Faculty Bibliography

BACKGROUND:Patients infected with novel COVID-19 virus have a spectrum of illnesses ranging from asymptomatic to death. Data have shown that age, sex, and obesity are strongly correlated with poor outcomes in COVID-19-positive patients. Bariatric surgery is the only treatment that provides significant, sustained weight loss in the severely obese. OBJECTIVES/OBJECTIVE:Examine if prior bariatric surgery correlates with increased risk of hospitalization and outcome severity after COVID-19 infection. SETTING/METHODS:test or Fisher's exact test. Additionally, overall length of stay and duration of time in intensive care unit (ICU) were compared using Wilcoxon rank sum test. Conditional logistic regression analyses were done to determine both unadjusted (UOR) and adjusted odds ratios (AOR). RESULTS:(SD = 6.5, P < .0001). There was also less burden of diabetes in the bariatric group (32%) compared with the control group (48%) (P = .0019). Patients with a history of bariatric surgery were less likely to be admitted through the emergency room (UOR = .39, P = .0001), less likely to require a ventilator during the admission (UOR=.42, P = .028), had a shorter length of stay in both the ICU (P = .033) and overall (UOR = .44, P = .0002), and were less likely to be deceased at discharge compared with the control group (OR = .42, P = .028). CONCLUSION/CONCLUSIONS:A history of bariatric surgery significantly decreases the risk of emergency room admission, mechanical ventilation, prolonged ICU stay, and death in patients with COVID-19. Even when adjusted for BMI and the co-morbidities associated with obesity, patients with a history of bariatric surgery still have a significant decrease in the risk of emergency room admission.

BACKGROUND:Laparoscopic adjustable gastric banding (LAGB) continues to be a valid surgical treatment option to address severe obesity. However, outcomes are varied and can be difficult to predict. Early prediction of suboptimal weight loss following LAGB may enable adjustments to postoperative care and consequently improve surgical outcomes. Therefore, our aim is to investigate the prognostic utility of using early weight loss following LAGB to predict long-term weight outcomes. METHODS:Clinical data from patients undergoing LAGB between 2001 and 2007 at a single institution were retrospectively collected and analysed. The data was used to inform a model for predicting long-term weight loss after LAGB surgery. Percent total weight loss (%TWL) greater than 20% 1 year after surgery was considered a measurement of success since it has been associated with the improvement of comorbidities and increased patient satisfaction. RESULTS:The average %TWL 1 year after LAGB surgery was 23.73% (n = 1524, SD = 8.68%). Weight loss of less than 10% in 1 year was a negative predictor of weight loss >20% in 8-12 years (OR = 0.449; p = 0.002; 95% CI = 0.272-0.742). Moreover, weight loss >20% in 1 year was a strong predictor of weight loss >20% in 8-12 years (OR = 5.33; p < 0.001; 95% CI = 3.17-8.97). CONCLUSION:Total body weight reduction of less than 10% 1 year after LAGB surgery suggests a lesser weight loss at 8-12 years. For these patients, targeted interventions would be appropriate to increase the chances of long-term success.

[Figure: see text].

BACKGROUND:The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. OBJECTIVE:To examine the effects of LSG on GERD symptoms. METHODS:One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7 months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). RESULTS:respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. CONCLUSION/CONCLUSIONS:These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.

Background/UNASSIGNED:. Bariatric surgery reduces progression of CKD to ESKD, but the risk of perioperative complications remains a concern. Methods/UNASSIGNED:The 24-month data spanning 2017-2018 were obtained from the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database and analyzed. Surgical complications were assessed on the basis of the length of hospital stay, mortality, reoperation, readmission, surgical site infection (SSI), and worsening of kidney function during the first 30 days after surgery. Results/UNASSIGNED:<0.001) times more likely to die compared with those with normal kidney function. However, absolute mortality rates remained relatively low at 0.53% in those with stage 3b CKD. Furthermore, absolute mortality rates were <0.5% in those with stages 4 and 5 CKD, and these advanced CKD stages were not independently associated with an increased risk of early postoperative mortality. Conclusions/UNASSIGNED:Increased severity of kidney disease was associated with increased complications after bariatric surgery. However, even for the population with advanced CKD, the absolute rates of postoperative complications were low. The mounting evidence for bariatric surgery as a renoprotective intervention in people with and without established kidney disease suggests that bariatric surgery should be considered a safe and effective option for patients with CKD.

Background/Purpose: Symptomatic knee osteoarthritis (SKOA) patients with obesity who undergo bariatric surgery experience knee pain relief, though the reduced mechanical load explains only part of the improvement. A reduction in inflammatory biomarkers from adipose tissue may also impact pain. We previously identified an IL1RN haplotype (TTG; rs419598, rs315952, and rs9005) that associates with OA severity and inflammatory markers. We aimed to determine whether TTG distinguishes patients who lose more weight and have more significant decreases in inflammation with greater knee OA pain relief.
Method(s): From 2013-2019 we enrolled patients >=30 years old with BMI >=30 kg/m 2 and painful knee OA who planned surgical (sleeve gastrectomy, gastric bypass, or laparoscopic band) or medical weight loss (MWL) at Bellevue Hospital or NYU Langone Health. Patients with lupus, rheumatoid arthritis, or psoriatic arthritis were excluded. Weight-bearing knee x-rays assessed OA severity to confirm a Kellgren-Lawrence grade of at least 1 (scale 0-4). Participants completed the Knee Injury and Osteoarthritis Outcomes (KOOS) questionnaire and provided blood at baseline and 1, 3, 6, and 12 months. Patients were genotyped to determine whether they carried 1 or 2 copies of the TTG haplotype (TTG-1/2) or none (TTG-0). Sleeve was the most common weight loss intervention, therefore our analysis is focused on this surgical subset to minimize variable effects on weight and biomarkers.
Result(s): We enrolled 113 patients (95 F, 18 M) with painful knee OA prior to their weight loss intervention. The mean age, BMI, and KOOS pain at baseline were 50.3 +/- 12.0 years, 44.8 +/- 8.9 kg/m 2, and 48.4 +/- 18.2 (0-100, with 100 = no pain). Of 113 patients, 48 underwent sleeve, 20 bypass, 9 laparoscopic banding, 12 did not have the surgery, and 24 pursued medical weight loss. The 77 who completed surgery had a mean % excess weight loss (%EWL) of 51.7 after 6 months, with significant decreases in hsCRP (4.4 mg/L) and leptin (32.8 ng/dL), and mean KOOS pain improvement of 22.4 (MCID= 16.7). The corresponding changes for patients who tried various MWL regimens were modest at best. We obtained the IL1RN haplotype for 45 of the 48 sleeve patients, and found 34 (70.8%) carried the TTG-1 or TTG 2 haplotype while 11 were TTG-0 (with similar baseline age, BMI, and KOOS for the two groups). At each follow-up time point through 6 months (Figure 1), TTG-1/2 patients had more difficulty losing weight than the TTG-0 group (p< 0.005 by ANOVA), with corresponding smaller reductions in hs CRP (p=0.36) and leptin (p=0.006). TTG-1/2 carriers also reported less KOOS pain relief relative to the TTG-0 group (p=0.021), markedly at 1 and 3 months with some improvement later (Table 1). All of these findings held true when only plotting data only from the 23 patients (18 TTG-1/2, 5 TTG-0) who completed each of the followup visits.
Conclusion(s): SKOA patients with obesity achieve marked excess weight loss, reductions in inflammatory mediators, and knee pain relief with bariatric surgery. The subset of patients with the TTG-0 IL1RN haplotype demonstrated more significant and/or rapid improvement in each of these outcomes, suggesting a potential predictor of which OA patients will have a more successful response to bariatric surgery

Background/Purpose: High body mass index (BMI, kg/m2) is a modifiable risk factor that has been associated with the development and progression of osteoarthritis (OA) and knee pain. While total knee arthroplasty (TKA) is the gold standard for the treatment of end stage OA, morbidly obese patients (BMI>=40kg/m2) are often required to lose weight prior to TKA due to increased surgical risk and a higher rate of complications. While conservative weight-loss often fails to help these patients, bariatric surgery can be an alternative option. Here we present interim data from the trial entitled "Surgical Weight-loss to Improve Functional Status Trajectories following arthroplasty for painful knee osteoarthritis". This current multi-center, prospective study compares pain and functional outcomes in patients receiving bariatric surgery prior to TKA versus obese patients who go straight to TKA.
Method(s): Patients with BMI >=40 kg/m2 and painful knee osteoarthritis who met the indications for TKA were recruited at four hospital centers. Patients with a BMI >35 kg/m2 were also recruited if they had a qualifying comorbid condition including obstructive sleep apnea, diabetes, hypertension or hyperlipidemia. Patients were assigned to either the bariatric (BAR) or TKA arm based on surgical choice (goal n=150 for each arm), with all bariatric patients having anatomy-altering sleeve gastrectomy or gastric bypass. At baseline and several time points after surgery (Figure 1), we documented height, weight, the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog pain (VAS) scales, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and had patients perform functional assessments (Timed-Up and Go, 30-second Chair Stand and 40-meter fast paced walk test). We targeted minimum detectable change (MDC) in outcomes for the VAS for knee pain (33% reduction), Timed Up and Go (decrease by 2 seconds), 30-second Chair Stand (increase by 2 reps), 40-meter fast paced walk (increase by 0.16 m/s), WOMAC score (16% reduction), and the KOOS pain score (10-point improvement). Using a logistic regression to adjust for age and baseline BMI, we compared the percentage of patients in the two arms who achieved an MDC for the various outcomes.
Result(s): To date, 25 BAR and 28 TKA patients have completed their follow-up visits through at least 6 months. Although there was a similar sex distribution, the bariatric group was younger (52 vs 60 years old, p=0.0023) with a higher baseline BMI (47.0 vs 41.6 p=0.0006). Most bariatric patients achieved comparable improvement to the TKA cohort with regards to the benchmarks of the 30-second Chair Stand (TKA 54% vs BAR 33%, p=0.156), KOOS pain score (TKA 91% vs BAR 67%, p=0.130), the Visual Analog Pain Scale (TKA 50% vs BAR 39%, p=0.466), Timed Up and Go test (TKA 43% vs BAR 22%, p=0.141) and the 40-meter fast paced walk (TKA 61% vs BAR 35%, p=0.073). The TKA cohort had a greater percent with a MDC for the WOMAC (TKA 88% vs BAR 54%, p=0.030).
Conclusion(s): In morbidly obese patients who are eligible for TKA, bariatric surgery may result in modest improvements in knee outcomes and may eventually delay the need for a TKA

In their relative infancy, intragastric balloons (IGB) offer a solution to patients who do not qualify for bariatric surgery due to their body mass index (BMI) or those reticent about major surgery with a promise of 10-15% of total body weight loss (TBWL%). Given a short implantation period of 6 months, weight regain following IGB removal has been commonly noted. This caveat prompted analysis of the addition of weight loss medications for improved efficacy in achieving sustained weight loss results post-IGB removal. In a single-center retrospective analysis from 2015 to 2018, 18 patients (mean age 39.72, 5 males, 13 females) with a saline-filled single intragastric balloon were evaluated for 12 months following IGB insertion. Exactly half of the patients (n=9) were on weight loss medications before, during, or after placement of IGB (IGB-M cohort) to compare to patients with IGBs only (IGB-O cohort). All patients were >18 years old, non-pregnant, and with no previous bariatric surgeries. Data was collected at 0, 3, 6, and 12 month intervals. Mean weight at baseline was 198.33lbs and 223lbs (p=0.814) and mean BMI was 32.79 kg/m2 versus 35.5 kg/m2 (p=0.546), in the IGB-O cohort versus the IGB-M cohort, respectively. At six months, the TBWL% in the IGB-O cohort versus the IGB-M cohort was 12.7% versus 13.1%, while mean BMI was 28.42 versus 31.62 (p=0.645), respectively. Attrition rate was 11.1% by 6 months and 72.2% by 12 months for both cohorts combined. At 12 months, TBWL% in the IGB-O cohort versus IGB-M cohort was 2.8% and 10.7%, while mean BMI was 33.77 and 29.17 (p=0.4), respectively. The most common class of medications utilized were glucagon-like peptide-1 (GLP-1) agonists (37.5%). Phentermine was the single most commonly prescribed medication (25%). The mean number of medications needed for a patient was 1.8. The TBWL% at six months demonstrated a slightly greater 0.4 TBWL% in the IGB-M cohort. This meant weight loss achieved with a balloon or weight loss pharmacotherapy was essentially equivalent in our study at the time of IGB removal at 6 months. However, a stark variance is noted at the 12 month mark in the IGB-O cohort with patients either partially regaining their previously lost weight or losing marginally further with a mean 2.8 TBWL% post IGB removal. Comparatively, the IGB-M cohort patients continued their weight loss or maintained their initial weight loss with a 10.7% TBWL creating a 7.9 TBWL% difference at the 12 month follow up between the two arms. Administration of medications might increase follow-up post IGB removal and decrease attrition rates. Results illustrate a two-pronged approach of combining weight loss medications with IGBs would culminate in a more clinically significant TBWL% with long term sustainability post IGB removal. Larger multi-center studies are recommended in order to achieve significant conclusions. [Formula presented] [Formula presented]
Copyright

Purpose: High body mass index (BMI, kg/m²) is a modifiable risk factor that has been associated with the development and progression of osteoarthritis (OA) and knee pain. The gold standard for the treatment of end stage knee OA remains total knee arthroplasty (TKA), though patients with morbid obesity (BMI>=40 kg/m²) are increasingly required to lose weight prior to TKA due to increased surgical risk and a higher rate of complications. Conservative weight-loss approaches often fail to help patients lose the recommended weight prior to TKA, potentially making them ineligible for surgery. Recent studies have shown that patients who undergo bariatric surgery experience short-term improvements in knee functionality and decreased pain, either obviating the need for arthroplasty - or at least improving the success of subsequent total knee replacements. Here we present interim data from the trial entitled "Surgical Weight-loss to Improve Functional Status Trajectories following arthroplasty for painful knee osteoarthritis". This current multi-center, prospective study compares pain and functional outcomes in patients receiving bariatric surgery prior to TKA versus obese patients who go straight to TKA.
Method(s): We recruited patients with BMI >=40 kg/m² and painful knee OA who met the indications for TKA from the bariatrics, orthopedics and rheumatology clinics at the four hospital centers. Patients with a BMI >35 kg/m² were also recruited if they had a qualifying comorbid condition including obstructive sleep apnea, diabetes, hypertension or hyperlipidemia. Patients were assigned to the bariatric (BAR) or TKA (TKA) arms based on surgical choice (goal n=150 for each arm), with all bariatric patients having anatomy-altering sleeve gastrectomy or gastric bypass, and not laparoscopic gastric banding. At baseline and several time points after surgery (see figure), we documented height, weight, the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog pain (VAS) scales, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and had patients perform functional assessments (Timed-Up and Go, 30-second Chair Stand and 40-meter fast paced walk test). We targeted minimum detectable change (MDC) in outcomes for the VAS for knee pain (33% reduction), Timed Up and Go (decrease by 2 seconds), 30-second Chair Stand (increase by 2 reps), 40-meter fast paced walk (increase by 0.16 m/s), WOMAC score (16% reduction), and the KOOS pain score (10-point improvement). Using a logistic regression to adjust for age and baseline BMI, we compared the percentage of patients in the two arms who achieve an MDC for the various outcomes.
Result(s): For the current analysis, 20 bariatric surgery patients and 22 TKA patients completed their 6-month follow-up visits. Each subcohort had a similar sex distribution (15% vs 14%, p=0.999) but the bariatric group was younger (53 vs 61 years old, p=0.0045) and had a higher baseline BMI (47.1 vs 40.9, p=0.0009). Many bariatric patients achieved significant improvement in knee pain and function as evidenced by the MDC in the various tests, though the percent with MDC consistently tended to be higher in the TKA cohort. These MDC benchmarks included the 30-second Chair Stand (TKA 60% vs BAR 29%, p=0.085), KOOS pain score (TKA 89% vs BAR 65%, p=0.130), the Visual Analog Pain Scale (TKA 50% vs BAR 34%, p=0.390), Timed Up and Go (TKA 45% vs BAR 21%, p=0.205), the 40-meter fast paced walk (TKA 61% vs BAR 42%, p=0.319), and the WOMAC (TKA 81% vs BAR 59%, p=0.225). Many of the bariatric patients have had subsequent arthroplasty, but not enough time has passed to report levels of improvement.
Conclusion(s): In morbidly obese patients who are eligible for TKA, bariatric surgery may result in modest improvements in knee pain and function when compared to TKA at 6 months post operatively. In addition to potentially altering the need for and timing of TKA, surgical weight loss may result in improved TKA outcomes. This study was supported by the Investigator Initiated Study Program of Ethicon-Endo Surgery, Inc. (Grant Number: 14-621). [Formula presented]
Copyright

Background/Purpose : Weight loss in obese patients can reduce knee osteoarthritis (OA) pain, even when physical therapy and intra-articular injections have failed. The impacts of either non-surgical or surgical weight loss on knee OA pain have been reported separately, but few studies have assessed them conjointly. While the decrease in mechanical load helps, the contribution of metabolic changes is less clear. We aimed to compare biomarker changes with weight loss as predictors of knee pain improvement, and consider a threshold of total weight loss necessary for these changes. Methods : Patients from the NYU Langone Weight Management program were screened for knee pain prior to bariatric surgery or the start of a medical weight loss (MWL) regimen. We excluded patients with autoimmune disease, recent malignancy, recent intra-articular knee injections, and lack of OA by Kellgren-Lawrence (KL) x-ray grading. The BMI, Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, and blood samples were obtained at baseline and 1, 3, 6 and 12 months for evaluation of pain and biomarker levels. Results : Of 140 patients screened, 81 were eligible and enrolled (82.7% female; BMI 45.2+/-9.6 kg/m2, 31-74; age 52+/-12 years, 30-80). A total of 49 patients had surgery (10 bypass, 30 sleeve, 9 LapBand) and 24 medical weight loss. 33 patients completed visits up to 6 months (2 bypass, 18 sleeve, 6 LapBand, 7 MWL). By 1 month, the surgical patients had lost much more total weight than the MWL group (9.8% vs 4.1 %, p=0.001), and realized marked pain relief (p< 0.001). By 6 months both groups had continued to lose weight, proportionately greater for surgical patients with further pain improvement. (Figure 1) Leptin levels dropped at 1 and then 6 months with both methods of weight loss. The pro-inflammatory protein IL-1Ra decreased significantly by 6 months in the bariatric patients, but increased with the medical regimen across both time points. Soluble vascular adhesion protein 1 (sVAP-1), another pro-inflammatory protein that facilitates leukocyte infiltration, decreased at both the 1 and 6 month intervals -but much more in MWL than in surgical patients. Consistent with the literature, the anti-inflammatory soluble receptor for advanced glycation endproducts (sRAGE) mirrored KOOS pain improvement only in surgical patients and stabilized after 1 month, but did not change in the MWL group. (Table 1) In a subgroup analysis, the 14 surgical patients who lost at least 10% of Figure 1. Surgical and medical outcomes for % total weight loss (TWL), knee pain and biomarkers Table 1. total weight by 1 month had significantly less pain at 6 months than the 12 who did not meet the threshold (DELTAKOOS 47.5 vs 29.9) but the biomarker levels were similar. (Figure 2) Conclusion : Surgical and medically supervised weight loss both lead to significant decreases in adiposity, but only those having bariatric surgery realize significant pain relief. The anatomical changes of surgical (vs. medical) weight loss result in different metabolic cascades given divergent biomarker trends. Bariatric patients who lose more than 10 percent of total body weight within the first month are more likely to have better pain relief by 6 months, but the biomarker changes reflect anatomic intervention -and are not dependent on the degree of surgical weight loss