintosh blade, as well as whether the application of external pressure might improve the visibility of the glottis during intubation. A prospective, observational study encompassing 110 patients with a BMI &gt; 40 undergoing elective bariatric surgery and intubation procedure was performed. The evaluation of the vocal cords was performed according to the Cormack–Lehane scale and POGO scale in the same patient during intubation, performed with a Miller and a Macintosh blade laryngoscope, in a random matter. The following parameters were assessed: body weight, height, BMI, neck circumference, thyromental distance, sternomental distance, mouth opening, and Mallampati scale and their impact on visualization of the vocal cords using the Miller blade without the application of external pressure. The Miller blade provides an improved view of the glottis compared to the Macintosh blade measured with both the Cormac–Lehane scale (45 (40.91%) without external pressure application on the larynx, and 18 (16.36%) with external pressure application on the larynx) and the POGO scale (45 (40.91%) without external pressure application on the larynx, and 19 (17.27%) with external pressure application on the larynx). The application of laryngeal pressure improved the view of the glottis. Among the measured features, a significant improvement in the visibility of the glottis could be found in patients with a BMI over 44.244 kg/m2 and a neck circumference over 46 cm. To conclude, the usage of the Miller blade improves the visibility of the glottis compared to the Macintosh blade in morbidly obese patients. The recommendation to use the Miller blade in this group of patients requires further investigation, taking into account the effectiveness of the intubation. Trial Registration: NCT05494463.

Bariatric surgery provision in response to the COVID-19 pandemic: retrospective cohort study of a national registry.

When surgery resumed following the outbreak of the COVID-19 pandemic, guidelines recommended the prioritization of patients with greater obesity-related co-morbidities and/or higher body mass index. The aim of this study was to record the effect of the pandemic on total number, patient demographics, and perioperative outcomes of elective bariatric surgery patients in the United Kingdom. The United Kingdom National Bariatric Surgical Registry was used to identify patients who underwent elective bariatric surgery during the pandemic (1 yr from April 1, 2020). Characteristics of this group were compared with those of a pre-pandemic cohort. Primary outcomes were case volume, case mix, and providers. National Health Service cases were analyzed for baseline health status and perioperative outcomes. Fisher exact, χ2, and Student t tests were used as appropriate. The total number of cases decreased to one third of pre-pandemic volume (8615 to 2930). The decrease in operating volume varied, with 36 hospitals (45%) experiencing a 75%-100% reduction. Cases performed in the National Health Service fell from 74% to 53% (P < .0001). There was no change in baseline body mass index (45.2 ± 8.3 kg/m2 from 45.5 ± 8.3 kg/m2; P = .23) or prevalence of type 2 diabetes (26% from 26%; P = .99). Length of stay (median 2 d) and surgical complication rate (1.4% from 2.0%; relative risk = .71; 95% CI .45-1.12; P = .13) were unchanged. In the context of a dramatic reduction in elective bariatric surgery due to the COVID-19 pandemic, patients with more severe co-morbidities were not prioritized for surgery. These findings should inform preparation for future crises.

FRI247 Case Of Metabolic Resolution Of Non-classic Congenital Adrenal Hyperplasia Post Roux-En-Y Gastric Bypass

Abstract Disclosure: K.G. Romo: None. S. Shu: None. M. Gabriel: None. S. Bhamre: None. Q.Z. Iqbal: None. A.A. Noor: None. G.I. Uwaifo: None. Background: Non-classic congenital adrenal hyperplasia (NCCAH) is an autosomal recessive disorder resulting from loss of function mutations of the 21-hydroxylase gene. It is characterized by mild cortisol deficiency, excess ACTH production, and androgen excess, often with various features of dysmetabolic syndrome. Elective bariatric surgery is one of the most effective long-term management strategies for morbid and complicated obesity. This case presents a woman with NCCAH and complicated morbid obesity who s/p Roux-en-Y Gastric Bypass (RYGB) had metabolic resolution of NCCAH and no longer required glucocorticoid (GC) therapy. Clinical Case: A 34-year-old G1P1 woman with NCCAH on glucocorticoid therapy, treated hypothyroidism with thyroid nodular disease, dyslipidemia, and morbid obesity (pre-RYGB BMI 60-69.9) initially presented to endocrinology on account of hirsutism and secondary amenorrhea attributed to PCOS. Work-up then confirmed diagnosis of NCCAH with 21-hydroxylase genetic testing showing deletion of one copy of CYP21A2 and the pathogenic variant p.V282L in the remaining copy. Outside the peripartum period, she was managed with OCP therapy, spironolactone, and metformin. She was additionally prescribed GC therapy of hydrocortisone 10mg TID following her diagnosis of NCCAH. She subsequently became pregnant unexpectedly. Post-partum course was complicated by significant weight gain, which led her to seek elective bariatric surgery for long-term weight management. At 5 months post-op, she had a weight deficit of ∼100lbs. Although she self-discontinued GC therapy due to fear of weight gain, her amenorrhea resolved, her hirsutism significantly improved, and lab testing revealed normalization of all NCCAH markers, including ACTH, 17-OHP, and androstenedione. Thus, GC therapy was not restarted. At 11 months post-op and still off GC therapy, she had a total weight deficit of ∼160lbs and continued metabolic resolution of NCCAH markers. Conclusions: This case presents a patient with NCCAH and morbid obesity who no longer required GC therapy post-RYGB. Presently, GC therapy remains the only available treatment for CAH; however, long-term GC therapy has the potential for myriad possible complications and side effects. Our case presents elective bariatric surgery as a potential and unique treatment option for patients with classic or non-classic CAH who have associated morbid obesity. The exact pathophysiologic basis for this effect and its potential role in long-term management of appropriate CAH patients requires further in-depth study. Presentation: Friday, June 16, 2023

Machine learning prediction of major adverse cardiac events after elective bariatric surgery.

Machine learning (ML) is an emerging technology with the potential to predict and improve clinical outcomes including adverse events, based on complex pattern recognition. Major adverse cardiac events (MACE) after bariatric surgery have an incidence of 0.1% but carry significant morbidity and mortality. Prior studies have investigated these events using traditional statistical methods, however, studies reporting ML for MACE prediction in bariatric surgery remain limited. As such, the objective of this study was to evaluate and compare MACE prediction models in bariatric surgery using traditional statistical methods and ML. Cross-sectional study of the MBSAQIP database, from 2015 to 2019. A binary-outcome MACE prediction model was generated using three different modeling methods: (1) main-effects-only logistic regression, (2) neural network with a single hidden layer, and (3) XGBoost model with a max depth of 3. The same set of predictor variables and random split of the total data (50/50) were used to train and validate each model. Overall performance was compared based on the area under the receiver operating curve (AUC). A total of 755,506 patients were included, of which 0.1% experienced MACE. Of the total sample, 79.6% were female, 47.8% had hypertension, 26.2% had diabetes, 23.7% had hyperlipidemia, 8.4% used tobacco within 1year, 1.9% had previous percutaneous cardiac intervention, 1.2% had a history of myocardial infarction, 1.1% had previous cardiac surgery, and 0.6% had renal insufficiency. The AUC for the three different MACE prediction models was: 0.790 for logistic regression, 0.798 for neural network and 0.787 for XGBoost. While the AUC implies similar discriminant function, the risk prediction histogram for the neural network shifted in a smoother fashion. The ML models developed achieved good discriminant function in predicting MACE. ML can help clinicians with patient selection and identify individuals who may be at elevated risk for MACE after bariatric surgery.

Role of Intraoperative Dexmedetomidine Infusion in Enhanced Recovery after Surgery Protocols for Reducing Postoperative Analgesic Requirements in Laparoscopic Bariatric Surgeries

Abstract Background The prevalence of obesity in modern societies leads to continuous growing of bariatric surgery throughout the world as it is an effective treatment for obesity. Dexmedetomidine (DEX), a selective α2-adrenergic agonist, is an opioid-sparing adjuvant sedative that avoids respiratory depression and has been shown to be beneficial in bariatric surgery patients Aim of the Work The aim of this study is to evaluate the analgesic profile of intraoperative Dexmedetomidine on postoperative analgesic requirements. Patients and Methods This study was carried out at bariatric surgery unit - Ain shams University Hospitals and included 06 patients of both sexes undergoing elective laparoscopic bariatric surgery. Results The main finding in this study was that nalbuphine consumption was less in group D compared to group C with p value &amp;lt; 0.001 with high significant difference between the two groups also it revealed a high significant difference between the two groups according to time for first use of rescue analgesia. There was a highly significant difference between the two groups according to hemodynamics including (MAP &amp; HR) but with no clinically significant differences. While there was no significant difference as regard SO2 or respiratory rate Conclusion In patients undergoing bariatric surgeries using of intraoperative dexmedetomidine infusion with its opioid-sparing effect enhanced the recovery of this study population of morbidly obese patients with minimal side-effects.

TO OBSERVE AND ASSESS RELATION BETWEEN PRE-OPERATIVE ANXIETY AND POST-OPERATIVE PAIN IN LAPAROSCOPIC BARIATRIC SURGERY PATIENTS

Background: Pre-operative anxiety in obese patients is expected to be more due to psychological reasons, body habitus, comorbidities, and fear of not waking up from anesthesia. It is associated with emotional and physical problems. Predictive factors are complexity of surgery, the anesthesia, post-operative pain, not being appropriately informed, and psychosocial characteristics of the patient. Not many such studies have been conducted in morbidly obese patients. Objectives: The objective of this study was to determine the correlation between pre-operative anxiety and post-operative pain in obese patients undergoing elective laparoscopic bariatric surgery. Methods: Total 200 patients of the American Society of Anesthesiologists Grade I–III were taken, with BMI &gt;30 kg/m2, who were undergoing elective laparoscopic bariatric surgeries. The amsterdam preoperative anxiety and information scale (APAIS) score was recorded a day prior to surgery. Heart rate, blood pressure, respiratory rate, and SpO2 were recorded pre- and postoperatively. Patients were assessed for pain on the visual analog scale (VAS) in post-operative period at 0-, 1-, 2-, 6-, 12-, and 24-h intervals. All the data were entered in master chart and statistically analyzed (Pearson coefficient of correlation test). Results: There is a positive, weak, statistically significant correlation (r=0.157, p=0.026) between anxiety score (APAIS) and post-operative pain (the highest VAS across all hours). Conclusion: Pre-operative anxiety is directly linked to post-operative pain in obese patients undergoing elective laparoscopic bariatric surgery.

Hypoalbuminemia as a risk factor for complications in revisional/conversional bariatric surgery: an MBSAQIP analysis.

Hypoalbuminemia (HA) is a risk factor for serious complications after elective bariatric surgery. Patients undergoing revisional/conversional bariatric surgery may represent a higher-risk group who often have underlying co-morbid medical illnesses and more complex surgery. This study investigated the postoperative complications in patients with HA undergoing revisional/conversional bariatric surgery. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), years 2015-2019. The MBSAQIP database was used to evaluate patients undergoing non-banding revisional/conversional bariatric surgery between 2015 and 2019. Patients were categorized by serum albumin (≤3.5 g/dL). Variables were assessed via bivariate analysis and multivariable regression. Propensity score matching was conducted to compare gastric bypass (RYGB) to sleeve gastrectomy (VSG). One hundred forty-seven thousand four hundred thirty patients underwent revisional/conversional procedures. After applied exclusions, 58,777 patients were available for analysis. The HA group had a significantly (P < .05) higher prevalence of being black (22.95% versus 17.76%), renal insufficiency (1.08% versus .36%), smoking history (9.47% versus 6.91%), chronic obstructive pulmonary disease (COPD) (2.54% versus 1.33%), and history of deep vein thrombosis (DVT) (4.03% versus 2.3%). Postoperative complications associated with HA included perioperative blood transfusion (3.1% versus 1.27%; P < .001), 30day readmission (10.87 versus 6.77%; P < .001), 30day reoperation (4.9% versus 3.18%; P < .001), and 30day mortality (.40% versus .14%; P < .0001). HA was a significant predictor of 30day readmission in the RYGB versus VSG matched cohort (odds ratio [OR], 1.30; 95% confidence interval [CI], [1.14, 1.48]; P < .001). HA is a risk factor requiring attention for patients undergoing revisional/conversional bariatric surgery and optimization of nutritional status or medical comorbidities associated with HA prior to bariatric surgery may help avoid postoperative complications.

A179 Cardiac Arrest after Elective Primary Bariatric Surgery: An Analysis of Clinical Outcomes and Predictors in The Metabolic And Bariatric Surgery Accreditation And Quality Improvement Program (MBSAQIP) Data Registry

A179 Cardiac Arrest after Elective Primary Bariatric Surgery: An Analysis of Clinical Outcomes and Predictors in The Metabolic And Bariatric Surgery Accreditation And Quality Improvement Program (MBSAQIP) Data Registry

A261 The Impact of the COVID-19 Pandemic on Elective Bariatric Surgery Outcomes, Complications and Readmission Rates

A261 The Impact of the COVID-19 Pandemic on Elective Bariatric Surgery Outcomes, Complications and Readmission Rates

Evaluation and Comparison of Two Different Combined Regimens for Prophylaxis of Nausea and Vomiting After Laparoscopic Bariatric Surgery: A Double-Blinded Randomized Clinical Trial

Postoperative Nausea and vomiting (PONV) are the most complications after laparoscopic surgeries, especially laparoscopic bariatric surgeries. The incidence of PONV has been estimated in over two-thirds of patients undergoing laparoscopic bariatric surgeries. Prophylactic combined antiemetic therapy is recommended for patients undergoing these surgeries. This is a double-blinded randomized clinical trial. Eighty-three patients of ASA physical status I and II undergoing elective bariatric laparoscopic surgery were enrolled in this clinical trial and divided into two equal groups through simple randomization using a random number table. One group (group A) received a combination of ondansetron, dexamethasone, and haloperidol (ODH); and the other group (group B) received a combination of ondansetron, dexamethasone, and promethazine (ODP). The ODP group received promethazine 25 mg IM 30 minutes before extubation and ODH group received haloperidol 2 mg IM at the beginning of the surgery. Nausea and vomiting were assessed in terms of severity and frequency in the recovery room, 6, and 24 hours postoperatively in both groups using the Numeric Verbal Rating Scale (NVRS). The frequency of PONV was significantly lower in the ODH group compared to the ODP group in the recovery room (20% versus 40%). PONV severity was lower in the ODH group compared to the ODP group. The time to first rescue antiemetic prescription in the ODP group was more than in the ODH group (7.2 h versus 2.6 h). In morbidly obese patients undergoing laparoscopic bariatric surgery, both antiemetic combinations decreased the incidence of PONV, but the combination of haloperidol, dexamethasone, and ondansetron was more effective than promethazine, dexamethasone, and ondansetron.

A 5-year characterization of trends and outcomes in elderly patients undergoing elective bariatric surgery.

The North American population with severe obesity is aging and with that so will the number of elderly patients (≥ 65years) meeting indications for metabolic surgery. Trends in bariatric delivery in this population are poorly characterized and outcomes remain conflicting, limiting potential uptake and delivery. The MBSAQIP database was used to identify elderly patients (≥ 65years) undergoing elective bariatric surgery from 2015 to 2019. Our objectives were to analyze their unique characteristics, surgical operative trends, and outcomes by comparing to a non-elderly cohort. Multivariable logistic regression identified independent predictors of serious complications and 30-day mortality. There was a total of 751,607 patients, 5.3% (n = 39,854) were elderly. Mean ages were 43 ± 11years (non-elderly) versus 68 ± 3years (elderly). Elderly patients were less likely to be female (70.7% elderly; 80.1% non-elderly) and had lower BMI (43.17 ± 6.64kg/m2 elderly; 45.42 ± 7.87kg/m2 non-elderly). They had higher American Society of Anesthesiologists classification, lower functional status, more insulin dependent diabetes, and hypertension, among other comorbidities. There were no clinically significant differences between the most frequently performed bariatric surgery. Sleeve gastrectomy remained the most common (73.7% non-elderly; 72.3% elderly); however, operative time was longer among the elderly. Functional status was most predictive for both serious complications (OR 1.72; CI 1.53-1.94) and mortality (OR 2.92; CI 1.98-4.31). Surgery among elderly patients was associated with poorer 30-day postoperative outcomes across all categories and was independently associated with serious complications (OR 1.23; CI 1.17-1.30, p < 0.001; AR 4.64%) and 30-day mortality (OR 2.49; CI 2.00-3.11, p < 0.001; AR 0.27%), after adjusting for comorbidities. After adjusting for comorbidities, functional status remains the most predictive factor for poor outcomes; however, elderly patients have increased 30-day odds of serious complications and 30-day mortality, suggesting a need to tailor our approach to these individuals that carry a unique operative risk.

Role of Tranexamic Acid (TXA) in Preventing Bleeding Following Sleeve Gastrectomy: a Systematic Review and Meta-analysis.

Tranexamic acid (TXA) has drawn growing interest over the last decade for its benefit in optimizing post-operative bleeding, yet its role in bariatric surgery is poorly understood. The medical librarian developed and executed comprehensive searches on September 28, 2022. The population of interest included adults who underwent elective bariatric surgery. The intervention was tranexamic acid administration while the comparison was placebo or standard peri-operative therapy. The primary outcome of interest was post-operative bleeding which was defined a priori. A total of four studies were identified comprising of 475 patients. Of those, 207 (50%) received TXA at induction and all underwent laparoscopic sleeve gastrectomy (LSG). The majority of patients were female (n = 343, 80.7%) with ages ranging from 17 to 70years of age and mean BMIs ranging from 37 to 56kg/m2. Post-operative bleeding after LSG ranged from 0 to 28% depending on bleed definition and TXA administration with no differences in venous thromboembolic events or mortality between groups. Meta-analysis of post-operative bleeding demonstrated a statistically significant benefit with TXA administration (OR 0.40; 95% CI 0.23-0.70; p = 0.001) for patients undergoing elective LSG. Intravenous tranexamic acid at the time of laparoscopic sleeve gastrectomy is associated with a significant reduction of post-operative bleeding with no observed differences in thromboembolic events or mortality. Further high-quality studies are needed to better delineate the ideal bariatric population to receives TXA in addition to the optimal timing, dose, and duration of TXA therapy.

Atrial dysrhythmias are independent predictors of serious complications and 30-day mortality after elective bariatric surgery: a retrospective study of 731,981 patients.

The objectives of this study were to characterize the prevalence of atrial dysrhythmias for elective bariatric surgery patients and to explore their impact on postoperative outcomes. Data was extracted from the North American Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to2019. All primary Roux-en-Y gastric bypass and sleeve gastrectomy procedures were included. Patients with atrial dysrhythmias (ADs) were identified as patients coded as receiving preoperative therapeutic anticoagulation without a prior history of deep vein thrombosis, venous thromboembolism, pulmonary embolism, or other conditions requiring anticoagulation. Multivariable logistic regression analysis was used to determine the impact of preoperative ADs on postoperative complications and 30-day mortality. We evaluated 731,981 patients, of whom 13,591 (1.9%) had preoperative ADs. Patients with ADs were more likely to be older, have a higher body mass index, and be male. Metabolic co-morbidities also were more common in those with ADs, as demonstrated by the higher rates of medication use and insulin-dependent diabetes, hypertension, dyslipidemia, and sleep apnea. After adjusting for co-morbidities using multivariable logistic regression, AD was the single greatest independent predictor of serious complications and 30-day mortality. ADs were observed in approximately 2% of MBSAQIP patients. ADs are among the greatest independent predictors of serious complications and mortality, suggesting that these patients are associated with a higher perioperative risk profile warranting further optimization.

Post-Operative but Not Pre-Operative COVID-19 Predicts Serious Complications and Mortality Following Elective Bariatric Surgery.

We sought to characterize the prevalence and subsequent impact of pre- and post-operative COVID-19 diagnosis on bariatric surgery outcomes. COVID-19 has transformed surgical delivery, yet little is known regarding its implications for bariatric surgery. The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was evaluated with three cohorts described: those diagnosed with COVID-19 pre-operatively (PRE), post-operatively (POST), and those without a peri-operative COVID-19 (NO) diagnosis. Pre-operative COVID-19 was defined as COVID-19 within 14days prior to the primary procedure while post-operative COVID-19 infection was defined as COVID-19 within 30days after the primary procedure. A total of 176,738 patients were identified, of which 174,122 (98.5%) had no perioperative COVID-19, 1364 (0.8%) had pre-operative COVID-19, and 1252 (0.7%) had post-operative COVID-19. Patients who were diagnosed with COVID-19 post-operatively were younger than other groups (43.0 ± 11.6years NO vs 43.1 ± 11.6years PRE vs 41.5 ± 10.7years POST; p < 0.001). Pre-operative COVID-19 was not associated with serious complications or mortality after adjusting for comorbidities. Post-operative COVID-19, however, was among the greatest independent predictors of serious complications (OR 3.5; 95% CI 2.8-4.2; p < 0.0001) and mortality (OR 5.1; 95% CI 1.8-14.1; p = 0.002). Pre-operative COVID-19 within 14days of surgery was not significantly associated with either serious complications or mortality. This work provides evidence that a more liberal strategy which employs early surgery after COVID-19 infection is safe as we aim to reduce the current bariatric surgery case backlog.