Outcomes In Bariatric Surgery Patients Research Articles

Perioperative Analgesia for Fast-Track Laparoscopic Bariatric Surgery.

Postoperative pain and analgesia present challenges in bariatric surgery patients. Multimodal analgesia may provide better efficacy, less complications and expedite fast-track bariatric surgical care. There are no studies of the broader topic of perioperative analgesia and the overall impact. This study highlights the impact of multimodal intraoperative analgesia on fast-track bariatric surgery. This observational study examined the perioperative outcome data of 412 consecutive laparoscopic bariatric surgery patients over a 6-year period. Perioperative outcome and variables were analysed and compared between different intraoperative analgesia types. Mean BMI was 49, mean age was 42 and male:female ratio was 1:4. About 82% of patients received multimodal intraoperative analgesia, comprising various combinations of bupivacaine infiltration and intravenous acetaminophen, morphine, tramadol, parecoxib or diclofenac. Morphine was administered in 83% of patients and tramadol in 17%. Multimodal intraoperative analgesia provided better postoperative analgesia, shorter postanaesthesia care unit (PACU) duration, lower postoperative opioid requirement, less postoperative vomiting, earlier postoperative oral intake, earlier ambulation and shorter hospital stay compared to unimodal intraoperative morphine analgesia (p=0.0001). Multimodal analgesia comprising tramadol + acetaminophen + diclofenac provided better postoperative analgesia, shorter PACU duration, lower postoperative opioid requirement, earlier ambulation, shorter hospital stay and less postoperative hypopnoea compared to patients who received morphine (p=0.0001). Multimodal intraoperative analgesia provides better postoperative analgesia, less complications and better perioperative outcomes and facilitates fast-track bariatric surgical care. Tramadol is suitable, efficacious and safe and associated with the best perioperative outcomes in bariatric surgery patients.

Using the presurgical psychological evaluation to predict 5-year weight loss outcomes in bariatric surgery patients

BackgroundPsychosocial factors contribute to poorer weight loss outcomes following bariatric surgery; however, findings on associations between preoperative psychiatric diagnoses, psychological testing, and weight loss are inconsistent. ObjectivesExamine associations between presurgical psychiatric diagnoses derived from a semi-structured clinical interview and test scores from the Minnesota Multiphasic Personality-Inventory−2 – Restructured Form (MMPI-2-RF) and 5-year Body Mass Index (BMI) outcomes. SettingCleveland Clinic Bariatric and Metabolic Institute Methods446 consecutively consented patients who underwent a Roux-en-Y gastric bypass (RYGB) at least 5 years prior were included in the study. A majority were women (74.2%) and Caucasian (66.2%). Patients’ mean presurgical BMI was 49.14 kg/m2 [SD = 9.50 kg/m2]. Psychiatric diagnoses were obtained from a presurgical, semi-structured clinical interview and all participants were administered the MMPI-2-RF at their presurgical evaluations. BMIs were collected at 4 postoperative time points across a 5-year trajectory. This prospective design utilized latent growth curve modeling. ResultsOlder patients evidenced a slower rate of BMI reduction over time. A presurgical diagnosis of Binge Eating Disorder predicted higher BMIs at the 5-year outcome. Scores on MMPI-2-RF measures of emotional and behavioral dysfunction domains incrementally predicted poorer weight loss outcomes. ConclusionPreoperative indicators of psychopathology, notably indicators that are dimensional in nature, are important in predicting postoperative outcomes. Closer follow-up with patients who evidence presurgical psychological factors, both before and after surgery, may help improve outcomes.

Postoperative day one neutrophil-to-lymphocyte ratio as a predictor of 30-day outcomes in bariatric surgery patients.

The neutrophil-to-lymphocyte ratio (NLR) is a marker that reflects systemic inflammation and organ dysfunction. Its use as a prognostic marker to predict complications following surgery has been recently described in the literature. The objective of our study was to evaluate the use of postoperative day one (POD1) NLR as a predictor of 30-day outcomes in patients undergoing bariatric surgery. University Hospital. We performed a retrospective chart review of 789 patients who underwent bariatric surgery at our institution between March 2012 and May 2014. Data were collected from electronic patient records and administrative databases used for quality improvement. POD1 NLR values were obtained from complete blood counts along with a variety of 30-day clinical outcomes. Univariate and multivariable analyses were conducted to determine whether POD1 NLR ≥10 was associated with 30-day outcomes. Seven-hundred and thirty-seven patients were included in the study. Six-hundred and fifty-three Roux-en-Y gastric bypass surgeries (88.6%) and 84 sleeve gastrectomy surgeries (11.4%) were performed. All surgeries were performed laparoscopically. We observed a 4.7% readmission rate, 2.2% reoperation rate, 10.7% postoperative occurrence rate, and 0.1% mortality rate. After covariate adjustment, POD1 NLR ≥10 was found to be significantly associated with overall complications (OR 1.98, 95% CI 1.01-3.87), major complications (OR 3.71, 95% CI 1.76-7.82), reoperation (OR 3.63, 95% CI 1.14-11.6), and prolonged postoperative length of stay (OR 3.70, 95% CI 2.2-6.22). POD1 NLR was independently associated with 30-day outcomes following bariatric surgery. This easily obtained inflammatory marker may be used to help identify patients at a higher risk of developing early complications.

A138 - Venous Thromboembolism Outcomes In Bariatric Surgery Patients: The Role of Operative Time

A138 - Venous Thromboembolism Outcomes In Bariatric Surgery Patients: The Role of Operative Time

Current Evidence for Physical Activity in the Bariatric Surgery Patient for Weight Loss Success

Leading a physically active lifestyle is critical for optimal health. Observation and intervention studies show that behavioral weight loss in overweight and class 1 obesity (body mass index=30-34.9 kg/m2) interventions are more successful in the long-term by adhering to a physical activity regimen, including at least 150 minutes per week of moderate intensity exercise. Although substantial research has been conducted in behavioral based weight loss programs, there are very limited studies that have investigated the effect that physical activity has on weight and body composition outcomes in bariatric surgery patients. In that bariatric weight loss surgery is accepted as the most effective short and long-term weight loss intervention for morbid obesity, research in this area needs to be a priority. This review summarizes the current evidence in this realm by examining both pre- and post-surgical studies that have been conducted in this field. Observational studies in individuals eligible for bariatric weight loss surgery indicate the majority of patients have zero minutes of vigorous activity and less than one-half of the recommended moderate activity minutes. In the pre-surgical patient, there have just been a few feasibility studies to investigate the incorporation of physical activity into the behavioral intervention to support weight loss and lifestyle change. These studies were generally confined to a walking program for the surgery patients. Importantly, these did not examine post-operative outcomes. Although weight loss following bariatric surgery is superior to behavioral interventions in severely obese individuals, there is still significant variability in the amount of weight loss achieved. Physical activity is one possible factor that has been examined that may contribute to the variability. Post-surgical observation studies consistently show a positive association between physical activity and improved weight loss, with physical activity and sedentary behaviors being the highest predictors for post-surgery weight loss. In spite of this evidence there are currently no large-scale, long-term randomized trials that have investigated a structured, well-controlled, physical activity intervention in post-surgical patients. The intervention studies to date have been small in number, nonrandomized in design, and were for a short duration. Future directions in this area are many, with questions on the type of exercise prescription that is going to be the most successful for long-term weight loss success and health improvements being on the forefront.

Impact of Gastrointestinal Surgery on Cardiometabolic Risk

Bariatric surgery has gained acceptance as the only treatment with long-term efficacy for severe obesity. Recent publications emphasize the usefulness of bariatric surgery in the reduction of long-term cardiometabolic risk, cardiovascular disease incidence and mortality, and the management of uncontrolled type 2 diabetes (T2DM), an important cardiovascular risk factor in individuals with severe obesity. The present review article offers a brief overview of the literature published over the past several months relevant to cardiometabolic outcomes in bariatric surgery patients. A recent report from the Swedish Obese Subjects (SOS) study specifically reported a reduced incidence of cardiovascular events on long-term prospective follow-up after bariatric surgery. In addition, abundant studies have been recently published on gastric bypass surgery showing high T2DM remission rates as well as improved blood lipids and inflammatory markers after surgery. Sleeve gastrectomy is increasingly performed as a stand-alone operation. Recent reports on this surgery pertaining to cardiometabolic risk showed variable T2DM remission rates that may possibly be explained by age of the patients and duration of T2DM. Available data suggest a possible favorable impact of the surgery on CRP levels and improvements in the blood lipid profile. How sleeve gastrectomy compares to other surgical approaches will require further study. Biliopancreatic diversion with duodenal switch has been reported to offer some of the best long-term weight loss for obese patients. Approximately 9 out of 10 patients treated with this surgical procedure show long-term remission rates of T2DM. Significant improvements in the cardiometabolic risk profile are also observed after BPD-DS; they are especially pronounced regarding dyslipidemia. In conclusion, bariatric procedures improve the cardiometabolic risk profile, a phenomenon that appears to be only partly explained by the magnitude of the weight loss. Significant variations are observed with respect to the type of surgery and patient characteristics. More research is clearly needed on the short and long-term cardiometabolic outcome of obesity surgeries.

Early Outcomes of Bariatric Surgery in Patients with Metabolic Syndrome: An Analysis of the Bariatric Outcomes Longitudinal Database

Metabolic syndrome (MetS) complicating obesity is endemic in the United States. Bariatric Outcomes Longitudinal Database, the national database for the American Society for Metabolic and Bariatric Surgery Bariatric Surgery Center of Excellence Program, was queried to identify patients undergoing bariatric surgery from June 2007 through November 2010. MetS was defined as the presence of hypertension, diabetes, and dyslipidemia at presentation for bariatric surgery. Ninety-day and 1-year outcomes were assessed to determine early outcomes in bariatric surgery patients with MetS. Among 186,576 research-consented patients, 23,106 (12%) were diagnosed with MetS. Patients with MetS were more likely to be male (35% vs 20%; p < 0.0001), older (mean age 54 vs 44 years; p < 0.0001), and Caucasian (81% vs 74%; p < 0.0001). Of the 23,106 MetS patients, more underwent gastric bypass (RYGB) (62%) compared with gastric banding (32%), sleeve gastrectomy (4.5%), and biliopancreactic diversion with duodenal switch (BPD/DS)(1.5%). MetS patients had an increase in serious complications (2.4% vs 1.0%; p < 0.0001), readmissions (6.2% vs 4.7%; p < 0.0001), and mortality (0.3% vs 0.1%; p < 0.0001) within 90 days of operation. After adjusting for sex, age, and body mass index, RYGB patients with MetS had an increased risk of 90-day serious complications compared to RYGB patients without MetS (odds ratio 1.43; 95% CI, 1.27 to 1.61; p < 0.0001). The 12-month remission rate of diabetes was least for gastric banding (28%) compared with the other procedures (RYGB 62%, sleeve gastrectomy 52%, BPD/DS 74%). Patients with MetS undergoing bariatric surgery showed dramatic improvement in diabetes 1-year after surgery; however, an adverse 90-day outcome was more common.

Six-year changes in health-related quality of life in gastric bypass patients versus obese comparison groups

BackgroundFew studies have evaluated the long-term outcomes of bariatric surgery patients in relation to obese individuals not participating in weight loss interventions. Our objective was to evaluate the 6-year changes in health-related quality of life (HRQOL) in gastric bypass (GB) patients versus 2 obese groups not undergoing surgical weight loss. The study setting was a bariatric surgery practice. MethodsA total of 323 GB patients were compared with 257 individuals who sought but did not undergo gastric bypass and 272 population-based obese individuals using weight-specific (Impact of Weight on Quality of Life-Lite) and general (Medical Outcomes Study Short-Form 36 Health Survey) HRQOL questionnaires at baseline and 2 and 6 years later. ResultsAt 6 years, compared with the controls, the GB group exhibited significant improvements in all domains of weight-specific and most domains of general HRQOL (i.e., all physical and some mental/psychosocial). The 6-year percentage of excess weight loss correlated significantly with improvements in both weight-specific and physical HRQOL. The HRQOL scores were fairly stable from 2 to 6 years for the GB group, with small decreases in HRQOL corresponding to some weight regain. ConclusionsGB patients demonstrated significant improvements in most aspects of HRQOL at 6 years compared with 2 nonsurgical obese groups. Despite some weight regain and small decreases in HRQOL from 2 to 6 years postoperatively, the HRQOL was relatively stable. These results support the effectiveness of weight loss achieved with gastric bypass surgery for improving and maintaining long-term HRQOL.

Bariatric Surgery Outcomes in the Elderly: An ACS NSQIP Study

IntroductionMortality and complications following bariatric surgery occur at acceptable rates, but its safety in the elderly population is unknown. We hypothesized that short-term operative outcomes in bariatric surgery patients ≥65 years would be comparable to younger persons. MethodsPatients with a body mass index ≥35 kg/m2 who underwent bariatric surgery in the 2005–2009 American College of Surgeons National Surgical Quality Improvement Program were identified. Controlling for confounders, multivariate regression was used to predict the impact of age on mortality, major events and prolonged length of stay at 30 days. ResultsWe identified 48,378 patients who underwent bariatric procedures between 2005 and 2009. Multivariate regression analysis demonstrated advancing age trended towards predicting mortality, but was not statistically significant. Additionally, patients ≥65 years did not experience higher risk of major complications for either open or laparoscopic procedures. However, patients age ≥65 years were more likely to experience prolonged length of stay for both open and laparoscopic procedures. ConclusionThis multi-hospital study demonstrates older age predicts short-term prolonged length of stay but not major events following bariatric surgery. Older age trends toward predicting mortality, but it is not statistically significant.

Advantages of doxapram for post-anaesthesia recovery and outcomes in bariatric surgery patients with obstructive sleep apnoea

Advantages of doxapram for post-anaesthesia recovery and outcomes in bariatric surgery patients with obstructive sleep apnoea

Audit of nutritional and dietary outcomes of bariatric surgery patients

Bariatric surgery is the most effective means of achieving sustainable weight loss for the morbidly obese but resultant gastrointestinal functional changes and altered diet may lead to a number of eating and nutritional problems. This audit was conducted to evaluate Guernsey outcomes in relation to UK national standards and to determine the adequacy of current dietetic provision. A postal questionnaire was sent to 177 patients. Sixty-eight responded (48 gastric bypass, 15 banding and five other procedures). Mean body mass index preoperatively was 44.2 (five had body mass index <35). Five respondents (7%) had received preoperative and 26 post-operative dietary advice. Only 12 (18%) received any dietetic follow-up. Only one patient had any psychological support. Mean maximal weight loss and regain was 42.7 kg and 4.5 kg, respectively. Micronutrient supplementation and monitoring was variable. Deficiencies of B(12) (44%), iron (25%), vitamin D (10.2%) and folate (6.2%) were recorded. Problems with food intolerances were common and often protracted. The majority of respondents expressed satisfaction with the procedure, but many recognized that it had not solved their food-related issues. There was dissatisfaction with dietetic intervention. Overall, current treatment was shown to fall short of UK standards. A number of recommendations have been made to improve future outcomes, including re-audit and improved dietetic service provision.

Patients who endorse more binge eating triggers before gastric bypass lose less weight at 6 months

Background Patients presenting for gastric bypass surgery often demonstrate binge eating behaviors. The present study sought to determine whether binge eating triggers are predictive of weight loss outcomes in bariatric surgery patients at 6 months postoperatively in the setting of a university hospital. Methods A total of 48 patients presenting for gastric bypass surgery at an academic medical center in the Southeastern United States and who had returned for the 6-month follow-up visit were included in the present study. The patients were mostly women (85%), white (71%), and middle-aged (mean age 47 years), with an average weight of 100.9 kg. The patients completed the Inventory of Binge Eating Situations at baseline, and weight loss outcomes were assessed at 6 months. Weight loss success was indexed using 2 methods: the percentage of excess weight lost (continuous variable) and whether the patient was on track with their weight loss as defined by a ≥50% excess weight loss (dichotomous variable). Results A significant negative correlation ( r = −.31, P = .03) was found between the preoperative Inventory of Binge Eating Situations scores and the percentage of excess weight loss at 6 months after gastric bypass surgery. Logistic regression analysis showed that “on track” status at 6 months was predicted by the Inventory of Binge Eating Situations score at baseline (Wald chi-square = 3.97, df = 1, P = .046). Conclusion Careful assessment of binge eating situations could serve as a potential predictor of poor weight loss outcomes in patients seeking gastric bypass surgery. These findings support the baseline assessment of binge eating triggers and future research to examine the effectiveness of interventions for coping with binge eating triggers for gastric bypass surgery patients.

M1364 Stratification and Prediction of Outcomes of Bariatric Surgery Patients Using the Relative Wellness Index (RWI)

Introduction: intragastric balloons are not commonly used as a therapy for obesity due to concerns about the possible side effects and doubts about effectiveness in long-term. Recent publications suggest a sustained effect on weight loss. In this study we present the results in a non-academic community practice.Methods: All patients who had received an intragastric balloon(BIB) therapy in our hospital and had retained the balloon for at least 3 months were retrospectively evaluated. Succesful therapy was defined as a weight loss ≥ 10 % of weight at baseline. To assess the long-term effects on weight reduction we contacted the patients in whom the balloon was removed for longer than 2 years. Results: 181 patients were treated with an intragastric balloon between January 2002 and September 2009. All balloons were placed and afterwards removed by a gastroenterologist under general anesthesia in day hospital. There were no major complications . 10 balloons were removed during the first month due to intolerance, 2 were spontaneously released and 3 balloons were removed elsewhere. The remaining 166 patients fulfilled the inclusion criteria and were used for the analysis. Mean BMI(body mass index)) at baseline was 34,7(range: 27-52) and mean weight 92 kg (range: 66-140). The balloons were removed after a mean of 7 months (range: 3-23). The mean BMI at removal was 30,1 (range: 19,6-48,5). Mean weight loss was: 11,4 kg (range: 0-33). 102 individuals (61,4 %) had a ≥ 10 % baseline weight loss by time of the balloon removal. 50 patients could be contacted for the long-term evaluation. Mean time after removal was 5,5 years (range: 2-7). 11 patients (22 %) had received bariatric surgery. 16 of the 39 patients(41 %) had retained the weight loss of≥ 10 %. Conclusions: Intragastric balloon therapy was associated with a successfull weight loss at removal in 61,4 %. There were no major complications. In long-term there seems to be a sustained effect in a subgroup of patients . Prospective studies are needed to better define the patients who will benefit from this therapy. 39 patients with long-term results

Loss of Control Over Eating Predicts Outcomes in Bariatric Surgery Patients

This study examined the clinical significance of loss of control (LOC) over eating in bariatric surgery patients over 24 months of prospective, multiwave follow-ups. Three hundred sixty-one gastric bypass surgery patients completed a battery of assessments before surgery and at 6, 12, and 24 months following surgery. In addition to weight loss and LOC over eating, the assessments targeted eating disorder psychopathology, depression levels, and quality of life. The study was conducted between January 2002 and February 2008. Prior to surgery, 61% of patients reported general LOC; postsurgery, 31% reported LOC at 6-month follow-up, 36% reported LOC at 12-month follow-up, and 39% reported LOC at 24-month follow-up. Preoperative LOC did not predict postoperative outcomes. In contrast, mixed models analyses revealed that postsurgery LOC was predictive of weight loss outcomes: patients with LOC postsurgery lost significantly less weight at 12-month (34.6% vs 37.2% BMI loss) and 24-month (35.8% vs 39.1% BMI loss) postsurgery follow-ups. Postsurgery LOC also significantly predicted eating disorder psychopathology, depression, and quality of life at 12- and 24-month postsurgery follow-ups. Preoperative LOC does not appear to be a negative prognostic indicator for postsurgical outcomes. Postoperative LOC, however, significantly predicts poorer postsurgical weight loss and psychosocial outcomes at 12 and 24 months following surgery. Since LOC following bariatric surgery significantly predicts attenuated postsurgical improvements, it may signal a need for clinical attention.