Faculty Bibliography

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.

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: Portomesenteric vein thrombosis (PMVT) is a known complication after laparoscopic sleeve gastrectomy (LSG). Previous studies have indicated that many of these patients may have an undiagnosed thrombophilia. We recently changed our practice to check thrombophilia panel on every patient preoperatively undergoing LSG. The purpose of this study is to 1) estimate the prevalence of thrombophilia in patients seeking LSG and 2) determine if extended chemoprophylaxis post-LSG reduces PMVT.
Method(s): Thrombophilia panels were drawn on every patient seeking LSG after July 2018 at two high-volume bariatric surgery centers. A positive thrombophilia panel included: Factor VIII>150%, Protein C<70%, Protein S<55%, and Anti-thrombin<83%. Patients with positive thrombophilia panel were discharged on extended chemoprophylaxis. PMVT rates for all LSG performed from Jan 2014 thru July 2018 (no routine preop thrombophilia panel) were compared to PMVT rates after July thru March 2019 (routine preop thrombophilia panel).
Result(s): 1075 patients seeking LSG had thrombophilia panel checked preoperatively. The cohort was 83% female, 84% Hispanic and 15% non-Hispanic African American; mean age and BMI were 39.2 years and 43 kg/m², respectively. 577/1075 (54%) had abnormal thrombophilia panel preoperatively, including Factor VIII elevation (89.4%), Anti-thrombin III deficiency (5.9%), Protein S deficiency (2.9%), and Protein C deficiency (2.5%). Between January 2014 and July 2018, 18 PMVT were diagnosed among 4228 LSG (0.4%). After July 2018, 1 PMVT was diagnosed among 745 LSG (0.1%) who had thrombophilia panel checked preoperatively.
Conclusion(s): The estimated prevalence of thrombophilia is 54% in this patient population. Extended prophylaxis may decrease PMVT post-LSG.
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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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Background: The SWIFT trial, is a multi-site, prospective trial comparing knee physical function outcomes in patients with severe obesity who undergo bariatric surgery prior to TKA versus TKA only. This preliminary report compares knee outcomes in patients that completed bariatric surgery only vs. patients that had TKA without bariatric surgery.
Method(s): Knee outcomes for this analysis included Visual Analog Scale for knee pain, Timed Up and Go, 30-second Chair Stand, and 40-meter fast paced walk. The percent with >10% improvement in knee outcomes were compared between groups using logistic regression (adjusting for age and baseline BMI).
Result(s): This report includes 17 TKA eligible patients that completed 6-month follow-up after bariatric surgery and another 17 patients that completed 6-month follow-up after TKA only. The groups had a similar sex distribution (18% males in the bariatric group and 12% in TKA group, p=0.999) but the bariatric group was younger (53 vs 60, p=0.0056) and had a higher baseline BMI (47.1 vs 40.7, p=0.0020). Although the percent with >10% improvement was consistently higher in the TKA group, these differences were not significant for Visual Analog Pain Scale (48% vs 41%, p=0.762), Timed Up and Go (65% vs 59%, p=0.750), 30-second Chair Stand (77% vs 41%, p=0.091), or the 40-meter fast paced walk (76% vs 44%, p=0.147).
Conclusion(s): Bariatric surgery Results in modest improvements in knee outcomes in patients that are eligible for TKA and demonstrates potential to diminish the short term needs for knee replacement.
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OBJECTIVE:This study examined food addiction (FA) and acculturation among a Hispanic bariatric surgery-seeking sample. SETTING/METHODS:University hospital. METHOD/METHODS:Four hundred forty-four (n = 215 English-speaking; n = 229 Spanish-speaking) Hispanic adults seeking bariatric surgery completed established self-report measures examining food addiction and acculturation. RESULTS:35.8% met criteria for FA, which was significantly associated with acculturation level to the USA. Participants who endorsed greater acculturation also endorsed a significantly higher level of FA symptoms compared with those who endorsed less acculturation. Acculturation level was significantly associated with FA and BMI. CONCLUSIONS:FA rate in this bariatric surgery-seeking Hispanic patient group is similar to rates reported among bariatric candidates of varying ethnic backgrounds. Our results suggest a relationship between FA symptom expression and acculturation to the USA. Improving understanding of the onset and progression of severity of FA symptoms may have clinical implications for Hispanic patients seeking bariatric surgery.

This is a video of a 31 year old male with achalasia and severe obesity (Body Mass Index = 41). The patient reported a history of endoscopic balloon dilation 20 years prior and was having recurrent dysphagia. Manometry confirmed achalasia (aperistalsis, no relaxation and elevated LES pressure). The patient underwent Robotic Heller Myotomy and a Roux-en-y gastric bypass (RYGB). The patient was placed in the supine position. Trocars were placed for the robotic technique. Hiatal dissection was performed. The vagi were identified and preserved. The gastroesophageal junction (GEJ) was identified. A longitudinal myotomy was initiated between the anterior and posterior vagus nerves at the 11:00 position, extending 6 cm superiorly from the GEJ and 2-3cm distally. Repeat endoscopy was performed to confirm adequacy of the myotomy and air leak test was negative for mucosal injury. Next an ante-colic, ante-gastric RYGB was performed with a 75 biliopancreatic limb and 150 cm. The gastrojejunostomy was fashioned utilizing a 2-layer hand-sewn technique. The jejunojejunostomy was performed with a stapled technique and hand-sewn closure. The mesenteric defects were closed. The postoperative course was uneventful and the patient was discharged home post-op day #3. Surgical management of the severely obese patient with achalasia is complex and the goal is to alleviate the dysphagia and to promote weight loss. Heller myotomy provides excellent relief of dysphagia and the Roux-en-Y gastric bypass provides excellent control of reflux as well as weight loss. We prefer RYGB to laparoscopic sleeve gastrectomy (LSG) due the potential of exacerbation of reflux after LSG. We prefer to perform the myotomy first and then proceeding with the RYGB. The advantage of performing the myotomy first is that if the myotomy is difficult or if a perforation occurs, the surgeon has the option to perform a fundoplication and abort the RYGB. We prefer utilizing the hand-sewn technique for the gastrojejunostomy. An alternate option is the linear technique. The circular stapler technique (EEA) may be associated with difficulty in delivering the Orvil device due to the tortuous esophagus and potential mucosal disruption (if the myotomy has been performed first)

Chronic inflammation drives many obesity-associated conditions, including atherosclerosis. GlycA, a marker of systemic inflammation with lower intraindividual variability than hsCRP, is independently associated with incident cardiovascular events and mortality. Although GlycA is elevated in obesity, correlations with anthropometric measures are modest and the effect of weight loss on GlycA is untested. Obese (BMI 44.6±6.6kg/m² ), non-diabetic women (33.7±8.2 years) undergoing Roux-en-Y gastric bypass (n=23) or sleeve gastrectomy (n=31) were prospectively studied at baseline, 6 and 12 months post-procedure. Women with normal BMI (n=14) served as controls. Bariatric surgery significantly reduced GlycA by 6 months (451±47umol/L vs 383±50umol/L; p<0.001) with further reduction at 12 months (348±41umol/L; p<0.001) and no difference between procedures. At 12 months, despite 41% of surgical subjects maintaining BMI >30kg/m² , GlycA levels did not differ between surgical and control subjects (p=0.13). Increased HDL particle size was strongly associated with reduced GlycA (r=-0.49; p<0.001) and was found to mediate up to 43% of its weight-loss-associated fall. This is the first study to demonstrate that surgical weight loss markedly reduces levels of GlycA.

Mechanisms explaining the relationship between obesity and cardiovascular disease (CVD) are needed. Despite growing recognition of the importance of the anucleate platelet transcriptome, low levels of RNA in platelets make assessment difficult. We sought to perform unbiased platelet RNA profiling in obesity by performing a prospective study of severe obesity and weight loss via bariatric surgery on platelet characteristics and mRNA profile in 26 pre-menopausal, non-diabetic women (31.6 ± 8.4 years; BMI 43.0 ± 6.5 kg/m²) who underwent sleeve gastrectomy. Totally, 10 women of similar age with normal BMI served as controls. Platelet activation via flow cytometry was assessed before and after surgery. RNA-sequencing (RNAseq) was performed on platelet isolates from a subset of 13 subjects (eight obese women and five normal-BMI subjects). Platelet count, size, and age did not differ between control and obese women. However, platelet surface P-selectin and CD40 were higher in obesity. RNAseq demonstrated 629 differentially abundant transcripts in obesity. Notably, S100A9 and AGER, established markers of cardiovascular risk, were two of the most highly upregulated transcripts (each > 2.5 fold). At 6 months post-operatively, subjects lost 26.1 ± 5.8% body weight and inducible platelet P-selectin expression was reduced. Expression of 170 transcripts was affected by surgery, but only a small fraction (46/629) were genes found altered in obesity. We demonstrate that obesity is associated with an altered platelet transcriptome and increased platelet activation, which is partly attenuated by bariatric surgery. These observations suggest that platelets may contribute to increased cardiovascular risk in obesity through a variety of mechanisms.