Faculty Bibliography

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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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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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.

Perforated duodenal ulcer following RYGB is an unusual clinical situation that may be a diagnostic challenge. Only 23 cases have previously been reported. We present five cases. The hallmark of visceral perforation, namely pneumoperitoneum, was not seen in three of the four cases that underwent cross sectional imaging. This is perhaps due to the altered anatomy of the RYGB that excludes air from the duodenum. Our cases had more free fluid than expected. The bariatric surgeon should not wait for free intraperitoneal air to suspect duodenal perforation after RYGB.

The following review is being published by the American Society for Metabolic and Bariatric Surgery in response to numerous inquiries made to the Society by patients, physicians, society members, hospitals, and others regarding one-anastomosis gastric bypass as a primary treatment for obesity or metabolic disease. The review is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The review is not intended as, and should not be construed as, stating or establishing a local, regional, or national standard of care.

BACKGROUND: Bariatric surgery is frequently recommended prior to total joint arthroplasty (TJA) for morbidly obese patients with end-stage arthropathy. Current published data on the efficacy of bariatric surgery for preoperative medical optimization has yielded mixed results, and the effect of time from bariatric surgery to TJA on the preoperative risk profile is not well defined. Our study evaluated the effect of time from bariatric surgery to TJA on 90-day complication and readmission rates. METHODS: We utilized the Healthcare Cost and Utilization Project (HCUP) California State Inpatient Database (SID) to identify patients who underwent TJA following bariatric surgery between 2007 and 2011. Primary endpoints were 90-day complication rates and all-cause 90-day readmission rates following TJA. RESULTS: We identified 330 cases of bariatric surgery followed by total hip arthroplasty (THA) and 1017 cases followed by total knee arthroplasty (TKA). There were no significant demographic differences among patients who underwent TJA greater than or less than 6 months after bariatric surgery. Patients undergoing THA more than 6 months after bariatric surgery were significantly less likely to be readmitted within 90 days for any cause. There was no association between time from bariatric surgery to THA or TKA and 90-day complications. DISCUSSION: Delaying THA at least 6 months after bariatric surgery may help reduce the rate of 90-day readmissions in this high-risk patient population. Arthroplasty surgeons recommending bariatric surgery as preoperative risk modification should consider the patient's overall nutritional status, medical comorbidities, and overall response to surgery prior to booking for TJA.