Super-obese Research Articles

Detailed perioperative risk among patients with extreme obesity undergoing nonbariatric general surgery

BackgroundThe obesity epidemic has spread rapidly across the United States. Although overweight and obese patients have a paradoxically lower risk for postoperative morbidity and mortality, the risks associated with extreme classes of obesity (morbid obesity, super obesity, and super-super obesity) have not been described. MethodsWe queried the National Surgical Quality Improvement Program database from 2012 to 2016. Of 1,815,251 surgical cases, there were 3,946 vascular cases, 237,777 emergency procedures, and 75,177 cases with missing data that were removed. The remaining 1,378,711 cases were included in this analysis. Multivariable linear and logistic regression was performed to assess the impact of body mass index on postoperative outcomes. ResultsPatients within the super obesity and super-super obesity groups had the highest procedure-adjusted mortality risk among all body mass index classes (odds ratio = 2.31 and 2.63, respectively). Morbid obesity and underweight groups had moderate risk (odds ratio = 1.37 and 1.88, respectively), while those in the overweight and obesity class I and II cohorts had improved or equivocal mortality risk compared to normal body mass index class patients. Risk-adjusted and unadjusted multivariable models demonstrated that extreme obesity classes (morbid obesity, super obesity, and super-super obesity) have a graduated escalation of perioperative morbidity, infectious, and critical care complications. ConclusionFurther detailing extreme obesity-related risk beyond the obesity class III umbrella is necessary for accurate risk prediction, especially with the rising prevalence of elective nonbariatric surgery in this population. Preoperative risk assessment tools should consider subgroup risk adjustment to delineate true postoperative complication risk, facilitate patient education, and address modifiable risk factors before surgery.

Breathing at Extremes: The Restrictive Consequences of Super- and Super-Super Obesity in Men and Women

Massively obese subjects frequently undergo pulmonary function tests nowadays. Obesity-associated decreases in key operating lung volumes (reduced inspiratory capacity and reduced vital capacity) are particularly concerning because they may shorten the "room" for tidal volume expansion with negative physiologic and sensory consequences. Is massive obesity associated with reduced operating lung volumes? If so, is this effect more pronounced in men than women? We performed an observational, retrospective study in a tertiary, hospital-based laboratory. Pulmonary function test results from 248 super-obese (SO; BMI, 50 to 59.9kg/m2) and 83 super-super obese (SSO; BMI,≥60kg/m2) men and women were analyzed. Electronic medical records were screened to ensure that subjects were free of any disease that potentially could interfere with lung volumes. The prevalence of a low total lung capacity (restriction) was 26.9%, which increased to 38.6%in SSO. Despite the absence of between-sex differences in BMI and spirometric variables derived from the forced maneuver in both SO and SSO, men presented with higher prevalence of restriction (46.7%) than women (19.4%) (P< .05). Between-sex differences in residual volume differed according to the BMI group; SO men presented with higher values than SO women; the opposite was found in the SSO group. The prevalence of restriction with low operating lung volumes was approximately twice (SSO) and approximately thrice (SSO) as high in men compared with women (P< .01). Linear prediction equations as a function of sex, demographic, and anthropometric attributes markedly reduced the prevalence of these abnormalities across the population. Obesity-related restriction leading to low operating lung volumes is highly prevalent in the massively obese subject, particularly in men. These alterations that are associated with massive obesity should be taken into consideration for an accurate interpretation of pulmonary function tests in this growing population.

Obesity and unanticipated hospital admission following outpatient laparoscopic cholecystectomy.

Compared to other common outpatient operations, laparoscopic cholecystectomy has higher rates of unanticipated hospital admission with reports ranging from 1.0 to 39.5%. Identification of simple preoperative risk factors for admission can aid appropriate patient selection. The aim of this study was to evaluate the association of obesity with need for hospital admission and day of surgery postoperative complications. The ACS NSQIP database from 2007 to 2016 was used to evaluate patients ≥ 18years old who had undergone outpatient laparoscopic cholecystectomy. The primary outcome was hospital admission,defined as hospital length of stay ≥ 24h. The secondary endpoint was postoperative complications on day of surgery. A multivariable logistic regression was used to evaluate the association of body mass index (BMI) and the outcomes of interest. Odds ratio (OR) and their 95% confidence interval (CI) were reported. 192,750 patients underwent laparoscopic cholecystectomy in the outpatient setting. 38,945 (20.20%) required hospital admission. 89 (0.05%) had postoperative complications on the day of surgery. On multivariable logistic regression analysis, when compared to the baseline cohort of BMI ≥ 30 and < 40kg/m2, patients with a BMI ≥ 50kg/m2 had a 10% increased odds of hospital admission (OR 1.10, CI 1.02-1.19, p < 0.001). BMI ≥ 40kg/m2 and < 50kg/m2 was not associated with increased odds of hospital admission (OR 0.99, CI 0.95-1.03, p 0.725). There was no increased odds of postoperative complications for patients with higher BMI (OR 1.35, CI 0.32-3.89, p < 0.623). Patients with super obesity have a 10% increased odds of hospital admission following laparoscopic cholecystectomy. Obesity is not associated with increased odds of same-day postoperative complications. Ambulatory laparoscopic cholecystectomy for the morbidly obese is safe; however, those with BMI > 50kg/m2 should be considered on a case-by-case basis.

Comparison of Maternal and Perinatal Outcomes in Women With Super Obesity Based on Planned Mode of Delivery

(Aust N Z J Obstet Gynaecol. 2019;59:387–393) Guidelines on preferred delivery methods for pregnant women with super obesity are currently nonexistent. These women are more likely to have medical comorbidities and develop obstetric disorders such as gestational diabetes and preeclampsia. In addition, urgent cesarean delivery may be fraught with anesthetic and surgical challenges. As a result, these women are more likely to undergo an elective cesarean section (CS) despite a lack of evidence to support this approach. The current study was undertaken to compare outcomes based on the planned mode of delivery. The investigators also sought to identify factors that could predict a successful vaginal delivery.

Laparoscopic Single Anastomosis Sleeve Ileal (SASI) Bypass for Patients With Morbid Obesity: Technical Description and Short-term Outcomes.

Morbid obesity has been recognized as a public health crisis, particularly in developed countries. Single anastomosis sleeve ileal (SASI) bypass has been introduced as a novel bariatric and metabolic procedure. The present study aimed to describe the technical steps and assess the short-term outcomes of SASI bypass in patients with super morbid obesity. Adult patients of both sexes with body mass index (BMI) ≥50 kg/m underwent SASI bypass and were followed for 12 months postoperatively. Changes in BMI, excess weight loss (EWL), and improvement in comorbidities were recorded on follow-up. Twenty patients (17 female) of the mean age of 35.4 years were included in the study. The mean preoperative BMI (53.7±5.9) showed a significant decrease at 6 months (39.9±5.2) and then at 12 months (33.6±6) postoperatively. The mean %EWL was 44.3±7.8 at 6 months and 65.2±12.6 at 12 months. All patients with diabetes mellitus, osteoarthritis, and reflux esophagitis showed resolution at 12 months after the SASI bypass. Complications were recorded in 2 patients and no mortality was reported. SASI bypass is an effective and safe bariatric procedure that confers significant loss of weight and improvement in medical comorbidities. As compared with previous studies on patients with lower BMI, patients with super morbid obesity attained lower %EWL but similar resolution of diabetes mellitus at 12 months after SASI bypass.

Outcomes of Weight Loss, Diabetes, Hypertension and Obstructive Sleep Apnoea after Bariatric Surgery in Patients with Super Morbid Obesity

Introduction: There is currently a high prevalence of obesity in the Arabian Gulf yet relatively little research on bariatric surgery. In this study we investigate the efficacy of bariatric surgery in patients with super morbid obesity, defined as a Body Mass Index (BMI) of ≥ 50 kg/m2 . Methods: All records of bariatric surgery at a single centre were examined. Outcomes measured include Body Mass Index (BMI), percentage Excess Weight Loss (%EWL), Obstructive Sleep Apnoea (OSA), Hypertension (HTN) and Type 2 Diabetes Mellitus (T2DM). Statistical relationships between %EWL against age, type of surgery and gender were analysed. Results: 144 patients were found to meet the inclusion criteria. Mean pre-operative BMI was 56.9 ± 6.1 kg/m2 . 90 (62.5%) patients underwent sleeve gastrectomy, 24 (16.7%) had one anastomosis gastric bypass, 16 (11.1%) had biliopancreatic diversion (Scopinaro’s procedure), and 14 (9.7%) had sleeve gastrectomy with transit loop bipartition. 12 months post-operatively, mean BMI was 37.7 ± 7.5 kg/m2 , with a mean %EWL of 62.9% ± 17.9%. There was 100% OSA resolution, 95.3% HTN resolution, and 79.4% T2DM resolution. %EWL was found to decrease slightly with increased age, however no difference in %EWL was found between types of surgery or genders. Conclusion: Bariatric surgery is effective and may be justified in patients with super morbid obesity, including the elderly population. However, there is a great need for larger, longitudinal studies. This would be made possible by hospitals employing more regular and systematic reporting of data, and encouragement of patients to follow up.

Características de pacientes superobesos atendidos em serviço de referência em cirurgia bariátrica

Introduction: Obesity is a worldwide epidemic and people with super obesity (BMI &gt; 50 kg/m²) have the worse prognosis, related to physical complications but also to mental illnesses, physical and verbal abuse, as well as social exclusion. Objective: To determine the profile of super obese patients treated in a referential bariatric surgery service. Methods: Retrospective analysis of 56 medical records of patients treated at the HUUFMA’s Bariatric and Metabolic Surgery Service multidisciplinary ambulatory care in 2017-2019. Incomplete records or with body mass index (BMI) &lt; 50 kg/m² were excluded. Results are presented in mean and standard deviation. Chi-square test was used for association analysis, Shapiro-Wilks test for normality and significance was considered for p&lt;0.05. Results: Prevalence in sample of females (80.3%), brown skin (67.8%), average age of 37.8 ± 9.8 years, and 49.1% graduated high school. The average weight and BMI were that of 136.6 ± 12.4 kg and 59 ± 6.5 kg/m², respectively, with a patient standing out with a BMI of 71 kg/m². Among the comorbidities we found obstructive sleep apnea in 100%, insomnia in 98.2%, joint problems in 53.5%, anxiety in 50%, hepatic steatosis and systemic arterial hypertension with 48.2% each, dyslipidemia in 42.8%, intestinal constipation in 32.1% and type 2 diabetes mellitus in 17.8%. There was a significant relation (p&lt;0.05) between schooling and weight. An impact on mental health was observed, with 37.5% of the patients exhibiting depression, 44.6% binge eating and 17.6% suicidal thoughts and/or self-mutilation. Conclusion: The super obese patients’ profile is that of a young adult woman, with average schooling, various comorbidities and with significant impact on mental health.

Outcomes of robotic bariatric surgery in super-obese patients: first report based on MBSAQIP database

Bariatric surgery in the super-obese (SO) patient population represents a challenge. Although the robotic platform is increasingly used for these patients, there are limited data on outcomes compared with conventional laparoscopy. Our study compared the safety and short-term outcomes of robotic and laparoscopic platforms for SO patients compared with morbidly obese patients based on the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. University Hospital, United States. We evaluated all primary robotic and laparoscopic cases and extracted 30-day outcomes in patients with body mass index <50 and ≤50 kg/m2. For our primary analysis, we used the Cochran-Mantel-Haenszel method with surgery type Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG) as the stratification variable to determine the association between body mass index categories and outcomes. A total of 355,278 patients were included in our analysis. For the robotic RYGB (R-RYGB) group (n = 6645) and R-SG (n = 15,984) there were 1674 SO patients (25.2%) and 3688 SO patients (23.1%), respectively.For the laparoscopic RYGB (LRYGB) group (n = 95,374) and LSG group (n = 237,275), there were 24,991 (26.2%) and 51,524 SO patients (21.7%), respectively. The incidence of serious adverse events in SO patients for R-RYGB and LRYGB groups was 7.6% versus 7.2% (P>.05) and 4% versus 3.5% (P > .05) for R-SG and L-SG, respectively. The incidence of organ space infection in SO patients for R-RYGB and LRYGB groups was .5% versus .4% (P > .05) and .4% versus .2% (P < .05) for R-SG and LSG, respectively. Based on 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data, we found no difference in outcomes between robotic and laparoscopic approaches in SO patients. There was a higher incidence of serious adverse events in SO patients compared with morbidly obese patients for both approaches.

The role of C-reactive protein after surgery for obesity and metabolic disorders.

C-reactive protein (CRP) rise might be different in patients with obesity due to chronic inflammation. The aim was to analyze postoperative CRP rise and its role as an early prognostic marker of infectious complications. Center of maximum care in Germany. Patients who underwent laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic one-anastomosis gastric bypass as primary treatment for severe obesity were included. Serum CRP and leukocyte count were measured preoperatively, on postoperative days (POD) 1 and 4 and were analyzed regarding sex, body mass index, waist circumference, obesity-associated diseases, laboratory measurements (glycosylated hemoglobin, triglycerides, cholesterol), surgical procedure, infectious complications, and infectious with anastomotic leakage. Four hundred seventy-one patients underwent surgery. Postoperative CRP rise was similar across sexes but lower in the super-super obese group (P < .05) and higher in the gastric bypass groups (P < .05). Linear regression model showed, that the higher preoperative value of waist circumference, the higher the preoperative CRP (beta value: .159, P = .006) and the lower the postoperative CRP rise on POD1 (beta value: -.171, P = .004) and 4 (beta value: -.170, P = .003). Only in the laparoscopic one-anastomosis gastric bypass group did a higher glycosylated hemoglobin predict a higher postoperative CRP rise (POD1: beta value: .434, P = .012; POD4: beta value: .513, P = .006). Fourteen patients (3%) developed infections, 7 of whom (1.5%) had anastomotic leakage. Leukocyte count was no predictor of infectious complications. The cut-off for CRP was 80.5 mg/L (POD1) and 164 mg/L (POD4), with 57.1% and 85.7% sensitivity and 97.9% and 99.6% specificity for anastomotic leakage. Standard postoperative CRP rises less in patients with higher waist circumference and super-super obesity, but more after gastric bypass procedures. CRP but not leukocyte count predicts early anastomotic healing after obesity surgery. These findings should be considered when interpreting CRP values in the routine clinical setting.

Weight loss and effect on co-morbidities in the long-term after duodenal switch and gastric bypass: a population-based cohort study.

Unsatisfactory weight loss is common after bariatric surgery in patients with super obesity (body mass index [BMI] ≥50 kg/m2). Unfortunately, this group of patients is increasing worldwide. The aim of this study was to compare long-term weight loss and effect on co-morbidities after duodenal switch (DS) and gastric bypass (RYGB) in super-obese patients. University hospital, Sweden, national cohort. This observational population-based cohort-study of primary DS and RYGB (BMI ≥48 kg/m2) in Sweden from 2007 to 2017 used data from 4 national registers. Baseline characteristics were used for propensity score matching (1 DS:4 RYGB). Weight loss was analyzed up until 5 years after surgery. Medication for diabetes, hypertension, dyslipidemia, depression, and pain were analyzed up until 10 years after surgery. The study population consisted of 333 DS and 1332 RYGB, with 60.7% females averaging 38.5 years old and BMI 55.0 kg/m2 at baseline. DS resulted in a lower BMI at 5 years compared with RYGB, 32.2 ± 5.5 and 37.8 ± 7.3, respectively, (P < .01). DS reduced prevalence of diabetes and hypertension more than RYGB, while reduction in dyslipidemia was similar for both groups, during the 10-year follow-up. Both groups increased their use of antidepressants and a maintained a high use of opioids. This study indicates that super-obese patients have more favorable outcomes regarding weight loss and effect on diabetes and hypertension, after DS compared with RYGB.

Metabolic and Bariatric Surgery Accreditation Program and National Health Insurance System in Korea.

Since the first laparoscopic bariatric surgery in Korea introduced in January 2003, the number of metabolic and bariatric surgery has been steadily increasing. According to the report from National Health Insurance big data analysis, the prevalence of morbid and super obesity has greatly increased and metabolic and bariatric surgery also increased in the last 10 years. As the incidence of morbid obesity is more frequent in people of poor socioeconomic status, the need for a reimbursement by the government seemed to be necessary. Finally, the national health insurance system decided to financially cover metabolic and bariatric surgery from January 2019. In order to improve the safety and qualify of metabolic and bariatric surgery, the Korean Society for Bariatric and Metabolic Surgery (KSMBS) introduced surgeon’s and institution’s accreditation system. The authors intend to introduce comprehensive overview of accreditation system of bariatric surgery and discuss the contents of national health insurance for metabolic and bariatric surgery.

Surgery in Patients with Super Obesity: Medium-Term Follow-Up Outcomes at a High-Volume Center.

There is a need to determine which bariatric operations are the most effective for patients with super obesity and super-super obesity. A retrospective cohort study was performed on patients with super obesity and super-super obesity at Mohak Bariatrics and Robotics Surgery Center in Indore, India. Five hundred fourteen patients with super obesity and super-super obesity had surgery at our center from January 2010 through December 2013. The baseline characteristics were different in different operations. The initial average age, weight, and BMI were 44.4 (SD11.9) years, 145.4 (SD24.2) kg, and 55.48 (SD5.32) kg/m2 , respectively. Sleeve gastrectomy (SG) (227 [44.2%]) was the most common procedure, followed by one-anastomosis gastric bypass (OAGB) (124 [24.1%]), Roux-en-Y gastric bypass (RYGB) (102 [19.8%]), banded sleeve gastrectomy (BSG) (33 [6.4%]), and banded Roux-en-Y gastric bypass (BRYGB) (28 [5.4%]). After 3 years, the percentages of excess body weight loss (%EBWL) for SG, OAGB, RYGB, BSG, and BRYGB were 62.38%, 78.59%, 69.55%, 85.11%, and 75.77% (P < 0.0001), respectively. Failure to achieve BMI < 35 kg/m2 was more frequent in the group who underwent SG (67.9%), followed by RYGB (29.16%), BRYGB (22.2%), OAGB (9.87%), and none in the BSG group. BSG, OAGB, and BRYGB have very good to excellent midterm outcomes for patients with super obesity and super-super obesity, whereas RYGB and SG have average outcomes at 3 years. There is a need for multicenter, long-term, and prospective studies to be performed to confirm these findings.

The Anesthetic Management of an Adolescent with Autism Spectrum Disorder and Super-Super Obesity: a Case Report

We report the anesthetic management of a 15-year-old patient with super-super obesity (SSO) and autism spectrum disorder (ASD) presenting for dental surgery and debridement of ingrown toe nails. We discuss the major perioperative implications of SSO and ASD with special attention to the challenges of the morbid obesity difficult airway (MODA). We describe a pragmatic approach for managing MODA—predict difficulty, plan and prepare appropriate equipment, position and preoxygenate the patient, making appropriate pharmacological choices, and continue attention to airway and respiration in the postoperative period. The perioperative implications of a complex combination of ASD with SSO require a multidisciplinary approach with adequate experience, expertise, and equipment.

Perioperative outcomes after lower extremity bypass and peripheral vascular interventions in patients with morbid obesity and superobesity

ObjectiveAlthough the effect of body mass index (BMI) on the treatment of infrainguinal peripheral artery disease has been reported, outcomes of patients on the upper end of the obesity spectrum, including morbid obesity (MO) and superobesity (SO), are unclear. Our goal was to analyze perioperative outcomes after lower extremity bypass (LEB) and peripheral vascular interventions (PVIs) in this population of patients. MethodsThe Vascular Quality Initiative was reviewed for all infrainguinal peripheral artery disease interventions from 2010 to 2017. All patients were categorized into four groups: nonobese (BMI 18.5-29.9 kg/m2), obese (BMI 30-39.9 kg/m2), morbidly obese (BMI 40-49.9 kg/m2), and superobese (BMI ≥50 kg/m2). Patient and case details were recorded. Multivariable analysis was used to analyze outcomes. For statistical analysis, MO and SO groups were combined. ResultsWe identified 29,138 LEB cases (68.5% nonobese, 28.3% obese, 2.9% morbidly obese, 0.3% superobese) and 81,405 PVI cases (66.6% nonobese, 29.2% obese, 3.6% morbidly obese, 0.5% superobese). For both LEB and PVI, patients with MO and SO were more likely to be younger, female, nonsmokers, and ambulatory (P < .05). They also more often had diabetes, end-stage renal disease, congestive heart failure, and fewer previous inflow procedures (P < .05). LEB and PVI interventions in patients with MO and SO were less often elective and more often performed for tissue loss. Multivariable analysis showed that LEB in patients with MO and SO was not significantly associated with increased perioperative cardiac complications, return to the operating room, or mortality. Patients with MO and SO were significantly associated with increased surgical site infection (odds ratio, 1.43; 95% confidence interval, 1.02-1.98; P = .03) and increased respiratory complications (odds ratio, 1.6; 95% confidence interval, 1.11-2.31; P = .01). Multivariable analysis showed that MO and SO were not significantly associated with periprocedural access site hematoma, access site stenosis or occlusion, or mortality after PVI. ConclusionsMO and SO were significantly associated with increased incidence of wound infections and respiratory complications after LEB but were not significantly associated with increased incidence after PVI. Overall, patients with MO and SO have more comorbidities and more advanced presentation of vascular disease at the time of intervention, but MO and SO alone should not deter necessary and appropriate revascularization.

Perioperative outcomes of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in super-obese and super-super-obese patients: a national database analysis

BackgroundEvidence remains contradictory for perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients undergoing bariatric surgery. ObjectiveTo identify national 30-day morbidity and mortality of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients. SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. MethodsAll LSG and LRYGB patients from 2015 through 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were grouped based on body mass index (BMI) as follows: morbidly obese (MO; BMI 35.0–49.9 kg/m2), SO (BMI 50.0–59.9 kg/m2), and SSO (BMI ≥60.0 kg/m2). Complications and mortality within 30 days were compared between BMI groups using Pearson X2 or Fischer’s exact tests. Multivariate logistic regression was used to adjust for demographic characteristics and co-morbidities, and adjusted odds ratio (AOR) was reported for each outcome. ResultsOf 356,621 patients, 71.6% had LSG and 28.4% LRYGB. A total of 272,195 patients were in the MO group, 65,565 in the SO group, and 18,861 in the SSO group. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for SO (AOR = 1.20, 95% confidence interval [CI] 1.13–1.28 for LSG; AOR = 1.08, 95% CI 1.01–1.15 for LRYGB) and SSO (AOR = 1.44, 95% CI 1.31–1.58 for LSG; AOR = 1.31, 95% CI 1.19–1.45 for LRYGB) compared with the MO group. Mortality was also significantly higher for SO (AOR = 1.65, 95% CI 1.10–2.48 for LSG; AOR = 1.85, 95% CI 1.23–2.80 for LRYGB) and SSO (AOR = 3.30, 95% CI 1.98–5.48 for LSG; AOR = 3.32, 95% CI 1.93–5.73 for LRYGB) compared with the MO group. ConclusionsSO and SSO patients are at increased risk of 30-day morbidity and mortality compared with MO patients. Despite this elevated perioperative risk, the overall risk of these procedures remains low and acceptable especially as bariatric surgery is the durable treatment option for obesity.

A Multi-institutional Study on the Mid-Term Outcomes of Single Anastomosis Duodeno-Ileal Bypass as a Surgical Revision Option After Sleeve Gastrectomy

Recently, a single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has become increasingly popular for patients with BMI > 50 as a primary or staged surgery. Staging allows surgeons to do the sleeve gastrectomy (SG) first with the conversion only happening when a failure or technical challenge is identified. We present the mid-term outcomes of SADI bypass surgery after SG. A retrospective analysis was performed on a prospective database from four institutions. Ninety-six patients were identified from 2013 to 2018. Patients were divided into two groups: one had two-stage SADI because of insufficient weight loss, the second had planned two-stage SADI because of super obesity (BMI > 50kg/m2). Incidence of complications was divided into < 30days and > 30days. Of 96 patients, 3 patients were completely lost to follow-up. The mean age was 44.8 ± 11.3years. There were no deaths or conversion to open surgery. The postoperative early complication and late complication rate was 5.3% and 6.4% respectively. At 24months, group 2 had higher %weight loss (WL) and change in BMI units compared to group 1 with statistically significant difference. The average WL and change in BMI for entire patient's population at 24months after 2nd stage SADI was 20.5% and 9.4 units respectively. The remission rate for DM was 93.7% with or without the use of medication. The two-stage approach to SADI-S appears technically simpler than a single compromised operation. However, this approach needs more patients to understand its limitations.

The Risk of Post-operative Complications in Super-Super Obesity Compared to Super Obesity in Accredited Bariatric Surgery Centers.

The prevalence of super obesity (SO, BMI > 50.0kg/m2) and super-super obesity (SSO, BMI > 60kg/m2) is increasing. Current data are limited and discrepant on the relationship between SSO and post-bariatric surgery complication risk. We hypothesized there would be increased complications for both laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) in SSO compared to SO, but the relative risk (RR) would support the use of LSG in SSO patients. Metabolic and Bariatric Surgery Accreditation and Quality Improvement 2016 data were queried for SO and SSO patients undergoing LRYGB or LSG. Thirty-day post-operative complications were calculated. Univariate analyses were performed with a χ2 or Student's t test. Comparisons between multiple groups were performed using a one-way ANOVA. Statistical significance was defined as p < 0.05. A total of 5723 patients with SSO and 24,940 with SO were included for analysis. Patients with SSO had more co-morbidities. Patients with SSO had a higher likelihood of complications compared to SO patients (15.2% vs 12.6%, p < 0.0005). SSO patients, and specifically SSO RYGB, were significantly more likely to experience an unplanned intubation, prolonged ventilation, and unplanned ICU admission. Compared to SO LRYGB, the RR for complications in SSO LRYGB and LGS were 1.19 and 0.76 respectively (p < 0.0005). We found SSO patients had increased 30-day post-operative complications after both LRYGB and LSG compared to SO patients. LSG may be the preferred procedure for this high-risk population.

Use of phentermine-topiramate extended release in combination with sleeve gastrectomy in patients with BMI 50 kg/m2 or more

BackgroundSuper obesity (body mass index [BMI] ≥50 kg/m2) treatment can be complicated and high risk. ObjectivesWe studied whether the pre and postoperative use of phentermine and topiramate (phen/top) combined with laparoscopic sleeve gastrectomy (LSG) in super obesity increases the odds of achieving a BMI <40 at 2 years postoperatively. SettingAcademic medical center in Winston Salem, North Carolina. MethodsWe recruited patients between 2014 and 2016 who had a BMI ≥50 and planned to undergo LSG (n = 25) to participate in an open-label trial. Participants took phen/top (7.5/46–15/92 mg/d) for at least 3 months preoperatively and 2 years postoperatively. We compared weight loss, BMI changes, and odds for achieving BMI <40 for phen/top + LSG to historical controls. Controls had an initial BMI ≥50 and underwent LSG, without phen/top, at our center during the same timeframe (n = 40). ResultsOf the 25 participants recruited, 13 completed LSG. Phen/top participants had a baseline BMI of 61.2 ± 7.1 kg/m2 compared with 57.0 ± 5.6 kg/m2 for control participants. Percent initial weight loss was –39.3% (phen/top + LSG) versus –31.4% (control) at 12 months, P = .018; by 24 months, phen/top + LSG had an 11.2% greater initial weight loss, P = .007. At 24 months, the mean BMI was 33.8 kg/m2 for phen/top versus 42 kg/m2 for controls. The odds ratio for achieving a BMI <40 at 2 years with phen/top + LSG versus LSG alone was 4.1 (95% confidence interval, 0.8–21). ConclusionsCompared with LSG alone, phen/top combined with LSG may help patients with a BMI >50 achieve greater weight loss and reach a BMI <40. Long-term, controlled trials are needed to follow up these results.

SAT-528 BMI and Relationship to Prior Fracture in the Super Obese

Background: Super obesity, defined as BMI ≥ 50 kg/m2, comprises approximately 1.4% percent of the adult U.S. population and has been rising significantly over the past two decades. While obesity is considered to be protective against fracture, existing literature suggests that obesity affects fracture risk in a site-specific manner. In particular, higher risk of fracture has been observed at the lower leg/ankle and upper arm/shoulder, while lower risk of fracture has been observed at the hip, wrist, and spine. It is not clear if these site-specific relationships continue indefinitely as BMI reaches the super obese levels. Thus, the purpose of this study was to examine associations of BMI and history of fracture in a large academic center with a high rate of super obesity. Methods: Subjects at least 40 years old with BMI ≥50 were selected using the electronic medical record (EMR). History of prior fracture was identified via ICD codes and reviewed for accuracy. Comorbid conditions were also derived from ICD codes and used to derive the Charlson Comorbidity Index (Quan Modification) as a composite comorbidity index. Subjects with history of bariatric surgery were excluded. Clavicle fractures were excluded in multivariate modeling due to small number. Results: Of 6,181 subjects with super obesity, 145 subjects (2.3%) were identified as having prior history of fracture. These 145 subjects were of similar age, gender, and race-ethnicity, but lower BMI (53.3±4.1 vs. 54.2±5.2, p=0.039) than those without fracture history. Among these 145 subjects, a total of 172 fractures were identified. Lower leg/ankle fractures were most prevalent (30.2%), followed by forearm (15.7%), upper arm/shoulder (13.4%), and foot (11.6%). Of the 161 fractures where information regarding trauma severity was available, 62.7% were from minimal trauma (e.g. fall from standing height), 18.6% were from minor trauma (e.g. fall from multiple steps), and 18.6% were from major trauma (e.g. MVA, assault). In a multivariate model of lower leg and upper arm fractures only (controlling for age, gender, and race), higher BMI showed no association with prior fracture (OR 1.00 per 5 kg/m2, p=0.98, 95% CI 0.78-1.26). Interestingly, subjects with a higher comorbidity index had increased odds of prior fracture (OR 1.23 per 1 point increase, p<0.001, 95% CI 1.12-1.36). Conversely, at all other fracture sites, higher BMI was found to be strongly associated with lower odds of prior fracture (OR 0.57 per 5 kg/m2, p=0.002, 95% CI 0.40-0.81). Conclusion: In a large, super obese population, prior fracture occurred most frequently at the lower leg/ankle, forearm, and upper arm/shoulder and was due to minimal trauma. Higher BMI within the super obese range was not related to prior fracture of the lower leg and upper arm, but was still strongly associated with fewer fractures at other sites.

Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy for Super Super Obese and Super Obese: Systematic Review and Meta-analysis of Weight Results, Comorbidity Resolution.

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) used for super obesity (SO) and super super obesity (SSO) remain controversial. The meta-analysis was to summarize the evidence. We searched in MEDLINE and PubMed for studies concerning RYGB and SG for SO or SSO and pooled complication, percentage excess weight loss (%EWL), and resolution of comorbidities. Twelve studies were identified. RYGB achieved higher %EWL at 12months, but no significant difference at 24months. Resolution of diabetes mellitus and dyslipidemia reached a statistical significance; however, there was no significant difference in hypertension. RYGB was superior in %EWL for SSO and SO at 12months. However, regarding at 24months, RYGB was equal to SG, which is from a meta-analysis and cannot be seen as a definitive conclusion.