Faculty Bibliography

Purpose of Review: Sleeve gastrectomy has become one of the most common bariatric surgical procedures world-wide. The complication rate overall is low, but staple line leak remains one of the most morbid and difficult to manage complications. The management of staple line leaks has evolved over time and now several non-operative, endoscopic, and surgical options exist with varying rates of success. Recent Findings: Based on the available data some interventions appear to be more efficacious than others, and modern management has moved towards a core set of practices. Endoscopic interventions may help many patients avoid operative intervention. Importantly, many patients may require repeated and varying interventions to fully resolve their leak. Summary: Each case should be managed by a multidisciplinary team with the interventions chosen based on patient factors, leak characteristics, and institutional capabilities. Nutritional optimization remains paramount to promote healing regardless of the interventions used.

Stricture of the gastrojejunostomy is a possible complication after laparoscopic Roux-en-Y gastric bypass. We present the case of a patient with stricture refractory to endoscopic dilation. The patient underwent laparoscopic revision of the gastrojejunostomy with a hand-sewn anastomosis.

BACKGROUND:Adequate treatment requires control of hemorrhage and restoration of bile flow. Surgery is the last resort and is indicated when the other modalities fail. METHODS:A 65-year-old man with multiple comorbidities was admitted with cholangitis. The patient underwent PTBD (Figure 1) but had persistent cholestasis. Thus, he underwent endoscopic cholangiopancreatography (ERCP), in which a plastic stent was misplaced within the common bile duct (CBD) and could not be removed (Figure 2). Afterwards, as the patient had persistently high bilirubin levels and the previously placed stent was malpositioned, the decision was made to proceed with laparoscopic cholecystectomy and CBD exploration. RESULTS:The operation was performed with choledocoscope guidance, and the CBD was closed over a T-tube. The operative time was 280 min. Postoperative course was uneventful; the T-tube was clamped 1 week after discharge. Four weeks postoperatively, the T-tube cholangiogram showed a patent extrahepatic biliary tree with no filling defects (Figure 3). The T-tube was then removed. CONCLUSIONS:Biliary obstruction secondary to hemobilia is a rare occurrence after PTBD. Surgical CBD exploration is required when conservative management and endoscopic treatment fail and can be done successfully through a minimally invasive approach.

BACKGROUND:Lipoprotein insulin resistance (LPIR) score is a composite biomarker representative of atherogenic dyslipidemia characteristic of early insulin resistance. It is elevated in obesity and may provide information not captured in glycosylated hemoglobin and homeostatic model assessment for insulin resistance. While bariatric surgery reduces diabetes incidence and resolves metabolic syndrome, the effect of bariatric surgery on LPIR is untested. OBJECTIVES/OBJECTIVE:We sought to assess the effects of Roux-en-Y gastric bypass and sleeve gastrectomy on LPIR in nondiabetic women with obesity. SETTING/METHODS:Nonsmoking, nondiabetic, premenopausal Hispanic women, age ≥18 years, undergoing Roux-en-Y gastric bypass or sleeve gastrectomy at Bellevue Hospital were recruited for a prospective observational study. METHODS:Anthropometric measures and blood sampling were performed preoperatively and at 6 and 12 months postoperatively. LPIR was measured by nuclear magnetic resonance spectroscopy. RESULTS:. LPIR was reduced by 35 ± 4% and 46 ± 4% at 6 and 12 months after surgery, respectively, with no difference by procedure. Twenty-seven of 53 patients met International Diabetes Federation criteria for metabolic syndrome preoperatively and had concomitant higher homeostatic model assessment for insulin resistance, glycosylated hemoglobin, nonhigh-density lipoprotein-cholesterol and LPIR. Twenty-five of 27 patients experienced resolution of metabolic syndrome postoperatively. Concordantly, the preoperative differences in homeostatic model assessment for insulin resistance, glycosylated hemoglobin, and nonhigh-density lipoprotein-cholesterol between those with and without metabolic syndrome resolved at 6 and 12 months. In contrast, patients with metabolic syndrome preoperatively exhibited greater LPIR scores at 6 and 12 months postoperatively. CONCLUSION/CONCLUSIONS:This is the first study to demonstrate improvement in insulin resistance, as measured by LPIR, after bariatric surgery with no difference by procedure. This measure, but not traditional markers, was persistently higher in patients with a preoperative metabolic syndrome diagnosis, despite resolution of the condition.

BACKGROUND:Portomesenteric vein thrombosis (PMVT) may occur after laparoscopic sleeve gastrectomy (LSG). Previous studies have shown that PMVT patients may have undiagnosed thrombophilia. We recently changed our practice to check thrombophilia panel in every LSG patient preoperatively. OBJECTIVES/OBJECTIVE:To estimate the thrombophilia prevalence in patients seeking LSG, and determine if extended chemoprophylaxis post LSG reduces PMVT. SETTINGS/METHODS:University hospital. METHODS:Thrombophilia panels were drawn on every patient seeking LSG after July 2018 at 2 high-volume accredited bariatric surgery centers. A positive panel included factor VIII >150%; protein C <70%; protein S <55%; antithrombin III <83%; and activated protein C resistance <2.13. Patients with a positive panel were discharged on extended chemoprophylaxis. PMVT rates and bleeding occurrences were recorded for LSG patients from August 2018 to March 2019 and were compared with a historic cohort of LSG performed from January 2014 to July 2018. RESULTS:, respectively. Of the cohort, 52.4% (563/1075) had positive thrombophilia panel, including factor VIII elevation (91.5%), antithrombin III deficiency (6.0%), protein S deficiency (1.1%), protein C deficiency (.9%), and activated protein C resistance (.5%). Between January 2014 and July 2018, 13 PMVT were diagnosed among 4228 LSG (.3%) and there were 17 bleeding occurrences (.4%). After August 2018, one PMVT was diagnosed among 745 LSG (.1%) and there were 5 bleeding occurrences (.6%). CONCLUSIONS:The estimated thrombophilia prevalence in patients seeking LSG is 52.4%. The majority (91.5%) of these patients have factor VIII elevation. Extended prophylaxis may decrease PMVT postLSG.

New York City (NYC) has emerged as the global epicenter for the COVID-19 pandemic. The NYC Public Health System (NYC Health +Hospitals, NYC H + H) was key to the city's response because its vulnerable patient population was disproportionately affected by the disease. As cases rose in the city, NYC H+H carried out plans to greatly expand critical care capacity. Primary ICU spaces were identified and upgraded as needed, while new ICU spaces were created in emergency departments (EDs), procedural areas, and other inpatient units. Patients were transferred between hospitals in order to reduce strain. Critical care staffing was supplemented by temporary recruits, volunteers, and military deployments. Supplies to deliver critical care were monitored closely and obtained as needed to prevent interruptions. An ED action team was formed to ensure that the experience of frontline providers was informing network level decisions. The steps taken by NYC H+H greatly expanded its capacity to provide critical care during an unprecedented surge of COVID-19 cases in NYC. These steps, along with lessons learned, could inform preparations for other health systems during a primary or secondary surge of cases. [Editor's Note: This Fast Track Ahead Of Print article is the accepted version of the manuscript. The final edited version will appear in an upcoming issue of Health Affairs.].

Diagnosis of asthma in obese individuals frequently relies on clinical history, as airflow by spirometry may remain normal. This study hypothesised that obese subjects with self-reported asthma and normal spirometry will demonstrate distinct clinical characteristics, metabolic comorbidities and enhanced small airway dysfunction as compared with healthy obese subjects. Spirometry, plethysmography and oscillometry data pre/post-bronchodilator were obtained in 357 obese subjects in three groups as follows: no asthma group (n=180), self-reported asthma normal spirometry group (n=126), and asthma obstructed spirometry group (n=51). To assess the effects of obesity related to reduced lung volume, oscillometry measurements were repeated during a voluntary inflation to predicted functional residual capacity (FRC). Dyspnoea was equally prevalent in all groups. In contrast, cough, wheeze and metabolic comorbidities were more frequent in the asthma normal spirometry and asthma obstructed spirometry groups versus the no asthma group (p<0.05). Despite similar body size, oscillometry measurements demonstrated elevated R_5-20 (difference between resistance at 5 and 20 Hz) in the no asthma and asthma normal spirometry groups (0.19±0.12; 0.23±0.13 kPa/(L·s^-1), p<0.05) but to a lesser degree than the asthma obstructed spirometry group (0.34±0.20 kPa/(L·s^-1), p<0.05). Differences between groups persisted post-bronchodilator (p<0.05). Following voluntary inflation to predicted FRC, R_5-20 in the no asthma and asthma normal spirometry groups fell to similar values, indicating a reversible process (0.11±0.07; 0.12±0.08 kPa/(L·s^-1), p=NS). Persistently elevated R_5-20 was seen in the asthma obstructed spirometry group, suggesting chronic inflammation and/or remodelling (0.17±0.11 kPa/(L·s^-1), p<0.05). Thus, small airway abnormalities of greater magnitude than observations in healthy obese people may be an early marker of asthma in obese subjects with self-reported disease despite normal airflow. Increased metabolic comorbidities in these subjects may have provided a milieu that impacted airway function.

BACKGROUND:. At 3-year follow-up, surgery was very effective in T2D remission; furthermore, in the surgical group, those with a higher baseline soluble receptor for advanced glycation end products had a lower postoperative BMI. OBJECTIVES/OBJECTIVE:To provide long-term follow-up of this initial patient cohort. SETTING/METHODS:University Hospital. METHODS:Retrospective chart review was performed of the initial patient cohort. Patients lost to follow-up were systematically contacted to return to clinic for a follow-up visit. Data were compared using 2-sample t test, Fisher's exact test, or analysis of variance when applicable. RESULTS:; P = .007), and higher percent weight loss (21.4% versus 10.3%; P = .025). Baseline soluble receptor for advanced glycation end products was not associated with long-term outcomes. CONCLUSIONS:remains effective long term. Baseline soluble receptor for advanced glycation end products are most likely predictive of early outcomes only.

Background: We previously conducted a randomized controlled trial comparing diabetes surgery to intensive medical weight management (MWM) to treat patients with type 2 diabetes (T2DM) and Body Mass Index (BMI) 30-35 kg/m². At 3 year follow-up, we found that surgery was highly effective in T2DM remission and that the soluble form of RAGE (receptor for advanced glycation end-products) may be an adequate diabetes biomarker that may help determine which patient population would benefit most from surgery. The purpose of this study is to provide longer-term (5-year) follow-up of this initial patient cohort.
Method(s): Retrospective chart review was performed of the initial patient cohort. Demographic data from the initial cohort included baseline weight, glycated hemoglobin (HbA1c) as well as medications. Repeated measures linear models were used to model weight loss and change in HBA1c.
Result(s): Originally, 57 patients with T2DM and BMI 30-35 were randomized to surgery (bypass, sleeve or band based on patient preference; n=30) vs. MWM (n=27). At baseline, mean BMI was 32.6 kg/m² and mean HbA1c was 7.8. At 5 year follow-up, the surgery group continued to have lower HbA1c (6.58 vs. 7.99) and lower BMI (27 kg/m² vs. 29.9 kg/m²) vs. the non-surgical group. At 3 years, in the surgical group, those with a higher baseline sRAGE had a lower post-op BMI.
Conclusion(s): Diabetes surgery in T2DM patients with BMI 30-35 kg/m² remains effective up to 5 years. Higher baseline sRAGE may predict success with surgery.
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