Body weight and prandial variation of plasma metabolites in subjects undergoing gastric band-induced weight loss
Bruno, Joanne; Verano, Michael; Vanegas, Sally M.; Weinshel, Elizabeth; Fielding, Christine Ren; Lofton, Holly; Fielding, George; Schwack, Bradley; Chua, Deborah L.; Wang, Chan; Li, Huilin; AlemÃ¡n, JosÃ© O.
Background: Bariatric procedures are safe and effective treatments for obesity, inducing rapid and sustained loss of excess body weight. Laparoscopic adjustable gastric banding (LAGB) is unique among bariatric interventions in that it is a reversible procedure in which normal gastrointestinal anatomy is maintained. Knowledge regarding how LAGB effects change at the metabolite level is limited. Objectives: To delineate the impact of LAGB on fasting and postprandial metabolite responses using targeted metabolomics. Setting: Individuals undergoing LAGB at NYU Langone Medical Center were recruited for a prospective cohort study. Methods: We prospectively analyzed serum samples from 18 subjects at baseline and 2 months after LAGB under fasting conditions and after a 1-h mixed meal challenge. Plasma samples were analyzed on a reverse-phase liquid chromatography time-of-flight mass spectrometry metabolomics platform. The main outcome measure was their serum metabolite profile. Results: We quantitatively detected over 4,000 metabolites and lipids. Metabolite levels were altered in response to surgical and prandial stimuli, and metabolites within the same biochemical class tended to behave similarly in response to either stimulus. Plasma levels of lipid species and ketone bodies were statistically decreased after surgery whereas amino acid levels were affected more by prandial status than surgical condition. Conclusions: Changes in lipid species and ketone bodies postoperatively suggest improvements in the rate and efficiency of fatty acid oxidation and glucose handling after LAGB. Further investigation is necessary to understand how these findings relate to surgical response, including long term weight maintenance, and obesity-related comorbidities such as dysglycemia and cardiovascular disease.
Prior bariatric surgery in COVID-19-positive patients may be protective
Jenkins, Megan; Maranga, Gabrielle; Wood, G Craig; Petrilli, Christopher M; Fielding, George; Ren-Fielding, Christine
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), hadÂ aÂ shorter length of stay in both the ICU (P = .033) and overall (UOR = .44, PÂ =Â .0002), and were less likely to be deceased at discharge compared with the control group (ORÂ = .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.
First-year weight loss following gastric band surgery predicts long-term outcomes
Carvalho Silveira, Flavia; Maranga, Gabrielle; Mitchell, Fernanda; Nowak, Brittany A; Ren-Fielding, Christine J; Fielding, George A
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% (nÂ =Â 1524, SDÂ =Â 8.68%). Weight loss of less than 10% in 1 year was a negative predictor of weight loss >20% in 8-12â€‰years (ORÂ =Â 0.449; pÂ =Â 0.002; 95% CIÂ =Â 0.272-0.742). Moreover, weight loss >20% in 1 year was a strong predictor of weight loss >20% in 8-12â€‰years (ORÂ =Â 5.33; pâ€‰<â€‰0.001; 95% CIÂ =Â 3.17-8.97). CONCLUSION:Total body weight reduction of less than 10% 1 year after LAGB surgery suggests a lesser weight loss at 8-12â€‰years. For these patients, targeted interventions would be appropriate to increase the chances of long-term success.
The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease
Silveira, Flavia Carvalho; Poa-Li, Christina; Pergamo, Matthew; Gujral, Akash; Kolli, Sindhura; Fielding, George A; Ren-Fielding, Christine J; Schwack, Bradley F
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 20.4â€‰Â±â€‰2.7Â 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, pâ€‰=â€‰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, pâ€‰=â€‰0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, pâ€‰=â€‰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.
Gastrojejunostomy stricture after Roux-en-Y gastric bypass, a 17 year experience [Meeting Abstract]
Nowak, B; Fielding, G; Kurian, M; Schwack, B; Bedrosian, A; Ren-Fielding, C
Introduction: The gastrojejunostomy (GJ) during Roux-en-Y gastric bypass (RYGB) can be performed by stapled or hand-sewn techniques, and is at risk for anastomotic stricture, reported in the literature at rates from 0 to 33%. This study reviews a single center's experience with anastomotic stricture and intervention required. Methods and Procedures: A retrospective chart review was performed of 904 patients who underwent RYGB as primary or revisional surgery at a single institution from October 2000 through September 2017. There were 182 patients excluded for follow up duration of less than 1 year, 5 for an esophagojejunostomy rather than GJ, and 1 for gastroparesis as the surgical indication rather than morbid obesity. This left 716 patients to be included in the study. Demographic and operative data were collected including technique for GJ, postoperative follow up, and complications, with a focus on GJ stricture and subsequent interventions.
Result(s): Gastrojejunostomy (GJ) was performed with a 25 CEEA stapler in 674 (94.1%) patients, with a linear stapler in 25 (3.5%), was hand-sewn in 7 (1.3%), and the technique was unknown in the remaining 8 (1.1%). Roux-en-Y gastric bypass was performed as a primary surgery in 522 (72.9%) patients and as a revisional surgery in 194 (27.1%). Stricture of the GJ was diagnosed in 29 (4.1%) patients. The average time to diagnosis of early strictures occurring prior to 3 months was 40.3 days, and for late strictures was 871 days. By technique, stricture was diagnosed in 26 (3.9%) patients in the 25CEEAgroup, 1 (4%) in the linear stapler group, and 2 (22.2%) in the hand-sewn anastomosis group. In primaryRYGBpatients stricture was diagnosed in 20 (3.8%) patients, and in revisionalRYGB in 9 (4.6%) patients (p = 0.626). Esophagogastroduodenoscopy (EGD) with dilation was performed at least once (1-9 times) in 26 patients, 2 with concomitant stenting, 2 required operative intervention, and 1 patient awaits operative intervention. Both patients who required surgery also had marginal ulcers, and possible gastro-gastric fistula at time of surgery.
Conclusion(s): The results of this study show that the 25 CEEA circular stapler is a reasonable technique for performance of the GJ anastomosis in RYGB, with a stricture rate of 3.9%. There is also a slightly increased stricture rate in revisional surgical patients, though not statistically significant
Effects of a single subanaesthetic dose of ketamine on pain and mood after laparoscopic bariatric surgery: A randomised double-blind placebo controlled study
Wang, Jing; Echevarria, Ghislaine; Doan, Lisa; Ekasumara, Nydia; Calvino, Steven; Chae, Floria; Martinez, Erik; Robinson, Eric; Cuff, Germaine; Franco, Lola; Muntyan, Igor; Kurian, Marina; Schwack, Bradley F; Bedrosian, Andrea S; Fielding, George A; Ren-Fielding, Christine J
BACKGROUND:When administered as a continuous infusion, ketamine is known to be a potent analgesic and general anaesthetic. Recent studies suggest that a single low-dose administration of ketamine can provide a long-lasting effect on mood, but its effects when given in the postoperative period have not been studied. OBJECTIVE:We hypothesised that a single low-dose administration of ketamine after bariatric surgery can improve pain and mood scores in the immediate postoperative period. DESIGN/METHODS:We performed a randomised, double-blind, placebo-controlled study to compare a single subanaesthetic dose of ketamine (0.4â€Šmgâ€Škg) with a normal saline placebo in the postanaesthesia care unit after laparoscopic gastric bypass and gastrectomy. SETTING/METHODS:Single-centre, tertiary care hospital, October 2014 to January 2018. PATIENTS/METHODS:A total of 100 patients were randomised into the ketamine and saline groups. INTERVENTION/METHODS:Patients in the ketamine group received a single dose of ketamine infusion (0.4â€Šmgâ€Škg) in the postanaesthesia care unit. Patients in the placebo groups received 0.9% saline. OUTCOME MEASURES/METHODS:The primary outcome was the visual analogue pain score. A secondary outcome was performance on the short-form McGill's Pain Questionnaire (SF-MPQ). RESULTS:There were no significant differences in visual analogue pain scores between groups (group-by-time interaction Pâ€Š=â€Š0.966; marginal group effect Pâ€Š=â€Š0.137). However, scores on the affective scale of SF-MPQ (secondary outcome) significantly decreased in the ketamine group as early as postoperative day (POD) 2 [mean differenceâ€Š=â€Š-2.2 (95% bootstrap CI -2.9 to 1.6), Bonferroni adjusted Pâ€Š<â€Š0.001], compared with placebo group in which the scores decreased only by POD 7. Scores on the total scale of SF-MPQ for the ketamine group were smaller compared with the placebo group (Pâ€Š=â€Š0.034). CONCLUSION/CONCLUSIONS:Although there was no significant difference between ketamine and placebo for the primary outcome measure, patients who received ketamine experienced statistically and clinically significant improvement in their comprehensive evaluation of pain, particularly the affective component of pain, on POD 2. However, future studies are needed to confirm the enduring effects of ketamine on the affective response to postoperative pain. CLINICAL TRIAL REGISTRATION/BACKGROUND:NCT02452060.
ONE VERSUS TWO STAGE GASTRIC BAND CONVERSION TO SLEEVE GASTRECTOMY: A COMPARISON OF WEIGHT LOSS OVER FIVE YEARS Revisional surgery [Meeting Abstract]
Nowak, B.; Ren-Fielding, C.; Fielding, G.; Kurian, M.; Schwack, B.
WEIGHT LOSS AFTER ADJUSTABLE GASTRIC BANDING INVERSELY CORRELATES WITH WEIGHT LOSS AFTER CONVERSION TO ROUX-EN-Y GASTRIC BYPASS OR SLEEVE GASTRECTOMY Revisional surgery [Meeting Abstract]
Nowak, B.; Fielding, G.; Kurian, M.; Ren-Fielding, C.
Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass
Liu, Shinban; Ren-Fielding, Christine J; Schwack, Bradley; Kurian, Marina; Fielding, George A
BACKGROUND:Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure. OBJECTIVE:To investigate long-term results of salvage gastric banding. SETTING/METHODS:University Hospital, New York, United States. METHODS:Data were prospectively collected with retrospective review. Baseline characteristics were evaluated and weights at multiple time intervals (before RYGB, before LAGB, each year of follow-up). Additional data included approach (open or laparoscopic), operative time, hospital length of stay, and postoperative complications. RESULTS:with 22.5% total weight loss and 65.9% excess weight loss. The long-term reoperation rate for complications related to LAGB was 24%, and 8% of patients ultimately had their gastric bands removed. CONCLUSION/CONCLUSIONS:The results of our study have shown that LAGB had good long-term data as a revisionary procedure for weight loss failure after RYGB.
Gastric band conversion to Roux-en-Y gastric bypass shows greater weight loss than conversion to sleeve gastrectomy: 5-year outcomes
Creange, Collin; Jenkins, Megan; Pergamo, Matthew; Fielding, George; Ren-Fielding, Christine; Schwack, Bradley
BACKGROUND:Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are often used as revisional surgeries for a failed laparoscopic adjustable gastric band (LAGB). There is debate over which procedure provides better long-term weight loss. OBJECTIVE:To compare the weight loss results of these 2 surgeries. SETTING/METHODS:University hospital, United States. METHODS:A retrospective review was conducted of all LAGB to RYGB and LAGB to LSG surgeries performed at a single institution. Primary outcomes were change in body mass index (BMI), percent excess BMI lost, and percent weight loss. Secondary outcomes included 30-day complications and reoperations. RESULTS:The cohort included 192 conversions from LAGB to RYGB and 283 LAGB to LSG. The baseline age and BMI were similar in the 2 groups. Statistical comparisons made between the 2 groups at 24 months postconversion were significant for BMI (RYGBâ€¯=â€¯32.93, LSGâ€¯=â€¯38.34, Pâ€¯=â€¯.0004), percent excess BMI lost (RYGBâ€¯=â€¯57.8%, LSGâ€¯=â€¯29.3%, P < .0001), and percent weight loss (RYGBâ€¯=â€¯23.4%, LSGâ€¯=â€¯12.6%, P < .0001). However, the conversion to RYGB group had a higher rate of reoperation (7.3% versus 1.4%, Pâ€¯=â€¯.0022), longer operating room time (RYGBâ€¯=â€¯120.1 min versus LSGâ€¯=â€¯115.5 min, P < .0001), and longer length of stay (RYGBâ€¯=â€¯3.33 d versus LSGâ€¯=â€¯2.11 d, P < .0001) than the LAGB to LSG group. Although not significant, the conversion to RYGB group had a higher rate of readmission (7.3% versus 3.5%, Pâ€¯=â€¯.087). CONCLUSION/CONCLUSIONS:Weight loss is significantly greater for patients undergoing LAGB conversion to RYGB than LAGB to LSG. However, those undergoing LAGB conversion to RYGB had higher rates of reoperation and readmission. Patients looking for the most effective weight loss surgery after failed LAGB should be advised to have RYGB performed, while also understanding the increased risks of the procedure.