Outcomes In Bariatric Surgery Patients Research Articles

Nurse-led intervention for the management of bariatric surgery patients: A systematic review.

The prevalence of obesity has become a global health concern, and severe obesity is associated with various chronic diseases and decreased quality of life. Bariatric surgery has shown success in treating obesity. Nevertheless, some patients experience weight regain and unsatisfactory outcomes. Multidisciplinary interventions have been shown to improve postoperative outcomes. Case managers, often specialized nurses, play a crucial role in patient support and coordination of care. However, the diverse design of case-managing interventions hinders the assessment of their success. Thus, the aim of this review is to identify the most successful structural characteristics of case-managing interventions, with or without the support of e-Health, in the process of perioperative management of bariatric surgery patients. A systematic literature review was conducted following the PRISMA guidelines. PubMed, MEDLINE, EBSCOhost, and CINAHL databases were searched for relevant studies published in the last 10 years. Eligible studies included randomized controlled trials, controlled clinical studies, case studies, or observational studies that evaluated perioperative care in bariatric surgery. The PICO framework was used to frame the search strategy. The initial search yielded 225 articles, of which 10 studies met the inclusion criteria. Nurse-led case-managing interventions with a multidisciplinary approach showed positive results in weight loss, physical activity, and quality of life. Patient-centered care models were found to promote adherence to treatment and patient satisfaction. E-Health technologies improved quality of life but not weight loss. The duration of behavioral interventions and the long-term outcomes after surgery remained unclear. Nurse-led case-management interventions, with a focus on behavioral change and multidisciplinary approaches, show promise in improving outcomes in bariatric surgery patients. Patient-centered care models and longer term interventions may contribute to sustained weight loss and better postoperative outcomes. Further research is needed to determine the optimal duration of interventions and the long-term effects on weight maintenance.

Prevalence of adverse childhood experiences and effect on outcomes in bariatric surgery patients: a systematic review and meta-analysis.

Adverse childhood experiences (ACEs) are defined as childhood maltreatment (sexual, physical, and emotional abuse and neglect) and other childhood traumatic experiences. Published prevalence estimates for ACEs in bariatric samples vary greatly and evidence on the association between ACEs and bariatric surgery weight loss and psychosocial outcomes is inconclusive. A systematic literature search on PubMed/Medline, PsycInfo, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), and Open Grey for studies published until August 30, 2021, yielded 21 publications for qualitative synthesis: 20 reporting on prevalence of ACEs in bariatric surgery candidates and patients, and 10 on the association of ACEs with outcomes. In meta-analysis, overall moderate to high heterogeneity was observed for prevalence estimates and moderate heterogeneity was observed for associations. Prevalence estimate for at least 1 form of ACEs (6 studies, n = 1368 patients) was 51% (95% confidence interval [CI]: 32%-70%). Effect size (Hedge's g) for the difference between the groups of patients reporting any or a high number of ACEs versus no or a low number of ACEs was calculated from means, standard deviations and group size, or P values. Based on 7 studies (n = 946 patients), the association between ACEs and weight loss was not significant (Hedge's g = -.15 [95% CI: -.38 to .09]; I2 = 53%), regardless of short- or long-term follow-up (P = .413) and the proportion of patients in each study receiving Roux-en-Y gastric bypass (RYGB) (β = .0005, P = .868). Preliminary findings based on 3 short- and long-term studies (n = 414 patients) showed that ACEs were significantly (P = .001) associated with higher postoperative depressive symptoms (Hedge's g = .50 [95% CI: .22-.78]; I2 = 36%). Associations between ACEs and other psychosocial outcomes such as eating pathology were reported narratively. There is a need for additional long-term studies using validated assessment tools for ACEs to evaluate the effect of ACEs on weight and psychosocial outcomes after bariatric surgery.

Comment on: Prevalence of adverse childhood experiences and impact onoutcomes in bariatric surgery patients: a systematic review and meta-analysis.

In this issue, Konrad et al., provide the first systematic review of adverse childhood experiences (ACEs) in bariatric surgery candidates and patients1. Despite a dearth of studies evaluating the impact of ACEs on outcomes following bariatric surgery, this report serves as a valuable descriptor of the existing literature with well-reasoned recommendations for future research.

Millon Behavioral Medicine Diagnostic Scales Do Not Predict Long-term Weight Loss Outcomes in Bariatric Surgery Patients.

Psychological factors identified during presurgical screening have the potential to identify which patients may respond better to bariatric surgery, and which patients may need additional assistance. Previous research has validated a number of potential instruments for use in presurgical screening. This study evaluated archival data for 224 patients for a 60-month period following bariatric surgery to examine how presurgical scores on the Millon Behavioral Medicine Diagnostic predict body mass index (BMI) over time. Follow-up data was available on 96% of these patients at 12 months and 63% of these patients at 60 months. Hierarchical linear modeling was used to predict BMI based on demographic and psychopathology factors using linear and nonlinear coefficients while controlling for demographic factors and initial BMI. Results overall showed that demographic factors and initial BMI were significantly better predictors of BMI outcomes following bariatric surgery. Millon Behavioral Medicine Diagnostic scales did not significantly contribute to any models predicting outcomes. Although the Millon Behavioral Medicine Diagnostic has been recommended for presurgical screening prior to bariatric surgery, the current findings suggest that this measure and its specific scales do not predict BMI outcomes following bariatric surgery over time.

Elevated hemoglobin A1c level and bariatric surgery complications.

In cardiac and orthopedic surgery, elevated glycosylated hemoglobin (HbA1c) is a modifiable risk factor for postoperative complications. However, in bariatric surgery, there is insufficient evidence to assess the effectiveness of preoperative HbA1c assessment and its association with postoperative complications.The objective of this study was to assess the impact ofHbA1con early postoperative outcomes in bariatric surgery patients. Patients who underwent laparoscopic sleeve gastrectomy and laparoscopic Roux-En-Y Gastric Bypass between 2017 and 2018 were selected for a retrospective review from the metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP) database. The study population of 118,742 patients was analyzed for our primary outcome which was defined as a composite of any postoperative complications occurring within 30 days. Two groups were defined by HbA1c cutoff: comparison point A (≤ 8% vs > 8%) and comparison point B (≤ 10% vs > 10%). Procedure-related complications were also examined on subgroup analysis. Propensity score matching (PSM) was used with one-to-one matching. The complication rates before and after PSM were calculated and assessed by Fisher's exact test and conditional logistic regression, respectively. After PSM, demographic and clinical characteristics were all balanced and elevated HbA1C was not associated with worse outcomes. After adjusting for underlying comorbidities, there was no statistically significant difference seen in the composite outcome for comparison point A HbA1C ≤ 8 and HbA1C > 8 (p = 0.22). For comparison point B, patients with HbA1C ≤ 10 had more composite complications compared to patients with HbA1C > 10 (p < 0.001). Also, on subgroup analysis after PSM for procedure-specific complications, patients above the cutoff threshold of 8 did not have worsened composite outcomes (p = 0.58 and 0.89 for sleeve and bypass, respectively). Again, at cutoff threshold of 10, patients in HbA1C ≤ 10 had more composite complications (p = 0.001 and 0.007 for sleeve and bypass, respectively). In this study of bariatric patients, elevated HbA1c > 8% or 10% was not associated with increased postoperative complications. HbA1c lower than 10% was associated with some types of adverse outcomes in this bariatric dataset. More studies are needed to investigate these findings further. A high HbA1c alone may not disqualify a patient from proceeding with bariatric surgery.

S1035 Social Determinants of Weight Loss Following Transoral Outlet Reduction (TORe) at a Safety-Net Hospital

Introduction: Roux-En-Y gastric bypass (RYGB) is a bariatric surgery for weight loss (WL) among obese patients. Weight regain (WR) is a common complication of RYGB. One anatomic etiology of WR after RYGB is dilation of the gastrojejunal (GJ) anastomosis outlet. Transoral Outlet Reduction (TORe) is an endoscopic therapy using a full thickness endoscopic suturing device to narrow the GJ outlet. Given the novelty of bariatric endoscopy, most insurance does not cover the cost. There is little data on outcomes of bariatric endoscopy in underserved populations. Our study aimed to assess the impact of socioeconomic and demographic factors on WL after TORe at our safety net hospital. Methods: We performed a retrospective chart review of patients who underwent TORe for post-RYGB WR from November 2016 to September 2020. Data collected included age, gender, ethnicity, highest education level, income, marital status, insurance status, number of children and procedural outcomes (weight, metabolic parameters). We performed a multivariable linear regression analysis using R© software to assess the relationship of social factors to TORe outcomes. Results: We analyzed 45 TORe procedures. The cohort was predominantly female (98%) with a mean age of 42 years. Of the 45 TORes, 7 were performed in Black patients, 31 Hispanic, 3 Asian, 1 White and 3 in patients of unknown ethnic background. Thirty-one (69%) TORes were in patients with annual household incomes of less $50,000 and 22 (49%) with only a high school level education. Thirty-five (67%) procedures were performed in patients who were unmarried and 32 (71%) procedures were performed in patients with insurance. The mean diameter of the pre-TORe GJ outlet was 27.5 mm. Mean weight lost post-TORe was 12.5 lbs which corresponded to a 5.7% WL and 3.5% reduction in BMI. Compared to an annual income of less than $10,000, a patient with an annual income of $10,000-$50,000 would be 3.87 times as likely to have post-TORe per lb WL (p=0.15), and 4.50 times as likely to with an annual income of $50,000-$100,000 (p=0.26). We also found that having insurance made it 2.75 times as likely to promote post-TORe per lb WL compared to being uninsured (p=0.313). Conclusion: Social determinants of health are known to impact obesity and post-operative outcomes in bariatric surgery patients. We found in our analysis of an underserved bariatric population at our public hospital that a higher income and having insurance was positively associated with better post-TORe WL.Table 1.: Multivariable linear regression analysis of social determinants of post-TORe weight loss; Income 1: less than $10,000; Income 2: $10,000-$50,000; Income 3: $50,000-%100,000.

The Impact of Hemoglobin A1c on Post-operative Outcomes in Bariatric Surgery Patients

Pre-operative hemoglobin (Hb) A1c levels ≥ 8% can lead to increased post-operative complications. In bariatric surgery patients, attaining a pre-operative HbA1c < 8% can be a challenge. The purpose of this study was to identify the association of pre-operative HbA1c on post-operative outcomes in bariatric surgery patients. A retrospective chart review was conducted on diabetic patients (HbA1c ≥ 6.5%) who underwent primary bariatric surgery at a single institution between the years 2013 and 2019. Patients were divided into two groups based on their pre-operative HbA1c levels of < 8% and ≥ 8%. Univariate analyses were performed to determine an association between pre-operative HbA1c levels and post-operative outcomes. There were 351 primary diabetic bariatric surgery patients, 270 HbA1c <8%, and 81 HbA1c ≥ 8%. Procedure selection was significantly different between the HbA1c < 8% and HbA1c ≥ 8% group (49.3% sleeve, 50.4% bypass and 0.4% band versus 43.2% sleeve, 53.1% bypass and 3.7% band respectively, P < 0.04). There was no statistically significant difference in any 30-day post-operative outcome between the two groups. Post-operative HbA1c was significantly less in the HbA1c < 8% group at 3-6 month (6.0% ± 0.9 versus 7.4% ± 1.4, P <0.001) and 6-12 month (6.0% ± 1.1 versus 7.2% ± 1.4, P <0.001) follow-up. This study demonstrated no difference in post-operative outcomes of primary bariatric surgery patients based on a HbA1c cut-off of 8%. This highlights that bariatric surgery can be considered and safely performed in patients with a pre-operative HbA1c ≥ 8%.

The influence of preoperative carbohydrate loading on postoperative outcomes in bariatric surgery patients: a randomized, controlled trial.

Preoperative carbohydrate loading is a component of Enhanced Recovery After Surgery (ERAS) protocols, but there is limited literature in bariatric surgery patients. The objective of this study was to characterize the impact of preoperative carbohydrate loading on postoperative bariatric surgery outcomes. University Hospital. Patients undergoing a primary minimally invasive Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2018 and 2020 were randomized to standard management or intervention. Standard management patients were nothing by mouth (NPO) after midnight prior to surgery. Intervention patients consumed 2 carbohydrate drinks: 1 the night before and another 3 hours prior to surgery. Primary outcomes analyzed included postoperative nausea and vomiting (PONV), length of stay, and overall complications. In total, 134 patients were analyzed: 64 intervention (47.8%) and 70 (52.2%) standard. In the end, 7% and 15% of patients were lost to follow-up at 6-weeks and 3-months, respectively. There was no statistically significant difference in length of stay (2.0 ± 1.2 vs 2.1 ± .9 d; P = .65) or postoperative outcomes between the 2 groups. There were no episodes of aspiration among the intervention group. Among RYGB patients, intervention patients had a shorter duration of nausea compared with standard patients. There was no significant difference in glycemic control among patients with and without diabetes. Preoperative carbohydrate drinks can be administered to bariatric surgery patients without significant risks. Carbohydrate loading preoperatively can decrease the duration of PONV in RYGB patients. Carbohydrate drinks can be safely included in bariatric ERAS protocols for patients with and without diabetes, although the benefits remain unknown.

Eating behaviors and weight outcomes in bariatric surgery patients amidst COVID-19.

BackgroundRecent studies suggest that eating habits are an area particularly affected by the lockdown imposed by many countries to curb the COVID-19 epidemic. Individuals that received bariatric surgery may represent a particularly susceptible population to the adverse effects of lockdown for its potential impact on eating, psychological, and weight loss outcomes.ObjectivesThis study seeks to investigate the incremental impact of COVID-19 lockdown on treatment outcomes of postbariatric patients in the risk period for weight regain.SettingMain hospital center.MethodsThis work uses data from an ongoing longitudinal study of bariatric patients assessed before surgery (T0), 1.5 years after sugery (T1), and 3 years after surgery (T2). Two independent groups were compared: the COVID-19_Group (n = 35) where T0 and T1 assessments were conducted before the pandemic started and T2 assessment was conducted at the end of the mandatory COVID-19 lockdown; and the NonCOVID-19_Group (n = 66), covering patients who completed T0, T1, and T2 assessments before the epidemic began. Assessment included self-report measures for disordered eating, negative urgency, depression, anxiety, stress, and weight outcomes.ResultsGeneral linear models for repeated measures showed that the COVID-19_Group presented significantly higher weight concern (F = 8.403, P = .005, ƞ2p = .094), grazing behavior (F = 7.166, P = .009, ƞ2p = .076), and negative urgency (F = 4.522, P = .036, ƞ2p = .05) than the NonCOVID-19_Group. The COVID-19_Group also showed less total weight loss (F = 4.029, P = .05, ƞ2p = .04) and larger weight regain at T2, with more COVID-19_Group participants experiencing excessive weight regain (20% versus 4.5%).ConclusionThese results show evidence for the impact of the coronavirus outbreak on eating-related psychopathology and weight outcomes in postbariatric surgery patients.

Preoperative Psychological Assessment and Weight Loss Outcomes in Bariatric Surgery Patients at a Military Treatment Facility: A Retrospective Profile Analysis.

Research on effectiveness of preoperative psychological measures as predictors of weight loss success and weight regain following bariatric surgery has been inconsistent. Despite mixed findings, preoperative psychological assessment instruments are used routinely, including in military medical facilities. Health concerns associated with obesity potentially impact military family readiness, with accompanying utilization of medical resources. Examining psychological factors associated with successful bariatric surgery outcomes may help to optimize care. This retrospective, observational study sought to identify characteristic elevations on two recommended preoperative psychological assessment instruments for bariatric surgery candidates: the Personality Assessment Inventory (PAI) and the Millon Behavioral Medicine Diagnostic (MBMD). Additionally, profile analysis was performed on assessment scales based on groupings of whether or not patients (N = 194) met their ideal BMI over a 60-month period. The Institutional Review Board at Madigan Army Medical Center approved this study protocol. Means and standard deviations for PAI and the MBMD are presented for this sample of benefits-eligible patients in the military health system. Measures between bariatric outcome groups were not significantly different, but characteristic elevations for bariatric surgery candidates overall were identified. The average elevations of scales were not above clinical cutoff, but still indicate characteristic trends in patients undergoing surgery at an MTF. These scales may be important to attend to with bariatric surgery candidates, especially scales which are related to psychopathology, treatment prognosis, and treatment management. Study results about scale elevations on preoperative psychological assessment instruments may help patients better manage bariatric surgery and can lead to enhanced warfighter readiness and decreased utilization of healthcare resources. Future work should examine postoperative behavioral and psychological factors, as the adjustment to lifestyle limitations of bariatric surgery is substantial.

Bariatric Surgery Is Associated With Decreased Calcineurin Inhibitor Time in Therapeutic Range After Heart Transplantation

Bariatric surgery (BSg) is an effective treatment for morbid obesity, but little is known about the outcomes of BSg patients who undergo orthotopic heart transplantation (OHT). The aim of this study was to determine if BSg alters calcineurin inhibitor (CNI) level variability after OHT. Data were collected from 58 consecutive patients who underwent OHT at a single center from 1/2018 to 4/2019: 4 with BSg prior to OHT (BSg + OHT) and 54 without prior BSg (OHT). CNI level, cardiac biopsy, and left ventricular ejection fraction (LVEF) data were collected during the first 6 months post-OHT. Comparisons were made for 3 measures of CNI variability: coefficient of variation, time in therapeutic range (TTR), and TTR by the Rosendaal method. A Pearson’s correlation coefficient was calculated to assess the relationship between CNI TTR, episodes of rejection, and LVEF. The results show TTR was lower in BSg + OHT compared to OHT (12.5% vs 31.3%, P < .05). For the entire cohort, greater TTR correlated with fewer episodes of rejection (r = 0.31, P < .05). In conclusion, these findings suggest BSg + OHT patients may warrant closer monitoring of CNI levels post-OHT. Furthermore, episodes of rejection and LVEF were similar for BSg + OHT patients, indicating that BSg should not be a contraindication to transplant.

Five-Year Outcomes in Bariatric Surgery Patients.

Background and objectives: Obesity presents as a multifactorial, pandemic disease that arises as a consequence of unequal energy intake and energy consumption. Obesity adversely affects the quality of life, leading not only to disability, but also to various other disorders. Bariatric surgery is the most effective method for achieving significant and sustained weight loss in individuals with extreme obesity. The aim of this study was to examine how well surgically induced weight loss is maintained after five years of follow-up and its effects on cardiovascular risk factors and outcome. Materials and Methods: This is a retrospective cross-sectional study of 66 patients with morbid obesity, with body mass index (BMI) ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 and obesity-related health conditions, aged 20 to 61 years, mostly women (77.3%) who underwent laparoscopic Roux-en-Y gastric bypass surgery. Results: Average follow-up was 6.42 years (95% CI 6.30–6.54 years) after surgery, with survival rate of 97% in operated individuals. There was a statistically significant reduction of weight and body mass index 6 months and 5 years after surgery in comparison to the initial values (p < 0.001). Of 62 patients who presented weight loss at the end of the follow-up period, 38 were able to maintain the amount of weight loss that was attained 6 months after surgery, while 24 patients regained weight compared to their postoperative weight at 6 months. Two patients reported no weight loss after treatment. Significant weight reduction was associated with better control of diabetes and increased self-reported physical activity at 6 months and 5 years after surgery, as well as with a reduction of the use of anti-diabetic and anti-hypertensive medications. Conclusions: Our research demonstrates a positive long-term impact of bariatric surgery on patients’ health conditions, significant and sustained weight loss, and decrease in BMI, which were associated with a reduction of co-morbidities and risk factors for cardiovascular diseases.

A477 Effect of Mobile Electronic Health Application on Postoperative Outcomes of Bariatric Surgery Patients

A477 Effect of Mobile Electronic Health Application on Postoperative Outcomes of Bariatric Surgery Patients

Employing Enhanced Recovery Goals in Bariatric Surgery (ENERGY): a national quality improvement project using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

To date, there have been no large-scale enhanced recovery projects in bariatric surgery in the United States. The aim of this project was to implement an enhanced recovery protocol for selected Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program centers and determine its impact on length of stay, bleeding, readmissions, and reoperation rates. University and private practice programs, United States. Participating sites were identified based on historical extended length of stay (ELOS, ≥4 d). A 6-month run-up period was used to allow implementation of the protocol. Primary bariatric procedures were included in the analysis, which compared ELOS from historic data (2016) with outcomes during the Employing Enhanced Recovery Goals in Bariatric Surgery (ENERGY) project. Relationships between adherence to the 26 process measures and ELOS were analyzed. Specific adverse 30-day outcomes were monitored. Thirty-six centers participated in the project. The final analytic sample consisted of 18,048 cases total over a 24-month period, including 8946 from the 2016 calendar year and 9102 from the ENERGY period. The overall rates of ELOS for pre- and postintervention were 8.1% and 4.5%, respectively, without increasing readmission rates, reoperation rates, or overall morbidity. Bleeding rates increased from .8% preintervention to 1.1% during ENERGY (adjusted P = .06). There was a significant association between increased adherence score and decreased odds of ELOS (P < .01). Implementation of a large-scale enhanced recovery project is feasible and results in decreased ELOS without increasing overall adverse events or readmissions. Increased adherence to the protocol was closely associated with decreased ELOS. The ENERGY protocol or similar enhanced recovery pathways should be implemented on a larger scale to further improve the care and outcomes of bariatric surgery patients.

The impact of nausea on post-operative outcomes in bariatric surgery patients.

The evaluation and treatment of post-operative nausea in bariatric surgery patients has not been standardized. In this patient population, nausea can have a significant impact on quality outcomes. The primary objective of this study was to determine the impact of nausea on post-operative outcomes in bariatric surgery patients. A retrospective chart review was conducted of adult patients who underwent a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) between 2014 and 2017 at a single institution. Patients with post-operative nausea were identified. Post-operative nausea was defined as patients who had nausea that was documented by multiple providers, and which interfered with their oral intake. Demographic variables were identified for patients with and without documented nausea. Univariate analyses were performed to determine the impact of post-operative nausea on patients' length of stay, readmissions, reoperations, and overall complications. There were 449 primary bariatric surgery patients in the study period, 197 (43.9%) LRYGB and 252 (56.1%) LSG. Of these patients, 160 (35.6%) had documented post-operative nausea. Demographic factors that contributed to post-operative nausea included African-American race and undergoing a LSG (p = 0.004 and p = 0.01, respectively). Patients who underwent a LSG had a 2.0 times increased risk of post-operative nausea compared to LRYGB (p = 0.01). Patients with documented nausea had a statistically significant increased length of stay (2.4 ± 1.9days vs. 1.6 ± 1.0days; p ≤ 0.01). Documented nausea patients had an increased incidence of Emergency Department visits within 30days post-operatively (p = 0.02). Post-operative nausea was more likely in patients who underwent a sleeve gastrectomy. Gastric bypass and sleeve gastrectomy patients with documented nausea had an increased length of stay and Emergency Department visits. These results highlight the need for a metric to more accurately measure post-operative nausea, as well as a standardized anti-emetic treatment pathway to improve quality outcomes.

Prospective Study of Attachment as a Predictor of Binge Eating, Emotional Eating and Weight Loss Two Years after Bariatric Surgery.

Bariatric surgery remains the most effective treatment for severe obesity, though post-surgical outcomes are variable with respect to long-term weight loss and eating-related psychopathology. Attachment style is an important variable affecting eating psychopathology among individuals with obesity. To date, studies examining eating psychopathology and attachment style in bariatric surgery populations have been limited to pre-surgery samples and cross-sectional study design. The current prospective study sought to determine whether attachment insecurity is associated with binge eating, emotional eating, and weight loss outcomes at 2-years post-surgery. Patients (n = 108) completed questionnaires on attachment style (ECR-16), binge eating (BES), emotional eating (EES), depression (PHQ-9), and anxiety (GAD-7). Multivariate linear regression analyses were conducted to examine the association between attachment insecurity and 2-years post-surgery disordered eating and percent total weight loss. Female gender was found to be a significant predictor of binge eating (p = 0.007) and emotional eating (p = 0.023) at 2-years post-surgery. Avoidant attachment (p = 0.009) was also found to be a significant predictor of binge eating at 2-years post-surgery. To our knowledge, this study is the first to explore attachment style as a predictor of long-term post-operative eating pathology and weight outcomes in bariatric surgery patients.

Cardiovascular Outcomes in Bariatric Surgery Patients With Type 2 Diabetes

Cardiovascular Outcomes in Bariatric Surgery Patients With Type 2 Diabetes

Abstract P248: Increased Arterial Stiffness Measures in Morbidly Obese Patients After Bariatric Surgery

Introduction: The association between obesity and arterial stiffness is complex and has been reported to be modified by age, with a positive association in older adults and an inverse association in younger adults. Additionally, several diet and exercise-based programs have demonstrated conflicting results regarding changes in arterial stiffness before and after weight reduction. However, few have explored arterial stiffness outcomes in bariatric surgery patients. Objective: To characterize changes in arterial stiffness after bariatric surgery. Methods: In 72 morbidly obese patients, we evaluated two measures of arterial stiffness, cardio-ankle vascular index (CAVI) and heart-ankle pulse wave velocity (haPWV), ~1 month prior to and 6 and 12 months after bariatric surgery. Arterial stiffness measures were assessed twice at each visit and averages were reported. Paired t-tests were used to evaluate the significance of changes after bariatric surgery. Results: The mean age of our study sample was 44.5 years (SD 11.2), and 72.2% were female. Average BMI substantially decreased after bariatric surgery (from 47.1 to 34.8 kg/m 2 ). Similarly, systolic blood pressure declined after surgery (from a mean of 143.0 to 131.7 mmHg) whereas diastolic blood pressure did not significantly differ. Both arterial stiffness measures, CAVI and haPWV, were significantly elevated after bariatric surgery (Figure, p&lt;0.001). CAVI increased from baseline by an average of 0.64 (95% confidence interval [CI]: 0.42-0.87) at 6-month follow-up and 0.80 (95% CI: 0.53-1.07) 1 year after surgery. A similar pattern was observed for haPWV. Conclusions: Despite favorable changes in body weight and blood pressure, arterial stiffness measures were elevated after bariatric surgery. Although this observation is in line with an inverse association between obesity and arterial stiffness in younger adults, future studies are necessary to explore the underlying mechanisms and clinical implications of increased arterial stiffness after bariatric surgery.

Postoperative outcomes in bariatric surgical patients participating in an insurance-mandated preoperative weight management program

BackgroundMany insurance companies require patient participation in a medically supervised weight management program (WMP) before offering approval for bariatric surgery. Clinical data surrounding benefits of participation are limited. ObjectiveTo evaluate the relationship between preoperative insurance-mandated WMP participation and postoperative outcomes in bariatric surgery patients. SettingRegional referral center and teaching hospital. MethodsA retrospective review of patients who underwent vertical sleeve gastrectomy or Roux-en-Y gastric bypass between January 2014 and January 2016 was performed. Patients (N = 354) were divided into 2 cohorts and analyzed according to presence (n = 266) or absence (n = 88) of an insurance-mandated WMP requirement. Primary endpoints included rate of follow-up and percent of excess weight loss (%EWL) at postoperative months 1, 3, 6, and 12. All patients, regardless of the insurance-mandated WMP requirement, followed a program-directed preoperative diet. ResultsThe majority of patients with an insurance-mandated WMP requirement had private insurance (63.9%). Both patient groups experienced a similar proportion of readmissions and reoperations, rate of follow-up, and %EWL at 1, 3, 6, and 12 months (P = NS). Median operative duration and hospital length of stay were also similar between groups. Linear regression analysis revealed no significant improvement in %EWL at 12 months in the yes-WMP group. ConclusionThese data show that patients who participate in an insurance-mandated WMP in addition to completing a program-directed preoperative diet experience no significant benefit to rate of readmission, reoperation, follow-up, or %EWL up to 12 months postoperation. Our findings suggest that undergoing bariatric surgery without completing an insurance-mandated WMP is safe and effective.

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.