Faculty Bibliography

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.].

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)