Faculty Bibliography

AIMS: Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric procedure. Although bariatric surgery is becoming increasingly recognized as a treatment option for diabetes, there remain concerns about the operative risks faced by diabetic patients. This study's objective was to determine the safety of bariatric surgery in diabetic patients, specifically the type 2 diabetic (T2DM) population. METHODS: Patients over 18 years of age with a body mass index (BMI) >/= 35 kg/m2 who underwent LSG in 2012 in the ACS-NSQIP database were identified. Emergency cases were excluded from analysis. Data included patient demographics, comorbidities, length of stay, and 30-day complications. The primary outcome was 30-day overall complication rate, and secondary outcomes included major complications and reoperation rates. RESULTS: There were 6399 LSG in the NSQIP database in 2012. Three hundred and twenty-two patients were excluded for BMI < 35, and 15 cases were deemed emergencies and excluded. Of the 6062 LSG who met the study criteria, 4726 (78 %) of patients were non-diabetic, 941 (15.5 %) had T2DM, and 395 (6.5 %) had T1DM. T2DM patients were more likely to be male (28.9 vs. 19.3 %, p < 0.001), were older (47.6 years vs. 42.5 years, p < 0.001), and had a higher BMI (46.4 vs. 45.7 kg/m2, p = 0.027) compared with non-diabetics. The overall 30-day complication rate did not differ between groups (6.5 % T2DM vs. 5.6 % non-diabetic, p = 0.292). After controlling for possible confounders, T2DM remained at no increased risk of 30-day complications (OR 1.16, 95 % CI 0.87-1.55, p = 0.301). In sub-analyses of specific complications, T2DM had a slightly higher rate of blood transfusions (1.8 vs. 1.0 %, p = 0.037). Other postoperative complications did not differ between groups. The 30-day complication rate for type 1 diabetics was greater than for T2DM (9.9 vs. 6.5 %, p = 0.031) and non-diabetics (9.9 vs. 5.6 %, p < 0.001). CONCLUSION: Laparoscopic sleeve gastrectomy is a safe procedure for type 2 diabetics with regard to early postoperative complications.

BACKGROUND: There are minimal long-term data on biliopancreatic diversion (BPD) with or without duodenal switch (BPD/DS). OBJECTIVES: To investigate the long-term weight loss, co-morbidity remission, complications, and quality of life after BPD and BPD/DS. SETTING: An academic, university hospital in the United States. METHODS: We conducted a retrospective review of patients who underwent BPD or BPD/DS between 1999 and 2011. Outcomes included weight loss measures at 2, 5, and 10-15 years postoperatively; co-morbidity remission; long-term complications; nutritional deficiencies; and patient satisfaction. RESULTS: One hundred patients underwent BPD (34%) or BPD/DS (64%). Mean preoperative body mass index (BMI) was 50.2 kg/m2. Mean follow up was 8.2 years (range: 1-15 yr) with 72% of eligible patients in active follow up at 10-15 years postoperatively. Excess weight loss (EWL) was 65.1% at 2 years, 63.8% at 5 years, and 67.9% at 10-15 years. Approximately 10% higher %EWL was achieved for those with preoperative BMI<50 kg/m2 versus>/=50 kg/m2 and patients who underwent BPD/DS versus BPD. Although co-morbidities improved, 37% of patients developed long-term complications requiring surgery. There were no 30-day mortalities; however, there was one mortality from severe malnutrition. Nutritional deficiencies in fat-soluble vitamins, anemia, and secondary hyperparathyroidism were common. Overall, 94% of patients reported satisfaction with their choice of surgery. CONCLUSION: This clinical experience supports the long-term positive safety profile and efficacy of BPD and BPD/DS at a single U.S. center. Higher levels of excess weight loss are achieved by patients with a lower preoperative BMI and BPD/DS. Although nutritional deficiencies and postoperative complications are common, patient satisfaction remains high.

Background/Purpose: Obesity is a common risk factor for knee osteoarthritis (KOA). While it is intuitive that bariatric weight loss improves knee pain, it is not clear how much is due to decreased mechanical load vs metabolic changes. Methods: Patients were screened for knee pain prior to sleeve gastrectomy, gastric bypass, or laparoscopic gastric banding. We required pain for >15 days/month and VAS pain > 30, excluding lupus, inflammatory arthritis, crystal disease, psoriasis, and bilateral knee replacement. Enrolled patients took standing knee xrays for Kellgren-Lawrence (KL) grading. We measured BMI and used the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire at baseline and 1, 3, 6 and 12 months, calculating % excess weight loss (%EWL) and deltaKOOS. We collected blood at baseline and followup to study biomarkers for predicting KOOS scores. Results: Of 536 patients considering bariatric surgery, we found 308 with knee pain and enrolled 176 (91.5% female; BMI 43.6 kg/m2+/-7, 32-61; age 42 +/-11, 18-73) well distributed in xray severity (KL0-4). For the 150 patients who had surgery, knee improvement paralleled weight loss at the followups. At 1 year, %EWL correlated well with deltaKOOS pain (R = .262, n = 114, p = 0.005), similar to other intervals and to other KOOS measures. The sleeve and bypass (n=72 and 27) vs banding (n=15) resulted in higher deltaKOOS pain at 1 year: 32.9 +/-21.3 and 30.7 +/-22.6 vs 10.2 +/-21.4, p=0.001. Sleeve and bypass patients also achieved a higher % of their potential deltaKOOS pain improvement than did banding (65.2% and 60.1% vs 16.8% of remaining KOOS points to 100), and a higher % of patients improved to any degree (93.1% and 88.9% vs 66.7%). Radiographic severity did not predict deltaKOOS at 1 year, nor did the presence of key comorbidities. Patients lost weight in a near-linear fashion through 1 year (Fig. 1), but their KOOS improvements plateaued at 1 month. This held true in sleeve and bypass subgroups (with altered anatomy), while banding showed less consistent deltaKOOS despite a similar trend in %EWL. Baseline leptin levels in obese KOA were higher than non-obese KOA and non-obese/non-OA controls from other cohorts (100.2 +/-61.9 vs 26.2 +/-16.7 and 15.4+/-13.8, p<0.001). Similarly, IL-1Ra, a potential marker of OA progression, was much higher than non-obese KOA or controls (1123+/-940 vs 324.0+/-145.6 and 272+/-130.0, p<0.001). Within obese KOA, higher leptin levels predicted worse xrays (KL0/1 vs KL2/3/4, p = 0.037). After 1 year, mean leptin and IL1-Ra from obese KOA patients had decreased (p<0.001). Conclusion: Bariatric surgery improves knee OA symptoms proportionally to %EWL. Most relief occurs during the 1st month before much weight loss, suggesting a metabolic impact beyond mechanical load reduction on joints - at least with the sleeve and bypass that alter digestive anatomy. Leptin and IL-1Ra serum levels are elevated in obese KOA vs non-obese KOA and controls - and fall after bariatric surgery which could contribute to knee pain relief

BACKGROUND: Although metabolic surgery was originally performed to treat hypercholesterolemia, the effects of contemporary bariatric surgery on serum lipids have not been systematically characterized. METHODS AND RESULTS: MEDLINE, EMBASE and Cochrane databases were searched for studies with >/=20 obese adults undergoing bariatric surgery [Roux-en-Y Gastric Bypass (RYGBP), Adjustable Gastric Banding, Bilio-Pancreatic Diversion (BPD), or Sleeve Gastrectomy]. The primary outcome was change in lipids from baseline to one-year after surgery. The search yielded 178 studies with 25,189 subjects (pre-operative BMI 45.5+/-4.8kg/m2) and 47,779 patient-years of follow-up. In patients undergoing any bariatric surgery, compared to baseline, there were significant reductions in total cholesterol (TC; -28.5mg/dL), low density lipoprotein cholesterol (LDL-C; -22.0mg/dL), triglycerides (-61.6mg/dL) and a significant increase in high density lipoprotein cholesterol (6.9mg/dL) at one year (P<0.00001 for all). The magnitude of this change was significantly greater than that seen in non-surgical control patients (eg LDL-C; -22.0mg/dL vs -4.3mg/dL). When assessed separately, the magnitude of changes varied greatly by surgical type (Pinteraction<0.00001; eg LDL-C: BPD -42.5mg/dL, RYGBP -24.7mg/dL, Adjustable Gastric Banding -8.8mg/dL, Sleeve Gastrectomy -7.9mg/dL). In the cases of Adjustable Gastric Banding (TC and LDL-C) and Sleeve Gastrectomy (LDL-C), the response at one year following surgery was not significantly different from non-surgical control patients. CONCLUSIONS: Contemporary bariatric surgical techniques produce significant improvements in serum lipids, but changes vary widely, likely due to anatomic alterations unique to each procedure. These differences may be relevant in deciding the most appropriate technique for a given patient.

Aims: Our institution implemented a Value-Based Medicine (VBM) clinical pathway to standardize the pre-, peri-, and post-operative management of longitudinal sleeve gastrectomy (LSG) patients. The goal of the program was to decrease patient length of stay (LOS) while maintaining the same clinical outcomes seen prior to initiation. Methods: The VBM pathway was instituted in September of 2014. A retrospective review was performed of all primary LSG cases from 2011-2015. Pre-VBM LSG patients were matched to post-VBM patients in a 1:1 ratio. Matching criteria were age within five years, body-mass index (BMI) within 5 kg/m, expected LOS within 0.5 days, same sex, and same status for prior abdominal surgery. Patients < 18 years of age, body mass index (BMI) < 35, and those with prior bariatric surgery were excluded from analysis. Primary outcomes were LOS, LOS > 2 days, operating room (OR) time, and cost per admission. Secondary outcomes included 30-day readmissions and reoperations. Results: There were 426 pre-VBM and 507 post-VBM patients. After matching for age, sex, BMI, expected LOS and previous abdominal surgery, there were 330 patients in each of the pre-VBM and post-VBM groups. There were no clinically significant demographic differences between the two groups. The post-VBM group had shorter mean OR time (75.1 vs 95.8 min, p<.0001), shorter LOS (1.50 vs 1.94 days, p<.0001), lower cost (median cost $792 less than pre-VBM group, p<.0001), and lower reoperation rate (0.0% vs 2.1%, p=.015). Readmission rate was lower in the post-VBM group, but did not reach statistical significance (2.7% vs 4.9%, p=.154). After controlling for hospital trends over time, LOS > 2 days (p=.008) and median cost (p=.019) remained significant. OR time (p=.058) and mean LOS (p=.338) still showed an improved trend, but could not be directly correlated to VBM implementation. Conclusions: Standardization of clinical care for LSG patients is feasible and effective. Patient length of stay and hospital cost were successfully decreased with no negative impact seen on 30-day post-operative outcomes

Introduction: Endoscopic stent placement after sleeve gastrectomy (LSG) leak is usually considered part of the treatment algorithm. We have experienced varying success with stents and have also seen patients who have difficulty tolerating the stent or who have experienced worsening leak with the stent. The purpose of this study is to review our experiences with these stents to contribute to the growing literature of the effectiveness in the management of sleeve leaks. Setting: Academic medical center. Methods: A retrospective review of all reported sleeve leaks between 2 high-volume bariatric surgery centers were reviewed. Data was collected on the presentation of these leaks as well as the entire post-operative course. Cases spanned from 2006 to 2016. Information was collected on clinical presentation, radiographic findings, endoscopic findings, stent placement, stent complications, re-intervention rate, and re-operation rate. Stent complications were defined as any persistent leak, PO intolerance, nausea/vomiting, radiographic evidence of migration, or abdominal pain that required either replacement/repositioning or removal of the stent. Results: 32 sleeve leaks were identified across our institutions. Two cases were excluded for lack of post-operative course data. 18 (60%) of 30 were treated at some point with an endoscopic stenting procedure. Complications that could be attributed directly to the stent were identified in 14 of the 18 cases (78%).The average number of interventions in the stent group was 3.7 compared to 0.75 in the no stent group (p<0.005).The average number of total admitted days was significantly higher in the stent group with 25.5 days versus 12.58 (p = 0.006). Conclusion: Patients who undergo stenting for the management of leak following a sleeve gastrectomy appear to require more interventions and have higher length of stay. Further studies are needed in order to better identify those patients who may benefit from endoscopic interventions and those who should be managed alternatively

Aims: Liraglutide, a GLP-1 agonist, was recently approved by the Food and Drug Administration (FDA) for use in the treatment of obesity. A large subset of patients have weight regain after bariatric surgery, but would prefer medical obesity management over revisional surgery. Our study evaluated the efficacy of liraglutide in patients with prior bariatric surgery who experienced either suboptimal weight loss or weight regain after their procedures. Methods: A review was performed of all patients at our weight loss center who had been prescribed liraglutide for weight loss and had prior bariatric surgery. Patients with o4 months of liraglutide use were excluded from analysis, as this was felt to be an insufficient time period in which to evaluate efficacy. Results: There were twenty-five patients who met all inclusion and exclusion criteria. Thirteen patients had laparoscopic adjustable gastric bands (LAGB), eight had roux-en-Y gastric bypasses (RYGB), three had longitudinal sleeve gastrectomies (LSG), and one had LAGB over RYGB. Dosages varied from 1.2 mg to 3.0 mg daily of liraglutide, depending on insurance approval and patient tolerance. Average weight prior to therapy was 237.69 lbs and average body-mass index (BMI) was 39.22. Patients showed a significant weight loss at 16 weeks (230.36 lbs, p=.002), 20 weeks (228.02 lbs, po.0001), and 24 weeks (215.2 lbs, po.0001). BMI was significantly reduced at 24 weeks as well (35.29, po.0001). Conclusions: Medical weight management with Liraglutide may be an effective alternative treatment in patients with prior bariatric surgery

BACKGROUND: Bariatric patients may not always obtain long-term care by their primary surgeon. Our aim was to evaluate weight loss outcomes in patients who had surgery elsewhere. METHODS: We conducted a retrospective analysis. Postreferral management included nonsurgical, revision, or conversion. Primary outcomes were percent excess weight loss (%EWL) overall, according to original operation, and based on postreferral management. RESULTS: Between 2001 and 2013, there were 569 patients. Mean follow-up was 3.1 years. Management was 42% nonsurgical, 41% revision, and 17% conversion. Overall, mean %EWL was 45.3%. Based on original surgery type, %EWL was 41.2% for adjustable gastric banding vs 58.3% for Roux-en-Y gastric bypass (P