Population Of Bariatric Surgery Patients Research Articles

S1920 Laparoscopic-Assisted Trans-gastric ERCP: An Option for the Management of Choledocholithiasis in the Bariatric Surgery Patient Population Available in the Community Hospital Setting

S1920 Laparoscopic-Assisted Trans-gastric ERCP: An Option for the Management of Choledocholithiasis in the Bariatric Surgery Patient Population Available in the Community Hospital Setting

Bariatric Center Designation and Outcomes Following Repeat Abdominal Surgery in Bariatric Patients

IntroductionRepeat abdominal surgery in the bariatric surgery patient population may be challenging for non–bariatric-accredited institutions. The impact of regionalized bariatric care on clinical outcomes for bariatric surgery patients requiring repeat abdominal surgery is currently unknown. This study aims to investigate the association between bariatric center designation and clinical outcomes following hepatobiliary, hernia, and upper and lower gastrointestinal operations among patients with prior bariatric surgery. MethodsThis is a cohort study of a large sample of Ontario residents who underwent primary bariatric surgery between 2010 and 2017. A comprehensive list of eligible abdominal operations was captured using administrative data. The primary outcome was 30-d complications. Secondary outcomes included 30-d mortality, readmission, and length of stay. ResultsAmong the 3301 study patients, 1305 (40%) received their first abdominal reoperation following bariatric surgery at a designated bariatric center. Nonbariatric center designation was not associated with significantly higher rates of 30-d complications (5.73% versus 5.72%), mortality (0.80% versus 0.77%), readmissions (1.11% versus 1.85%), or median postoperative length of stay (4 versus 4 d). After grouping the category of reoperations, upper gastrointestinal (odds ratio [OR] 0.66, confidence interval [CI] 0.39-1.11) and abdominal wall hernia surgery (OR 0.52, CI 0.27-0.99) showed a lower adjusted OR for complications among bariatric centers. ConclusionsOur study demonstrates that after adjustment for case-mix and patient characteristics, bariatric surgery patients undergoing repeat abdominal surgery at nonbariatric centers is not associated with higher proportion of complications or mortality. Complex hernia surgery may be considered the most appropriate for referral.

Prevalence of thiamine deficiency is significant in patients undergoing primary bariatric surgery.

Patients undergoing metabolic and bariatric surgery are prone to developing micronutrient deficiencies, necessitating life-long nutritional supplementation and monitoring. Historically, these deficiencies were thought to be driven by postsurgical changes in absorption. Recent data, though, have demonstrated that obesity alone is also associated with micronutrient deficiencies. Thiamine deficiency, in particular, can lead to permanent neurologic deficits. Identify thiamine deficiency prevalence within the preoperative metabolic and bariatric surgery patient population. Single institution academic medical center. A retrospective review of deidentified data was examined that included whole blood thiamine measured from consecutive patients from April 2018 to June 2019 (n = 346). Cohort characteristics were assessed including age, operation, preoperative weight, and race/ethnicity. The majority of the cohort were women (83%) with an average age of 44.9 years. Racial representation included White/Caucasian (73%) and Black (21%), while operations included Roux-en-Y gastric bypass (58%), sleeve gastrectomy (31%), and revisions (10%). Thiamine concentration was normally distributed with a mean of 144 nM. Overall, 3.5% of patients had thiamine concentrations below the lower limit of normal of <70 nM, while 35 additional patients (14%) were at risk for thiamine deficiency with concentrations <100 nM. On the average, these patients were of similar age and were all undergoing primary procedures (50% gastric bypass, 50% sleeve gastrectomy). Regression methods demonstrated that patients with thiamine deficiency tended to be females with higher body mass index, even after controlling for sex, height, and preoperative weight. After covariate adjustment, male sex and increasing height were both associated with higher thiamine concentration. Previously quoted rates of thiamine deficiency in the preoperative patient are variable, but we describe a significant number of patients with, or at risk of, thiamine deficiency. Male sex and increasing height are likely associated with increased skeletal muscle mass, which is enriched with thiamine. Routine thiamine measurement, either preoperatively or at the time of surgery, is warranted given its limited stores within the body and potential catastrophic complications associated with acute or chronic deficiency.

Successful weight loss after bariatric surgery in Appalachian state regardless of food access ranking score.

Following bariatric surgery, an explicit dietary regimen is required to facilitate and maintain successful weight loss. Without adequate access to healthy foods, weight maintenance can be hindered. Examine influence degree of food access has on Appalachian bariatric surgery patient weight loss outcomes. Appalachian University hospital, United States. A retrospective chart review was used to examine the influence of food accessibility on weight loss outcomes in an Appalachian bariatric surgery patient population at a large tertiary hospital in West Virginia between 2013 and 2017. Demographic characteristics, health and family history, and 1-year surgery outcomes were collected. A state-specific food accessibility score was calculated for each patient address using the geographic information system. Patients were assigned a food access ranking score (FARS) between 0 (low food access) and 4 (high food access) based on criteria of quantity, quality, income, and vehicle access. Patients (n = 369) were predominately married (60.5%), white (92.4%), female (77.8%), and underwent laparoscopic Roux-en-Y gastric bypass surgery (75.9%), with a mean age of 45 years. Most patients had low FARS (M = 1.67 ± .73; 72.6%). Nonwhite patients (P = .03) with a preoperative diagnosis of depression (P = .02) or without a family history of obesity (P = .01) were found to be in the lower FARS categories. FARS was not indicative of weight loss post surgery (P > .05). Food accessibility in West Virginia was not associated with bariatric surgery weight outcomes at 1-year post operation. Lower food access was associated with nonwhite race/ethnicity, diagnosed depression at baseline, and no family history of obesity. Future studies should include moreextended follow-up data collection and mixed-method approaches to capture perceptions of food access and its impact on the patients' postoperative journey.

Pre-surgical stress and social support predict post-surgical percent excess weight loss in a population of bariatric surgery patients

ABSTRACT Although bariatric surgery is an effective treatment of morbid obesity, many patients fail to lose significant weight or regain weight over time. This study examined pre-surgical psychosocial predictors (stress, social support for healthy eating, emotion regulation, and sleep quality/quantity) of three-month post-surgical percent excess weight loss (EWL) in a population of adult bariatric surgery patients. Overall, findings suggest higher levels of stress (B = −.248, p =.017) and less social support for healthy eating (B =.311, p =.013) predict lower three-month post-surgery percent EWL. Emotion regulation, and sleep measures did not predict post-surgery percent EWL. Therefore, level of stress and social support should be assessed prior to bariatric surgery and considered important pre-surgical intervention targets.

Effect of bariatric surgery on outcomes in the operative treatment of hip fractures

IntroductionFew studies have evaluated the effect of prior bariatric surgery on outcomes following the operative treatment of hip fractures. The purpose of this study is to evaluate these metrics in a population of bariatric surgery patients compared to a control group who were operatively treated for hip fractures. Materials and MethodsThe California Office of Statewide Health Planning & Development (OSHPD) discharge database was accessed to identify patients who sustained a hip fracture between 2000–2014. CPT codes were utilized to identify patients who had a prior history of bariatric surgery within this time period. A control cohort of patients who had undergone previous appendectomy were queried similarly. The study evaluated complication rates and inpatient mortality at 30- and 90-days postoperatively as well as 30- and 90-day readmission rates. ResultsThere were 1,327 bariatric and 2,127 control patients identified. Survival rates were significantly lower in bariatric patients compared to controls (87.2% vs. 91.8%, p = 0.048) at 5 years. After controlling for confounders, bariatric patients had higher 30- (OR 1.46, p = 0.005) and 90-day (OR 1.38, p = 0.011) readmission rates. There were no differences in all-cause complication and inpatient mortality rates between groups at 30 or 90 days. DiscussionBariatric surgery patients are at increased risk of readmission after hip fracture surgery. Further research is warranted to delineate potential risk factors and mitigate readmission in these patients. Level of EvidenceIII

A role for foregut tyrosine metabolism in glucose tolerance

ObjectiveWe hypothesized that DA and L-DOPA derived from nutritional tyrosine and the resultant observed postprandial plasma excursions of L-DOPA and DA might affect glucose tolerance via their ability to be taken-up by beta cells and inhibit glucose-stimulated β-cell insulin secretion. MethodsTo investigate a possible circuit between meal-stimulated 3,4-dihydroxy-L-phenylalanine (L-DOPA) and dopamine (DA) production in the GI tract and pancreatic β-cells, we: 1) mapped GI mucosal expression of tyrosine hydroxylase (TH) and aromatic amino acid decarboxylase (AADC); 2) measured L-DOPA and DA content of GI mucosal tissues following meal challenges with different L-tyrosine (TYR) content, 3) determined whether meal TYR content impacts plasma insulin and glucose excursions; and 4) characterized postprandial plasma excursions of L-DOPA and DA in response to meal tyrosine content in rodents and a population of bariatric surgery patients. Next, we characterized: 1) the metabolic transformation of TYR and L-DOPA into DA in vitro using purified islet tissue; 2) the metabolic transformation of orally administrated stable isotope labeled TYR into pancreatic DA, and 3) using a nuclear medicine technique, we studied endocrine beta cells in situ release and binding of DA in response to a glucose challenge. ResultsWe demonstrate in rodents that intestinal content and circulatory concentrations L-DOPA and DA, plasma glucose and insulin are responsive to the tyrosine (TYR) content of a test meal. Intestinal expression of two enzymes, Tyrosine hydroxylase (TH) and Aromatic Amino acid Decarboxylase (AADC), essential to the transformation of TYR to DA was mapped and the metabolism of metabolism of TYR to DA was traced in human islets and a rodent beta cell line in vitro and from gut to the pancreas in vivo. Lastly, we show that β cells secrete and bind DA in situ in response to glucose stimulation. ConclusionsWe provide proof-of-principle evidence for the existence of a novel postprandial circuit of glucose homeostasis dependent on nutritional tyrosine. DA and L-DOPA derived from nutritional tyrosine may serve to defend against hypoglycemia via inhibition of glucose-stimulated β-cell insulin secretion as proposed by the anti-incretin hypothesis.

The impact of mental health disorders on 30-day readmission after bariatric surgery

BackgroundMental health disorders are common among bariatric surgery patients. Mental health disorders, particularly depression, have been associated with poorer surgical outcomes, indicating the bariatric surgery patient population warrants special clinical attention. ObjectiveOur study sought to examine the effect of diagnosed mental health disorders on 30-day readmission for those undergoing bariatric surgery in hospitals across Pennsylvania from 2011 to 2014. MethodsWe used Pennsylvania Healthcare Cost Containment Council data to perform this analysis. Inclusion criteria encompassed patients aged>18 years who underwent bariatric surgery at any hospital or freestanding surgical facility in Pennsylvania between 2011 and 2014. Mental health disorders were identified using predetermined International Classification of Disease, Ninth Revision codes. Logistic regression was used to model the risk of 30-day readmission and estimate the effect of mental health disorders on 30-day readmission. ResultsOf the 19,259 patients who underwent bariatric surgery, 40.3% had a diagnosed mental health disorder; 6.51% of all patients were readmitted within 30 days. Patients with a diagnosed mental health disorder had 34% greater odds of readmission (odds ratio = 1.34, 95% confidence interval: 1.19–1.51) relative to patients with no diagnosed mental health disorder. Patients with major depressive disorder/bipolar disorder had 46% greater odds of being readmitted compared with patients with no major depressive disorder/bipolar disorder diagnosis. ConclusionStudy findings imply the need for risk assessment of patients before postoperative discharge. Given that patients with mental health diagnoses are at increased risk of 30-day readmission after bariatric surgery, they may benefit from additional discharge interventions designed to attenuate potential readmissions.

A review of the safety and efficacy of bariatric surgery in adults over the age of 60: 2002-2013.

The purpose of this review is to compare outcomes of bariatric surgery in adults over 60 to younger patients. This analysis is important to determine if nurse practitioners (NPs) and other providers should recommend bariatric surgery to obese older adults. This review included 15 studies published between 2002 and 2013. Although older adults seem to experience less weight loss, bariatric surgery has potential benefits for these patients. Significant improvements in hypertension, diabetes, and, to a lesser extent, dyslipidemia are noted. Mortality and surgical complications in older adults are low, while differences in length of hospital stay are inconclusive. The risks of bariatric surgery in older adults need to be carefully evaluated based on individual medical condition. Overall the evidence suggests that bariatric surgery can be safely performed in older adults but more research is needed to determine which older adult patients are the best candidates for bariatric surgery. As bariatric surgery among older adults increases, interdisciplinary teams will continue to serve an important role in the management of bariatric surgery patients. NPs must be aware of trends in this emerging population of bariatric surgery patients.

The Correlation of Matrix Metalloproteinase 9–to-Albumin Ratio in Wound Fluid with Postsurgical Complications after Body Contouring

The authors' earlier retrospective report of surgical complications after abdominal contouring surgery provided evidence that post-bariatric surgery patients are at increased risk of developing wound complications compared with a normal population. This prospective pilot study was designed as a comparative analysis of both surgical and wound healing characteristics between massive weight loss and normal patients who present for abdominal contouring surgery. Excisional wounds were created and polytetrafluoroethylene tubing was inserted during the preoperative period for later harvesting in patients undergoing abdominal contouring following Roux-en-Y gastric bypass for weight loss (n = 16) or abdominoplasty (n = 17). Wound fluids were sequentially collected from drains and subjected to matrix metalloproteinase (MMP) analysis. Standard postsurgical complications were documented. Surgical complications were more common in weight loss patients (47 percent) than in control patients (25 percent). MMP analyses showed that MMP-9 levels remained significantly elevated at postoperative day 4 in patients who subsequently experienced complications in either the weight loss group (p = 0.02) or the control group (p = 0.03). Other parameters showed no significant differences between massive weight loss patients and controls. Although many markers were examined, the ratio of MMP-9 to albumin was the only predictor of postsurgical complications in any group. This lends further support to growing evidence that MMP-9 may be a useful biomarker of postsurgical complications. This pilot work showed no causal factors that explain the higher rates of postsurgical complications in the post-bariatric surgery patient population. Risk, II.

Nutritional Implications of Bariatric Surgery and the Role of Registered Dietitians

A S THE NUMBER OF INDIVIDUALS WITH OBESITY continues to increase, so has the prevalence of bariatric surgery in the United States and worldwide. Bariatric surgery is currently the only knownmethod that offers both considerable and long-termweight loss. Depending on the surgical procedure, patients can expect to lose between 29% and 87% of excess bodyweight 1 to 2 years postsurgery. Despite the substantial weight loss and improvements in comorbid conditions observed after bariatric surgery, these procedures are notwithout nutritional risk, which underscores the importance of registered dietitians (RDs) to the bariatric surgical care team. Nutritional deficiencies after bariatric surgery can arise from a variety of factors, including surgical modifications of the gastrointestinal tract that reduce dietary intake and/or promote malabsorption, or because of poor patient compliance with treatment recommendations (eg, diet and multivitamin supplementation). In this issue, MoizE and colleagues prospectively evaluated long-term nutritional deficiencies and dietary patterns after both sleeve gastrectomy and Rouxen-Y gastric bypass (RYGB). They demonstrated that nutritional deficiencies anddietary intake patternswere similar up to 5 years after sleeve gastrectomy and RYGB. Insufficient or deficient 25-hydroxyvitamin D appeared to be the most common problem before and up to 5 years after both surgeries, despite implementing a vitamin D supplementation protocol and living in aMediterranean climate (insufficiency defined by MoizE and colleges as 10 to 29 ng/mL [25 to 72 nmol/L] and deficiency defined as 10 ng/mL [ 25 mmol/L]). Considering that amajority of patients in theMoizE and colleagues studywere either insufficient or deficient before surgery suggests that routine supplementation of vitamin D should occur preoperatively. Moreover, the results from MoizE and colleagues and others highlight the importance of vitamin D supplementation in the bariatric surgery patient population and suggest that the frequently recARTICLE INFORMATION

Frequencies of obesity susceptibility alleles among ethnically and racially diverse bariatric patient populations

BackgroundGenetic factors likely play a role in obesity and the outcomes after bariatric surgery. Single nucleotide polymorphisms in or near the insulin-induced gene 2 (INSIG-2), fat mass and obesity-associated gene (FTO), melanocortin 4 receptor gene (MC4R), and proprotein convertase subtilisn/kexin type 1 gene (PCSK-1) have been associated with class III obesity in whites. Minimal data are available regarding the genetic susceptibility to obesity in class III obese nonwhites, especially Hispanics. Our objective was to perform a comparative analysis of 4 common genetic variants (INSIG-2, FTO, MC4R, and PCSK-1) associated with obesity in a diverse population of bariatric surgery patients to determine whether a difference exists by ethnicity (white versus Hispanic). The setting of the study was 2 university hospitals in the United States. MethodsBariatric surgery patients from 2 different institutions were enrolled prospectively, and genotyping was performed. Differences in the distribution of INSIG-2, FTO, MC4R, and PCSK-1 single nucleotide polymorphisms among the different ethnicities (whites and Hispanics) were compared using an additive model (0, 1, or 2 risk alleles). A propensity-matched analysis was used to account for cohort differences. ResultsA total of 1276 bariatric patients were genotyped for the INSIG-2, FTO, MC4R, and PCSK-1 obesity single nucleotide polymorphisms. Statistically significant differences in FTO, INSIG-2, MC4R, and PCSK-1 were seen using an additive model. FTO, PCSK-1, and MC4R (test for trend) remained significantly different in the propensity analysis. ConclusionSignificant differences in the frequencies of several common obesity susceptibility variants in or near FTO, PCSK-1, and MC4R were found in white and Hispanic patients with class III obesity undergoing bariatric surgery. Larger studies in more class III obese Hispanics of different nationalities are needed.

P-66: Implementation of a pilot program utilizing a nursing driven protocol for intravenous insulin infusion to achieve tight glycemic control in bariatric surgery patients on a general surgical unit

Medical literature supports the findings that tight glycemic control decreases morbidity and mortality in post operative patients. The bariatric surgery patient population frequently requires intravenous (IV) insulin infusion to maintain blood sugars in the normal range. The bariatric surgeons did not want to admit these patients to critical care for administration of an insulin infusion protocol.

Vitamin and Trace Mineral Levels after Laparoscopic Gastric Bypass

Nutritional deficiencies are a concern after any bariatric surgery procedure. Restriction of oral intake and/or decreased absorption may cause vitamin abnormalities. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. An investigation was undertaken to examine preoperative and short-term (1-year) postoperative levels of vitamins/trace minerals in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Serum preoperative and postoperative vitamin/trace element levels of LRYGBP patients were recorded in a retrospective chart review (n = 100). Unavailable and undrawn levels were not included in the results. Preoperative and 1-year postoperative percentage of abnormal levels were: vitamin A 11% and 17%, vitamin B(12) 13% and 3%, vitamin D-25 40% and 21%, zinc 30% and 36%, iron 16% and 6%, ferritin 9% and 3%, selenium 58% and 3%, and folate 6% and 11%. Abnormal vitamin and trace mineral values are common both preoperatively and postoperatively in a bariatric surgery patient population. Routine evaluation of serum levels should be performed in this specific patient population.

Psychiatric Diagnoses and Psychiatric Treatment Among Bariatric Surgery Candidates

This study investigated the psychiatric diagnoses and psychiatric treatment histories of 90 bariatric surgery candidates. Prior to surgery, all participants completed the Weight and Lifestyle Inventory, the Questionnaire on Eating and Weight Patterns, and the Beck Depression Inventory-II. Participants also underwent a behavioral/psychological evaluation with a psychologist, which reviewed responses to the measures and provided further assessment of participants' psychiatric status. The evaluation also was used to produce a recommendation on the patients' psychological appropriateness for surgery. Almost two-thirds of patients received a psychiatric diagnosis, the most common of which was major depressive disorder. Nearly two-fifths of all participants, and more than half of those given a psychiatric diagnosis, were engaged in some form of psychiatric treatment at the time of the evaluation. Nevertheless, 64% of patients were unconditionally approved for surgery; 31% were recommended for additional psychiatric or nutritional counseling prior to surgery. Three patients were not recommended for surgery. Results of this study provide important information on the preoperative psychiatric status and treatment histories of bariatric surgery candidates. Given the increasing population of bariatric surgery patients, evaluation of patients' preoperative psychiatric status may play an important role in maximizing successful postoperative outcomes.